Every finding on record at Westminster Village Kentuckiana

Based on observation, interview and record review, the facility failed to ensure the kitchen was maintained in a sanitary manner related to the drywall hanging down and gaps in construction for 1 of 1 kitchen observations. This deficient practice had the potential to affect 64 of 65 residents residing in the facility. Findings include:On 6/23/26, between 8:30 a.m. and 9:15 a.m., the following was observed in the kitchen: -The ceiling to the left of the food prep table had a taped area that was dislodged with a 4-inch gap. The drywall was hanging down from the area,-A piece of board that had been nailed to the ceiling, measuring 3 feet by 3 feet, was observed bowing on two different sides with a 2-inch gap which was located over a food prep table. A 4-slice toaster was observed directly under it.During an interview on 6/23/26 at 9:03 a.m., the Dietary Manager indicated maintenance staff pulled it down and did not tape it back up. She mentioned it in the morning meeting last Friday, 6/19/26, and it was still hanging down today. On 6/22/26 at 12:56 p.m., the healthcare Director of Nursing provided a current, undated copy of the document titled Maintenance Service. It included, but was not limited to, Policy Statement .Maintenance service shall be provided to all areas of the building .The maintenance department is responsible for maintaining the buildings .in a safe .manner at all times .maintaining the building in good repair and free from hazards This citation relates to Intake 3037066 410 IAC (Indiana Authorization Code) 16.2-3.1-19 (a)(4)

Based on interview and record review, the facility failed to ensure pest control services were timely and effective. This deficient practice had the potential to affect 65 of 65 residents residing in the facility. Findings include: On 6/23/26 at 11:00 a.m., the pest activity logs were reviewed and indicated the following pest concerns:- rooms [ROOM NUMBERS], staff reported weird looking bugs on 3/7/26- Admissions office, staff reported ants on 3/9/26A- room [ROOM NUMBER], family reported ants on 3/23/26- room [ROOM NUMBER], staff reported ants on 4/28/26- room [ROOM NUMBER], staff reported ants on 5/15/26- room [ROOM NUMBER], staff reported ants on 5/18/26- room [ROOM NUMBER], roaches were reported on 5/19/26- room [ROOM NUMBER], staff reported bugs on 6/8/28- room [ROOM NUMBER], staff reported ants on 6/23/26Review of the pest control treatment services indicated the facility pest service treated the facility on 1/20/26 and 5/11/26.The pest control treatment services lacked documentation of which resident rooms were treated.On 6/23/26 at 10:53 a.m., the Assisted Living Executive Director indicated the facility did not currently have a pest control contract with a service complain. On 6/23/26 at 12:56 p.m., the healthcare Director of Nursing provided a current copy of the document titled Pest Control dated 4/1/24. It included, but was not limited to, Purpose .To control pests in the environment through inspections/observations and treatment for pests .In the event pests are identified the facility staff shall report their findings to their supervisor/Maintenance Director/Administrator. The pest control company will be notified for additional inspection/treatment This citation relates to Intake 3037066 410 IAC (Indiana Authorization Code) 16.2-3.19 (f)(4)

Based on observation, record review, and interview, the facility failed to ensure glucometers were cleaned per guidelines for infection control when obtaining blood sugar readings for 4 of 4 residents observed for glucometer use. (Residents 71, 45, 33, and 7)Findings include:1. During an observation, on 1/14/26 at 10:59 a.m., Licensed Practical Nurse (LPN) 4 indicated that each resident had their own glucometer. The LPN entered Resident 71's room and completed the accu-check (blood sugar monitoring). The resident's blood sugar reading indicated 296 milligrams per deciliter (mg/dL). The LPN administered the required dosage of Lispro insulin. The LPN had placed the glucometer back into the resident's glucometer holder in the top drawer of the medication cart, without cleaning it. There was no visible blood or stains on the glucometer. During an interview, on 1/14/26 at 11:02 a.m., LPN 4 indicated the glucometers were usually cleaned after he had obtained all of each resident's blood sugar readings during the day. I can clean it if you want me to. He obtained the Sani-Cloth wipe and cleaned the glucometer within 15 seconds and placed it back into the resident's glucometer holder. He indicated he cleaned it for 30 seconds and let it dry in the resident's holder for 2 minutes. He opened the glucometer holder and indicated it was still wet. The record for Resident 71 was reviewed on 1/16/26 at 10:56 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, anemia, morbid obesity due to excess calories, and hyperlipidemia. The Health Status note for the admission review, dated 1/15/26, included, but was not limited to, the resident had diabetes with routine accu-checks and insulin administration. 2. During an observation, on 1/15/26 at 11:02 a.m., LPN 5 entered Resident 45's room to obtain a blood sugar reading which indicated 193 mg/dL. The LPN cleaned the glucometer by wrapping it in a Sani-Cloth wipe and set it on the medication cart on a tissue. The LPN indicated she would let it set for over 2 minutes. There was no visible blood or stains on the glucometer. The record for Resident 45 was reviewed on 1/16/26 at 11:43 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with hyperglycemia, morbid obesity due to excess calories, and pure hypercholesterolemia. During an interview, on 1/15/26 at 11:43 a.m., LPN 5 indicated the glucometer would be cleaned after the blood sugar reading was obtained. It should be cleaned for 2 minutes. She should use the Sani-Wipes to wash and rub it or wrap it in the Sani-Wipes. She would leave it there for 2 minutes. She didn't feel that the glucometer would be cleaned well if she just wrapped it and did not wipe it. 3. During an observation, on 1/15/26 at 11:14 a.m., Resident 33's accu check was completed by LPN 3. The Glucometers for each resident requiring an accu checks were in the top drawer of the medication cart, but the LPN used a glucometer laying freely in the cart. The LPN cleaned the glucometer for 15 seconds prior to checking the resident's blood sugar. The result was a blood sugar reading of 184 mg/dL. The LPN indicated she would clean the glucometer but laid it on the medication cart and left to get another resident to test in the Main Dining Room. There was no visible blood or stains on the glucometer. She returned and cleaned the glucometer for 10 seconds and laid it on the medication cart on a tissue for two minutes. The LPN indicated the resident did not want to leave a game she was playing in the dining room. She would test another resident's blood sugar. The record for Resident 33 was reviewed on 1/16/26 at 11:15 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, acute kidney failure, and hydronephrosis. 4. During an observation, on 1/15/2026 at 11:25 a.m., Resident 7's blood sugar reading was obtained by LPN 3. The same glucometer was used to test the resident as was used for the other residents requiring accu checks on the hall. The result of the accu check indicated a blood sugar reading of 213 mg/dL. 5 units of Lispro were required per sliding scale order. The glucometer was laid on the top of the medication cart. There was no visible blood or stains on the glucometer. The insulin was administered by vial and syringe. The glucometer was left on the medication cart as the LPN left to check on the previous resident to see if she was ready to leave her game for the blood sugar check without cleaning it. The LPN indicated she wiped off the glucometer, which the LPN had not done. The LPN placed the glucometer in the medication cart's top drawer uncleaned. The record for Resident 2 was reviewed on 1/16/26 at 12:15 p.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with hyperglycemia, dementia, Alzheimer's disease, morbid obesity, dysphagia, and hyperlipidemia. During an interview, on 1/15/26 at 11:38 a.m., LPN 3 indicated she should clean the glucometer for two minutes or one minute. The glucometer should stay wet for 15 or 30 seconds. The Sani-Cloth wipe was used to clean the glucometer. She indicated she probably didn't clean the glucometer between the residents. Typically, the residents don't share the same glucometer, but they were out of strips for their own glucometers. The LPN was told those couldn't be located. She should clean the glucometer before the blood sugar was obtained and after it was obtained. The LPN then pulled the glucometer from the top drawer of the medication cart and wiped it down. During an interview, on 1/15/26 at 1:10 p.m., the Director of Nursing (DON) indicated the staff should clean the glucometer after each use. They could let the glucometer lay wrapped in the Sani-Cloth wipe to keep it moist. She wanted to check the manufacturer guidelines. During an interview, on 1/15/25 at 1:58 p.m. the Infection Preventionist (IP) indicated for cleaning the glucometer, the nurse would place a clean paper towel on the surface and clean the glucometer with the Sani-cloth thoroughly. She indicated by thoroughly; she would turn the glucometer front and back to clean with the Sani-cloth and then lay it to dry on the paper towel. It had to be cleaned first before wrapping the glucometer. They couldn't just wrap the glucometer. For one glucometer to be used for all residents, it should be allowed to dry before going to the next resident. The current manufacturer guidelines for Germicidal Disposable Wipe use, included, but were not limited to, . To Disinfect and Deodorize Hard, Nonporous Surfaces: If present, use a wipe to remove visible soil prior to disinfecting. Unfold wipe and thoroughly wet surface. Allow surface to remain wet for two (2) minutes. Let air dry. The Environmental Protection Agency [EPA] Regulatory [Reg]. Number [No].: was 9480-4, EPA Establishment [Est]. No.: 9480-NY-1.The Cleaning and Disinfection of Resident-Care Items and Equipment policy, revised July 2014, included, but was not limited to, . d. Reusable items are cleaned and disinfected or sterilized between residents. (1) Single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards.The current Infection Control for Glucose Testing policy, included, but was not limited to, . Utilize Sanicloth to clean glucometer. Contact time for Sanicloth is 2 minutes. glucometer must stay wet with Sanicloth for those 2 minutes. To achieve this, wrap glucometer with Sanicloth and glucometer in dedicated container. Each resident should have their own glucometer and supplies (if applicable) located in individual containers to ensure proper infection control. Each glucometer must be label with resident's name.3.1-18 (j)3.1-18 (l)

Based on observation, record review and interview, the facility to ensure the kitchen equipment, floors, and meal carts were clean and sanitary. This deficient practice affected 64 of 64 residents who currently received meals from the kitchen.Findings Include:1.During the initial kitchen tour, on 1/13/26 at 9:00 a.m., the following areas of concern were observed: -The dish machine had three areas of long white lime streaks going down the front of the dish washer.-The steam table machine had a heavy soil of yellow, brown and black material inside the two doors at the bottom. The same soil was observed along the sliding edge of the two doors and along the edge below the five control knobs.-Inside the two closed food carts, there were multiple brown and white spills on the bottom of the carts. One cart had lunch trays set up waiting for the food.-The floor underneath the flat top grill, had multiple brown spills and grease on it.-The fryer had a moderate amount of brown particles in the oil and along the inside shelf of the fryer. The fryer was greasy and sticky to the touch along the front and two sides.-The conveyor toaster had a moderate amount of brown crumbs inside and on the turning racks. The four slicer toaster had a heavy amount of brown and black crumbs inside the bottom of the toaster.-The cart which held the slicer had brown crumbs around the slicer. Both sides of the cart had brown and white streaks going down the sides of the cart.-Inside the bottom of the hot box there was a large amount of tan and white crumbs. -There was one box of cod filets open to air in the walk in freezer. No ice was observed on the fish and it was observed that fish was on the lunch menu today. 2. During a tour of the kitchen and meal observation, on 1/13/26 at 11:40 a.m., the following concerns were observed:-The area under the flat top grill remained with brown soil and grease.-The fryer remained with the crumbs inside the oil and the shelf.-The flat top grill had dried yellow egg on it and the inside edges of the flat top all around it had brown food and grease crumbs in the creases.-Two of two closed food carts and two of two open shelf food carts had brown and white particles on the inside bottoms of the cart and on the tray shelves.-The dish washer food traps under the machine and on the top left side of the machine had a heavy amount of brown and yellow food pieces in it along with pieces of plastic and bread ties.-The top of the dishwasher had a heavy amount of tan and brown particles on it.-The dish washer had the same three streaks running down the front of the machine. There were also brown and tan particles in the streaks.-There was a moderate amount of eggs, cucumbers and oatmeal on the side after the items came out to the clean side of the machine. Steam table pans were observed in the racks above the food particles.-The hot plate machine had streaks which went down the sides of it. The top around the openings of the dish storage had white spots. 3. During an observation in the kitchen, on 1/16/26 at 11:25 a.m., the following concerns were observed:-Heavy food particles in the trap in front of the entrance to the dish machine and in the trap below - the items consisted of green beans, red pepper, pieces of paper, bacon, sausage and egg pieces.During an interview with the Dietary Manager at this time, she indicated the machine was drained and all food traps were cleaned every night. If it was a bad day, then it would be changed sooner.-The slicer had a light amount of pink substance on the slicer blade. When shown to the Dietary Manager, she indicated it was last used 2 weeks ago but someone must have used it since then without cleaning it. The pink substance on the slicer blade was not present on the 1/13/26 at 9:00 a.m. observation.-The top convection oven had a heavy soil of small black particles inside the bottom which were able to be wiped away.-The right outer side of the convection oven had a heavy soil of small brown and black particles on it.-The four slice toaster remained with the heavy build up of brown food crumbs in the bottom.-The inside of two closed food carts and two open shelf carts had brown and white spills on the shelf edges and bottom. Trays were already set up on the carts waiting for the meal plate.-The fryer oil was clean but the shelf inside remained with brown food crumbs. The three sides of the fryer remained greasy and sticky to the touch.-The inside of the hot box had a large amount of tan and white food crumbs on the bottom. Two pans of baked sweet potatoes were inside uncovered. Review of the Daily Role Based Daily Cleaning Schedule for Week 1/11/26 through 1/16/26, indicated the following equipment was signed off as having been cleaned daily: clean top oven, clean stove top/grill, clean Healthcare steam table, clean warmer 2, clean oven bottom, and clean fryer. Review of the Daily Kitchen/Food Service Observations between 11/10/25 and 1/8/26, completed by the Dietary Manager, indicated the following areas were marked as completed with no issues: -Food Surfaces were thoroughly cleaned and sanitized.-Equipment (e.g. food grinders, choppers, slicers, toasters, fryers, microwave, can opener, oven, stove burners, stove top, vents, drip pans and mixers) were clean.-Dishware was stored in a clean, dry location and not exposed to splash, dust or other contamination, and covered or inverted.-Cleaning schedule for the kitchen and food service equipment was followed.-All cleaning logs were completed and initialed by staff assigned.-Deep fryer is clean to include area around the deep fryer was clean, free of debris and grease. There were a few days on the form when the cleaning schedule needed initialing during the first few days of monitoring.There were no further observations of the kitchen by the Dietary Manager after 1/8/26.The facility's current policy on Kitchen Sanitation included, but was not limited to, Cleaning and Sanitation of Dining and Food Service Areas: Policy: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Procedure: 1. 2. The director of food and nutrition services will determine all cleaning and sanitation tasks needed for the department. Tasks shall be designated to be the responsibility of specific positions in the department. 3. Staff will be trained on the frequency of cleaning as necessary. 4. The methods and guidelines to be used and agents used for cleaning shall be developed for each task or piece of equipment to be cleaned. 5. The methods and guidelines to be used and agents used for cleaning shall be developed for each task or piece of equipment to be cleaned. A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks completed. 6. Staff will be held accountable for cleaning assignments.3.1-21(i)(3)

Based on observation, record review, and interview, the facility failed to ensure residents were provided with the adaptive equipment necessary to maintain independence while eating or drinking for 1 of 1 resident who utilized adaptive feeding equipment reviewed. (Resident 9)Findings include: During a dining room observation, on 1/13/26 at 12:50 p.m., the tray card for Resident 9 indicated he was to have a two handled cup for liquids. No two handled cup was present and he was drinking from plastic cups with no handles for his tea and water.An interview with the Staff Coordinator, on 1/13/26 at 1:00 p.m., she indicated as far as she knew, the resident did not require any specific adaptive devices at meal times.During a second observation of the dining room on 1/16/26 at 12:45 p.m., Resident 9 was observed drinking his shake, water and tea from a regular plastic cup. No two handled cups were in sight.The record for Resident 9 was reviewed on 1/16/2026 at 1:39 p.m., The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, transient cerebral ischemic attack, generalized muscle weakness, essential tremor, and dysphagia, oropharyngeal phase.The Quarterly Minimum Data Set (MDS) assessment, dated 12/16/25, indicated the resident had moderate cognitive impairment; required supervision and assistance for eating after tray set up; and impairment of bilateral upper extremities in functional Range of Motion (ROM).A care plan, dated 10/16/25, indicated the resident had a nutritional problem or potential problem related to mechanically altered and therapeutic diet, was underweight, received hospice care, and had a diagnosis of dysphagia. The goal was for the resident to consume food and fluids of choice. The interventions included, but were not limited to, two handled cup at all times.A physician's order, dated 7/3/24 with a revision date of 12/8/25, indicated the resident was to receive a regular diet with mechanical soft texture, with regular or thin liquids consistency. He was supposed to have a two handled cup for liquids.An interview, dated 1/16/26 at 1:30 p.m., with Dietary aides 11 and 12 indicated, they indicated they were responsible for making sure the residents had whatever adaptive equipment they required when the tray was set up. The adaptive cups and silverware were available right on the tray below on the cart. When asked if they knew if Resident 9 required any adaptive equipment for his meals and beverages, they indicated they were not aware of him needing anything. When they were shown the resident's tray card where it indicated the resident required a two handled cup for all liquids, they indicated they would make sure he got it from now on.During an interview with RN 13 and CNA 8, on 1/20/26 at 10:53 a.m., they indicated the resident had issues with his hands. He needed the two handled cup because of the way he grabbed things. He used it at breakfast and lunch. He had a tendency to spill things if he did not use the cup.Review of the facility's current policy on Adaptive Equipment, included, but was not limited to, Adaptive (Assistive) Eating Devices: Policy: The facility will provide special eating equipment, utensils, and assistance as appropriate to assure that each individual can use the adaptive (assistive) device when consuming meals and snacks. Procedure: 1. Individuals will be evaluated on admission, and periodically to assess the need for adaptive (assistive) devices. Referrals for needed equipment may come from speech therapy, occupational therapy, nursing, the physician or designee, the registered dietitian nutritionist (RDN) and/or designee. 2. Individuals will be referred to the therapy department as needed to evaluation for adaptive (assistive) devices. 3. A written order must be obtained for adaptive (assistive) devices. 4. Adaptive (assistive) devices should be noted on each individual's meal identification (ID) card/ticket and in the person centered care plan and/or in the medical record. 5. The food and nutrition services department will be responsible for ensuring that each individual receives the appropriate feeding devices as ordered for each meal. Adaptive (assistive) devices will be cleansed and sanitized, then stored in the kitchen and provided for each meal and/or snack as appropriate.3.1-21(h)

Based on observation, interview and record review, the facility failed to ensure a resident with a history of Urinary Tract Infections (UTIs) was provided proper management of the urinary catheter drainage system by maintaining the drainage system off the floor for 1 of 4 residents reviewed for bowel and bladder. (Resident 33)Findings include:During an observation, on 1/13/25 between 12:00 p.m. and 1:00 p.m., Resident 33 had been in the dining room for 60 minutes with her urinary catheter collection bag and tubing sitting on the floor. The resident had been rolling in her wheelchair back and forth across the catheter tubing with the wheelchair wheels. There were multiple staff members in the dining room at that time. During an observation, on 1/15/26 at 8:30 a.m., Resident 33 was lying in bed and just finished eating her breakfast. Her foley catheter was sitting on the floor with no barrier between the indwelling urinary catheter collection bag and the floor.During an observation, on 1/15/25 at 1:00 p.m., Resident 33 was wheeling down the hall from the dining room dragging the indwelling urinary catheter collection bag and catheter tubing. During an interview, on 1/14/25 at 1:20 p.m., Licensed Practical Nurse 9 (LPN) indicated the resident's catheter was always falling to the floor. During an interview, on 1/15/25 at 1:40 p.m., the DON indicated therapy had gotten the resident a new wheelchair and she thought the chair was too low to the ground. The facility would be ordering urine drainage bags to hang on the back of the wheelchair to prevent the catheter collection bag from falling on the floor. The resident self-transferred herself to and from the chair. The DON told the staff to watch for the catheter bag and tubing, and made sure they hang it on the back of the wheelchair off the floor. The record for Resident 33 was reviewed on 1/15/26 at 10:25 a.m. The resident's diagnoses included, but were not limited to, obstructive and reflux uropathy, hydronephrosis, retention of urine, chronic kidney disease stage 3, and personal history of urinary tract infections. The care plan, dated 11/23/24, indicated the resident was at risk of complications related to Chronic UTIs. The interventions, dated 11/23/24, included, but were not limited to, encourage fluids as tolerated, observe for changes in output, observe for signs and symptoms of UTI.The care plan, dated 11/5/25 and revised 11/10/25, indicated the resident had an indwelling catheter upon readmission on [DATE]. The interventions, dated 11/5/25 and revised 11/10/25, included, but were not limited to, check tubing for kinks each shift, monitor for pain/discomfort due to the catheter, and monitor for signs of a UTI: pain, burning, blood tinged urine, cloudiness, increased pulse, increased temperature, foul smelling urine, chills, altered mental status, change in behavior.The care plans lacked documentation of any interventions related to placing a barrier between the indwelling urinary catheter collection bag and the floor.A physician's order, dated 11/5/25, indicated the resident was to have the indwelling urinary catheter collection bag changed, as needed for occlusion.A physician's order, dated 11/12/25, indicated the resident was to be in enhanced barrier precautions. The staff were to put on appropriate personal protective equipment (PPE) for all high-contact resident care followed by proper removal of the PPE and then complete handwashing.The Quarterly Minimum Data Set (MDS) assessment, dated 12/30/25, indicated that the resident was cognitively intact. The resident had an indwelling catheter and was always incontinent of stool. The resident required partial assistance for any transfers.A nurse's note, dated 1/10/26 at 11:28 a.m., indicated the resident pulled her catheter out. Resident 33 indicated to staff that she pulled her catheter out by accident. The catheter was then reconnected, and the resident was encouraged not to pull on her catheter. A nurse's note, dated 1/14/26 at 4:00 p.m., indicated that the resident came to the nurse's station saying my catheter came out. The catheter was inserted without difficulty with clear yellow urine return by the nursing staff.A physician's order, dated 1/15/26, indicated the resident would have a urinary leg bag placed on her lower extremity every morning.A physician's order, dated 1/15/26, indicated the resident would have the urinary collection bag placed back on at bedtime.The current policy, titled The Catheter Care, Urinary was provided by the DON on 1/15/25 at 11:15 a.m. The policy indicated, Purpose: The purpose of this procedure is to prevent catheter associated urinary tract infections.Maintaining Unobstructed Urine Flow: 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Infection Control: 2.b Be sure the catheter tubing and drainage bag are kept off the floor. 3.1-41(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of urine received the necessary care and services of brief changes before the brief and bed padding underneath the resident was not overly saturated with urine for 1 of 4 residents reviewed for Activities of Daily Living. (Resident 13)Findings include:During an observation, on 1/13/26 at 10:00 a.m., upon entering Resident 13's room, there was a strong odor of urine and feces present. Observation of Resident 13 in bed, indicated the resident was lying on a draw pad under her which was observed to have a light brown stain that covered the whole pad, within an inch of the edges. The resident's brief and pad was observed to be saturated with urine. A second observation of the resident's room, on 1/13/26 at 2:30 p.m., the soiled pad remained on her bed and was still wet to the touch. The resident was in an activity at this time.During an observation of the resident and her bed, from 1/14/26 to 1/21/26, with a confidential informant, the resident's brief was observed to be heavily saturated with urine as well as the pad underneath her. The confidential informant indicated the resident was soaked and that she was going to change the resident and her bed even though it wasn't her section. During the confidential interview, it was indicated that this happened more often than it should as it seemed like night shift was not changing the residents before they left for the day. The informant indicated that upon arrival to their shift, the staff were supposed to do a walk through and checked the residents before starting their duties. If a resident was wet, the person responsible for that resident's care was notified the resident needed to be changed.The record for Resident 13 was reviewed on 1/15/26 at 9:30 a.m. The resident's diagnoses included, but were not limited to, Parkinson's disease without dyskinesia, rheumatoid arthritis, dementia, chronic pain, and history of urinary tract infections (UTIs).The Quarterly Minimum Data Set (MDS) assessment, dated 10/30/25, indicated the resident had severe cognitive impairment; occasionally felt down or depressed; was dependent on staff for toileting hygiene; was always incontinent of bladder, and was at risk for the development of pressure ulcers.A care plan, with a revision date of 1/14/26, indicated the resident was always incontinent of bowel and bladder and had large amounts of urine. The goal was for the resident to remain free from skin breakdown due to incontinence and brief use. The approaches included, but were not limited to, check as required for incontinence and observe and document number of voids.The Braden Scale for Predicting Pressure Sores, dated 11/6/25, indicated the resident was at moderate risk for pressure sores; sensory perception was slightly limited; skin was often very moist with linens needing to be changed at least once a shift; could not bear own weight and needed assistance into a wheelchair; the ability to change and control body position was slightly limited as the resident could make slight changes in body or extremity position independently; food intake pattern was inadequate as she rarely completed a meal and generally ate only half of any food offered; and, also was able to maintain relatively good position in her chair or bed most of the time but occasionally slid down.The physician's order, dated 7/4/24, indicated staff were to apply the house barrier cream to the resident's perineal area and the buttocks after each incontinent episode as needed and a pressure relieving mattress (6 inch foam mattress).During an interview, on 1/14/26 at 8:15 a.m., with the Certified Nurse Aide (CNA) 8 she indicated she had changed the resident when she first came on duty at 6:30 a.m. and that the resident was frequently incontinent of a large amount of urine.On 1/20/26 at 9:21 a.m., the Director of Nursing (DON) provided the January 2026 Medication Administration Record (MAR) for Resident 13. Review of this form indicated a skin assessment was checked off as being completed. The record lacked an actual assessment of what the skin looked like.3.1-41(a)(1)3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to ensure residents' choices for likes, dislikes and requests for special food items on their food trays cards were honored at every meal. This deficient practice affected 19 of 64 residents reviewed for tray cards. (Residents 7, 8, 9, 10, 13, 17, 20, 34, 38, 40, 51, 55, 57, 58, 62, 63 , 64, 65, and 66) Findings include:During an interview with Resident 7 on 1/13/26 at 9:45 a.m., she indicated that she frequently did not receive what was ordered on her tray card.During an interview with Resident 51 on 1/13/26 at 9:50 a.m., she indicated the kitchen was not following what was written on their tray cards. She indicated that her tray card, under dislikes, listed No Sausage or Eggs, but she still received them every morning anyway. She sent them back every time as she did not eat them. Observation of her tray card at this time, indicated sausage and eggs were listed under the dislike section. Observation of her plate indicated she received sausage and eggs for breakfast.During an observation of the main dining room lunch tray cards, on 1/13/26 between 12:45 p.m., and 1:30 p.m., the following concerns were observed:Resident 17's tray card indicated no green beans; she was given pureed green beans.Resident 20's tray card indicated he was to receive power mashed potatoes (fortified) and gravy; gravy was not on the tray.Resident 64's tray card indicated she was to have gravy with her meal; no gravy was served.Resident 62's tray card indicated no beans; was served green beans.Resident 58's tray card indicated he was to have extra gravy or sauce; gravy not on the meal tray.Resident 65's tray card indicated she was to receive a bowl of gravy with her meals; no gravy was on the tray.Resident 63's tray card indicated he wanted a grilled cheese and extra gravy with his meal; he did not receive either item.Resident 38's tray card indicated no green vegetables and extra gravy; he was given green beans and did not receive the gravy.Resident 34's tray card indicated the resident was to have peanut butter with every meal; he did not receive the peanut butter.An observation on 1/13/26 at 1:35 p.m. of Resident 40's tray card and meal tray indicated the tray card listed he did not want pasta. He was served puree pasta on his tray.During an observation of room meal trays and tray cards on 1/14/26 between 8:15 a.m. and 8:40 a.m., the following was observed:Resident 51's tray card indicated she was to get peanut butter with all meals. No peanut butter was on the tray. The resident at that time indicated she kept a stash of peanut butter because it was frequently not always on her tray as ordered.Resident 57's tray card indicated she did not like scrambled eggs and was crossed out on the card. Observation of her tray at that time indicated she was served scrambled eggs. The resident indicated that happened frequently that the kitchen served her items she had indicated she did not like. She also indicated that that was also the reason she had a lot of her food brought in from the outside. Resident 58's tray card indicated he was to have yogurt on his tray for breakfast. No yogurt was observed on the tray. After discussing the missing item from his tray with LPN 7 (Licensed Practical Nurse), she indicated she would go get him some yogurt.During the Resident Council meeting on 1/14/26 at 11:00 a.m., the residents indicated the kitchen was not honoring their food preferences and dislikes. The Resident Council President Resident 8 also indicated he ordered corn flakes every morning on his tray card and had never gotten it like he wanted.During an observation of room lunch meal trays and tray cards on 1/14/26 between 12:45 pm and 1:10 p.m., the following was observed:Resident 10's tray card indicated he was to receive fortified pudding at lunch and supper. No fortified pudding was on his tray.Resident 51's tray card indicated she was to receive power potatoes at lunch and supper every day. No potatoes were on her tray. She indicated at that time that she wondered what the power potatoes were and that she would have eaten them if they were on her tray.Resident 66's tray card indicated she was to have power potatoes. No potatoes were on her tray. LPN 7 indicated at that time that they were getting her some potatoes since they were not on her tray.Resident 58's tray card indicated he was supposed to have one cup of milk and extra gravy or sauce with his lunch. Neither item were on his meal tray.A random interview on 1/15/26 at 9:50 a.m. Resident 57 indicated she again received scrambled eggs on her tray even though it was listed as a dislike. When asked if she had notified anyone that she was continuing to receive scrambled eggs every morning and sent it back to get something else, she indicated she had not, as she did not want to been seen as a pest.On 1/15/26 at 1:05 p.m., Resident 55's family member voiced her concern over the resident having difficulty eating due to not following the items listed on his tray card. The card indicated he was a vegetarian who disliked eggs, gravy and meat. The family member indicated the resident did not eat meat and that previously, the facility used to send him tomato soup, but had since stopped. Now all they offered was chicken noodle soup which he could not eat. No other soup was offered. The family member indicated she had told several management staff about the issue but the kitchen continued to only offer chicken noodle soup. She also indicated that the company the facility used to stock food items, had little cans of tomato soup at one time. The family member indicated she would gladly heat up the soup for the resident when it came on his tray. The family member also indicated that it was extremely difficult to feed the resident his grilled cheese sandwich without being able to dunk it in the tomato soup to soften it. Right now she was having to dunk the sandwich in water to soften it.During an interview with the Dietary Manager, on 1/16/25 at 11:45 a.m., she was asked if it was possible to order small cans of tomato soup from their food distributor. She indicated that she could just place the soup on the order sheet and would come on the next truck in a few days. She did not know why it had been stopped being ordered. Also spoke with her regarding Resident 55's family request for tomato soup as the only soup being offered was chicken noodle soup which he could not eat. The Dietary Manager indicated everyone knew Resident 55 could not eat chicken noodle soup and that she would add tomato soup to his tray card when it came in.During this interview, the Dietary Manager also indicated the Registered Dietitian would see the resident right after admission or readmission or the next day or when changes occurred. She also indicated she saw each resident when first admitted to get their likes and dislikes and special requests. She indicated there was a check off sheet the dietary staff were supposed to follow to ensure all items were on the tray and the resident was not served something they did not like. When informed of there being several observations of the residents missing items on their tray or they were receiving food they did not like as listed on their tray card, she indicated the dietary staff must have been rushing when completing food trays and were not watching carefully.The Resident Rights given to all employees upon hire and yearly, indicated the following: .Living Accommodations and Care Rights: To receive care in a manner which promotes and enhances your quality of life. This includes food of the quantity and quality to meet your needs and preferences.The facility's current policy on Meal Identification and Preference Cars/Tickets, dated 2019, included, but was not limited to, Policy: A meal identification and food preferences card (meal ID card/ticket) will be used to properly identify each individual's needs including food and beverage preference.Procedure: 1. The Director of food and nutrition services or designee will visit a new admitted individual to obtain food and beverage preferences, dislikes and food allergies/intolerances before a permanent meal ID card/ticket is written.3. The permanent meal ID card/ticket should include the name of the individual, diet order, beverages preferences, food dislikes and any other applicable information.4. Meal ID card/tickets will be used during meal service to assure the correct diet is being served and food preferences are honored. 3.1-3(a)

Based on interview and record review, the facility failed to ensure an assessment was completed by a licensed nurse and authorization given to administer an as needed narcotic pain medication by a qualified medication aide for 1 of 3 residents reviewed for quality of care. (Resident C)Findings include:The clinical record for Resident C was reviewed on 9/3/25 at 9:55 a.m. The resident's diagnoses included, but were not limited to, fibromyalgia, depression and pain.The physician's order, dated 6/20/25, indicated the resident was to receive oxycodone with acetaminophen (narcotic pain medication) 7.5 mg (milligrams) every 4 hours as needed for pain.The August controlled drug record indicated the resident received the as needed pain medication on the following dates and times by Qualified Medication Aide (QMA) 10: 7/31/25 at 8:00 p.m., 8/01/25 at 12:00 a.m. and 4:00 a.m., 8/09/25 at 9:15 p.m., 8/10/25 at 12:30 a.m., 4:00 a.m. and 8:00 p.m., 8/11/25 at 12:00 a.m. and 4:00 a.m., 8/13/25 at 9:00 p.m., 8/14/25 at 12:00 a.m., 4:00 a.m. and 8:00 p.m., 8/15/25 at 12:00 a.m. and 4:00 a.m., 8/20/25 at 8:00 p.m., 8/21/25 at 12:00 a.m. and 4:00 a.m., 8/23/25 at 8:00 p.m., 8/24/25 at 12:00 a.m. and 4:00 a.m., 8/27/25 at 8:00 p.m., and 8/28/25 at 12:00 a.m. and 4:00 a.m.The clinical record lacked a resident assessment, by a licensed nurse, for the as needed pain medication and an authorized signature on the controlled drug record.During an interview, on 9/4/25 at 10:15 a.m., QMA 5 indicated a licensed nurse must assess the resident when the need for the as needed narcotic pain medication was requested and co-sign with the QMA on the controlled drug record.On 9/3/25 at 3:15 p.m., the Director of Nursing provided a current, undated copy of the document titled Qualified Medication Aide Scope of Practice. It included, but was not limited to, The following tasks are within the scope of practice for the QMA unless prohibited by facility policy .Administer previously ordered pro re nata (PRN) medication only if authorization is obtained from the facility's licensed nurse on duty or on call. If authorization is obtained, the QMA must do the following .Document in the resident record symptoms indicating the need for the medication and the time the symptoms occurred .Document in the resident record that the facility's licensed nurse was contacted, symptoms were described, and permission was granted to administer the medication, including the time of contact .Obtain permission to administer the medication each time the symptoms occur in the resident .Ensure that the resident's record is cosigned by the licensed nurse who gave permission by the end of the nurse's shift This Citation relates to Intake 26031163.1-37

Based on interview and record review, the facility failed to ensure misappropriation of resident property did not occur for 1 of 3 residents reviewed for misappropriation. (Resident B)Findings include:The clinical record for Resident B was reviewed on 9/2/25 at 2:24 p.m. The resident's diagnoses included, but were not limited to, diabetes, depression and chronic pain.The physician's order, dated 6/3/25, indicated the resident was to receive Hydrocodone-Acetaminophen (narcotic pain medication) 5-325 mg (milligrams) every 6 hours as needed for pain.Review of the pharmacy delivery receipt, dated 8/16/25 at 6:45 p.m., indicated the resident's 30 Hydrocodone-Apap (acetaminophen) 5-325 mg were delivered and signed for by LPN 6.The incident report, dated 8/16/25, indicated on 8/19/25 Registered Nurse (RN) 7 called the pharmacy to find out why a narcotic medication that was ordered for Resident B had not been delivered. The pharmacy reported that 30 tablets of the narcotic pain medication was delivered on 8/16/25. The pharmacy sent over the signature page which showed the narcotic pain medication was signed for by Licensed Practical Nurse (LPN) 6. The LPN (6) reported she did sign for the medication and gave it to LPN 9, who was responsible for Resident B's medication. An investigation was initiated.During an interview, on 9/3/25 at 9:52 a.m., Qualified Medication Aide (QMA) 5 indicated he had noticed the resident was getting low on her pain medication. He called the pharmacy for a refill, and the pharmacy told him they would send the medication out as the resident had a current script on file. At the change of shift on 8/16/25 at 6:30 p.m., QMA 5 informed LPN 9 he had ordered the pain medication for Resident B and she was to keep an eye out for it. On 8/17/25 at 7:15 a.m., QMA 5 was about 45 minutes late after the normal shift change and did not count the narcotics in the cart with LPN 9. LPN 8 had counted the narcotics in the cart with LPN 9. QMA 5 checked the cart to see if Resident B's pain medication had arrived and he could not locate the resident's pain medication. Since LPN 8 counted the cart with LPN 9, QMA 5 asked LPN 8 if the medication for Resident B had arrived. LPN 8 indicated to QMA 5 the medication was not there when she counted with LPN 9. QMA 5 figured it had not arrived yet. LPN 9 called the facility at 5:30 p.m. on 8/17/25 and told them she had quit. At the end of QMA 5 shift, on 8/17/25, LPN 11 and QMA 5 counted the narcotics in the cart. QMA 5 advised LPN 11 he had ordered Resident B's pain medication but it had not arrived to the facility yet. On Monday, 8/18/25, Resident B's pain medication had not arrived and it was reported it to RN 7 by QMA 5. RN 7 called the pharmacy and was advised the pain medication was sent on Saturday 8/16/25 at 6:45 p.m.During a telephone interview, on 9/3/25 at 10:53 a.m., LPN 6 indicated, on 8/16/25, she had seen the pharmacy delivery person at the nurse's station. She did not see LPN 9 on the hallway anywhere. She went to the nurse's station for the medication delivery and signed for Resident B's 30 Hydrocodone's tablets. The protocol was to sign for the medication and place a signed copy in a file, which she did. LPN 6 found LPN 9 and gave LPN 9 the medication for her to put in the residents medication cart.During a telephone interview, on 9/3/25 at 12:34 p.m., RN 7 indicated on Monday, 8/18/25, QMA 5 reported to her that he had ordered pain medication for Resident B early on 8/16/25 and as of 8/18/25 the pain medication had not arrived. RN 7 called the pharmacy and was advised the medication was sent to the facility on 8/16/25 and was signed by a facility staff member. RN 7 asked the pharmacy if they could send over a copy of the requisition on who had signed for the narcotic pain medication. The pharmacy sent over the requisition which was signed in by LPN 6. When RN 7 discovered the resident's medication was missing, she then notified the Director of Nursing that somewhere between Saturday night, 8/16/25 and Sunday morning, 8/17/25, Resident B's narcotic pain medication disappeared.During a telephone interview, on 9/4/25 at 10:00 a.m., LPN 8 indicated on the morning of Sunday, 8/17/25, when she arrived to work, LPN 9 asked her to count the narcotics with her so she could leave. LPN 8 and LPN 9 counted the narcotics in the medication cart and the residents' medication cards and sheet counts were correct.During an interview, on 9/3/25 at 12:02 p.m., the Director of Nursing (DON) indicated she was notified by RN 7 about the missing narcotic pain medication for Resident B. The DON initiated an investigation and requested a drug screen for QMA 5, LPN 6, RN 7, LPN 8, and LPN 11, which were all negative. LPN 9 had refused the drug screen via text message. On 9/2/25 at 10:22 a.m., the Director of Nursing provided a current copy of the document titled Resident Rights dated 12/2016. It included, but was not limited to, Policy Interpretation and Implementation .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to .be free from .misappropriation of property The Past noncompliance began on 8/16/25. The deficient practice was corrected by 8/20/25 after the facility implemented a systemic plan that included the following actions: A 30-day look back narcotic audit was completed on all residents (8/18/25); All nursing staff were educated on abuse and misappropriation of resident property (8/19/25); The facility Implemented a narcotic count the count sheet (8/19/25); Drug screens were completed (8/20/25).This Citation relates to Intakes 2579876 and 2597024.3.1-28(a)

Based on interview and record review, the facility failed to ensure a resident's (Resident C) medication administration record accurately reflected the administration of narcotic pain medication for 1 of 3 residents reviewed for documentation.Findings include: The clinical record for Resident C was reviewed on 9/3/25 at 9:55 a.m. The resident's diagnosis included, but was not limited to, fibromyalgia.The physician's order, dated 6/20/25, indicated the resident was to receive oxycodone with acetaminophen, 7.5 mg (milligrams) every 4 hours as needed for pain.The August 2025 controlled drug record indicated the resident received the medication on the following dates and times:-8/02/25 at 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/03/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m. and 4:00 p.m.-8/08/25 at 10:00 p.m.-8/09/25 at 2:00 a.m., 6:00 a.m., 10:15 a.m., 2:15 p.m. and 9:15 p.m.-8/10/25 at 12:30 a.m. and 12:00 p.m.-8/11/25 at 12:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/12/25 at 12:00 a.m., 4:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/13/25 at 12:00 a.m., 4:00 a.m., 12:00 p.m. and 9:00 p.m.-8/14/25 at 12:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/15/25 at 12:00 a.m., 12:00 p.m. and 8:00 p.m.-8/16/25 at 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/17/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/18/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 6:00 p.m. and 10:00 p.m.-8/19/25 at 12:00 a.m., 6:00 a.m. and 8:00 p.m.-8/20/25 at 12:00 a.m., 4:00 a.m. and 8:00 p.m.-8/21/25 at 12:00 a.m., 8:00 a.m. and 8:00 p.m.-8/22/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/23/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/24/25 at 12:00 a.m., 8:00 a.m., 12:00 p.m. and 4:00 p.m.-8/25/25 at 12:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/26/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.-8/27/25 at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.08/28/25 at 12:00 a.m., 8:00 a.m., 4:00 p.m. and 8:00 p.m.The August 2025 medication administration record for Resident C lacked documentation of the administration of the narcotic medication on the above dates and times.During an interview, on 9/4/25 at 2:18 p.m., Licensed Practical Nurse (LPN) 12 indicated when a resident's as needed pain medication was administered, the medication should be signed out on the controlled drug record and the medication administration record.On 9/4/25 at 12:24 p.m., the Director of Nursing provided a current copy of the document titled Documentation of Medication Administration dated 4/2007. It included, but was not limited to, The facility shall maintain a medication administration record to document all medications administered .A Nurse or Certified Medication Aide .shall document all medications administered to each resident on the resident's medication administration record .Administration of medication must be documented immediately after (never before) it is given .Documentation must include .Signature and title of the person administering the medication This Citation relates to Intake 2603116 3.1-50(a)(2)

Based on observation, interview and record review, the facility failed to provide a clean and sanitary kitchen. This had the potential to affect 59 of 59 residents that received food from the kitchen. Findings include: On 1/21/25, between 11:35 a.m. and 12:03 p.m., the following concerns were observed in the kitchen: -Upon entrance to the dry storage area and to the left, rodent droppings and jelly packets were observed behind the shelves along the wall. -Behind the shelving, on the right side of the storage area, rodent droppings and condiment packets were observed. -Under the shelf where the large canned foods were kept was, a rodent trap that contained a rodent was observed. Directly behind the trap was a potato on the floor. -In the kitchen area, to the right of the ice machine, rodent droppings were observed in the corner. During an interview on 1/21/25 at 2:05 p.m., the Dietary Manager indicated there was not a cleaning schedule for the Month of January 2025. They had switched to a new system with more detailed forms, however the new forms had not been implemented yet. She could not locate the deep cleaning schedule for the month of December 2024. On 1/22/25 at 3:15 p.m., the Executive Director provided a current copy of the document titled Sanitization dated 10/2008. It included, but was not limited to, Policy Statement .The food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents This Citation relates to Complaint IN00449149 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure a resident's (Resident B) medications were available, in a timely manner, for 1 of 3 residents reviewed for discharges. Findings include: The clinical record for Resident B was reviewed on 1/21/25 at 10:04 a.m. The resident's diagnoses included, but were not limited to, congestive heart failure, acute respiratory failure with hypoxia, heart disease, diabetes, hypertension and atrial fibrillation. The progress note, dated 12/28/24 at 10:31 a.m., indicated the resident was discharged from the facility to her home. The resident's medication orders were faxed to the pharmacy of choice. During an interview on 1/21/25 at 10:35 a.m., the complainant indicated the resident's medication list did not get sent to the pharmacy. Prior to the resident discharge, he asked about medications to take with her but was told it was not facility policy, but that the resident's medications were faxed to the pharmacy. He called the facility the next day and was told they would fax the medications over to the pharmacy again. That next day, the pharmacy indicated they did not receive the medication list. He went to the facility on the Wednesday after discharge (1/1/25) because the pharmacy never received the medication list. The facility did provide some medications that they had on stock. During an interview on 1/22/25 at 9:59 a.m., the Director of Nursing indicated she could not locate the fax confirmation where the residents medication list was sent to the pharmacy. She indicated the progress note said they were faxed. The next day, the family member called and said the pharmacy did not have the medication list. They refaxed the list again. The family member called again on Monday (12/31/24) due to the pharmacy reported they had not received the medication list. We told him to come to the facility and he was given the medications for the resident that were still at the facility. If a resident was Medicare, the facility pays for the medications. Once discharged , the medications are returned for credit. The facility will send a 3-day supply if requested. On 1/22/25 at 10:40 a.m., a request was made for a copy of family signature for the medications that were provided. The Director of Nursing indicated they only have the family sign for narcotics, but she would look for the paperwork. On 1/22/25 at 2:05 p.m., the Director of Nursing indicated the family picked up the resident's medications except for the as needed medications which were narcotics. Medications did not have to be signed for unless they are narcotics. On 1/22/25 at 3:20 p.m., the Director of Nursing indicated the family wanted the medications sent to their pharmacy of choice. The policy stated that only with a physician's order could medications be sent home with residents that are Medicare and Resident B did not have a physician's order. On 1/22/25 at 2:36 p.m., RN 8 provided a current copy of the document titled Discharge Medications dated 12/2016. It included, but was not limited to, Policy Statement .Unless otherwise specified by facility policy, or contrary to current law or regulations, medications shall be sent with the resident upon discharge On 1/22/25 at 2:56 p.m., RN 8 provided a current copy of the document titled Discharge Medications dated 1/2023. It included, but was not limited to, Policy .Medications will be sent with a discharged or transferred resident only under conditions which protect the resident and assure compliance with the law .For medications to be sent with a resident, the physician's discharge or transfer order must state which medications may be sent .For Medicare A residents, only a 5 day supply will be sent home This Citation relates to Complaint IN00450387 3.1-12(a)(21)

Based on observation, interview and record review, the facility failed to ensure residents' drawers were free of rodent droppings for 2 of 3 residents reviewed for sanitary environment. (Resident F and Resident G) Findings include: 1. The clinical record for Resident F was reviewed on 1/21/25 at 1:35 p.m. The resident's diagnoses included, but were not limited to, diabetes, hypertension and anemia. During an interview on 1/21/25 at 11:02 a.m., the resident indicated he believed the mouse problem had been taken care of as he had not seen any lately. During an observation on 1/12/25 at 11:03 a.m., the following concerns were observed: - The top drawer of the resident's night stand had multiple storage containers with snacks and crackers. The bottom of the drawer was observed with rodent droppings. - The middle drawer of the night stand was empty with rodent droppings on the bottom. - The bottom drawer of the night stand contained personal hygiene items. Rodent droppings were observed on the bottom. - The top drawer of the chest was observed with storage containers with snacks. The drawer had rodents droppings in the bottom of it. During an interview on 1/21/25 at 11:10 a.m., Staff Member 7 indicated there had been a rodent problem for a couple of months. She had went through all the resident drawers, cleaned and placed items in totes not too long ago. 2. The clinical record for Resident G was reviewed on 1/22/25 at 9:55 a.m. The resident's diagnoses included, but were not limited to, left dominant side hemiparesis, diabetes and multiple sclerosis. During an interview on 1/21/25 at 10:53 a.m., the resident indicated the last time she had seen a mouse was in the bathroom. She could not recall exactly when that was. There was definitely an issue with mice. On 1/21/25 at 10:55 a.m., the following concerns were observed: - In the top drawer of the night stand was a storage container with a lid. Rodent droppings were observed on the lid of the container and on the bottom of the drawer. - The middle drawer of the night stand was observed with rodent droppings. Review of the facility pest control logs indicated pest services were provided to the facility on 11 different occasions between 11/1/24 and 1/16/25. This Citation relates to Complaint IN00449149 3.1-19(a)

Based on observation, interview, and record review, the facility failed to follow guidelines related to dishwasher temperatures for 2 of 2 kitchen observations, infection control during dining for 1of 3 dining observations, and to maintain a resident snack refrigerator in a sanitary manner for 1 of 2 resident snack refrigerators observed. This deficient practice had the potential to affect 55 of 55 residents who received food from the kitchen. Findings include: 1. During an observation and interview of the dishwasher on 12/03/24 at 9:30 A.M., the Dietary Manager indicated there was a wash and rinse valve to monitor for the temperatures on the dishwasher. The valve indicated the rinse temperature was at 140 degrees. The Dietary Manager indicated the dishwasher temperature for the rinse cycle should be 180 degrees. She was going to have the staff stop washing the dishes and have the Maintenance Director look at it. The Dish Machine daily Temperature Record Logs for November 2024 indicated from 11/01/24 through 11/27/24 for breakfast, lunch, and dinner the rinse temperature was less than 180 degrees. During an observation and interview on 12/04/24 at 9:25 A.M., the dishwasher had the following rinse temperatures: - 140 degrees, - 160 degrees, and - 175 degrees. The Dietary Manager indicated she had in-serviced staff on reading the final rinse gauge as it was a different one then the one she had showed the day before. She was unsure why the temperature was not reaching 180 degrees. She told the staff to stop washing dishes until the maintenance director looked at it again. Her staff would rewash the dishes once the machine reached the appropriate temperature. The current facility policy titled, Dishwashing Machine Use, with a revision date of March 2010, was provided by the Administrator on 12/04/24 at 11:06 A.M. The policy indicated, .Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation .Dishwashing machine hot water sanitation rinse temperatures may not be more than 194 degrees, or less than: 180 degrees . 2. During a continuous observation on 12/03/24 from 11:28 A.M. through 11:48 A.M., the following was observed: - At 11:28 A.M., the food cart was delivered to the 100 Hallway. At 11:29 A.M., CNA 11 pushed the cart down the hall, opened the cart and took a tray into Resident 51's room. At 11:42 A.M., CNA 11 was in the hallway at the food cart. She adjusted her pants with both hands, retrieved a milk from the tub with her right hand, replaced the milk in the tub, retrieved a coffee cup with her right hand, and put coffee creamer in the cup. She squatted down and placed her right hand on her right knee, retrieved a sugar packet with her left hand, and used both hands to put the sugar in the coffee cup. She poured coffee into the cup and served the tray to a resident. At 11:44 A.M., CNA 11 retrieved a towel and cleaned spilled coffee off the floor in the hallway with her bare hands, placed the towel in a bag, and took the bag to the soiled utility room. She fixed her glasses with her right hand, fixed her shirt with both hands, touched a couple of meal tray cards in the meal cart, removed a tray from the cart, and served it to Resident 38. At 11:48 A.M., the CNA 11 retrieved an over the bed table out of a quiet room and placed it in front of Resident 54 and served her a meal tray. The CNA never washed or sanitized her hands during the meal service. During an interview on 12/09/24 at 1:52 P.M., CNA 12 indicated when serving resident's their meal trays she would wash her hands before started. If she had touched anything on herself or cleaning up spills then she would wash or sanitize her hands. The current facility policy titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, with a revision date of October 2017, was provided by the Director of Nursing on 12/10/24 at 10:17 A.M. The policy indicated, .All employee who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing forborne illness .Employee must wash their hands .After personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc .After engaging in other activities that contaminate the hands . 3. During an observation on 12/09/24 at 2:01 P.M., the resident snack refrigerator on the 100 Hallway contained the following items: - a plastic container that contained food that belonged to room [ROOM NUMBER] with no date on it, - two undated, plastic food containers with food in them that belonged to room [ROOM NUMBER], - 1/2 pumpkin pie with a use by date of 12/02/24, - 1/2 pecan pie with a use by date of 12/02/24, - left over dinner plate on the bottom shelf that belonged to Resident 52, that was dated 12/05/24, - a Styrofoam container labled for Resident 53 that was dated 11/28, - a plastic circle food container that contained food for Resident 53 that was dated 11/28, and - three rectangular plastic food containers that contained food for Resident 53 that were in a plastic bag, dated 11/28. During an interview on 11/09/24 at 2:03 P.M., RN 5 indicated food should be thrown out after three days. The night shift staff were to clean the refrigerators on Mondays, Wednesdays, and Fridays. There was a sign on the refrigerator to remind them. The undated sign from the refrigerator was provided by the Director of Nursing on 12/10/24 at 9:50 A.M. The sign indicated, .All items in the refrigerator must have a name and date on them. Any item not dated, or the date exceeds 3 day[s] will be thrown away. Per state law. 3RD SHIFT CNA'S You are to clean out the refrigerators on Monday, Wednesday, and Friday . The current facility policy titled, Food Brought by Family/Visitors with a revised date of October 2017, was provided by the Director of Nursing on 12/10/24 at 9:50 A.M. The policy indicated, .The nursing staff will discard perishable foods on or before the use by date . 3.1-21(i)(3)

Based on observation and interview, the facility failed to ensure the equipment in resident rooms were kept clean for 6 of 26 rooms reviewed for environment. (Rooms 105, 107, 111, 114, 115, and 120) Findings include: During a tour of the facility on 12/4/24 at 11:00 a.m., the 100 and 200 Halls had several rooms observed to have a black spotty substance covering most of the slats on the following heater vents: - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. - room [ROOM NUMBER] had a black substance covering the heater vents. During an interview on 12/4/24 at 9:46 a.m., Resident 47 indicated she had black mold on her heater vents. When she woke up in the mornings the first thing she did was to start sneezing. During an observation on 12/5/24 at 10:00 a.m., in room [ROOM NUMBER] with the Maintenance Supervisor, he indicated the black substance on the heater vent was not black mold and it was dirt buildup. He did not have a cleaning schedule for when the vents needed cleaned. The staff would let him know when the vents were dirty and maintenance would clean them. During an interview on 12/5/24 at 1:22 p.m., CNA (Certified Nursing Aide) 4 indicated the nursing staff did not clean the heater vents. They would inform maintenance if they needed clean. She was not aware of any vents that needed cleaned. During an interview on 12/6/24 at 11:00 a.m., RN 5 indicated staff could clean the heater vents if they observed them dirty. They would also let the maintenance department know when they needed cleaned. She was not aware the vents were dirty. The Maintenance Director Job Description, dated 2023, included, but was not limited to, .To assist to maintain the physical plant, grounds, and all equipment in good working order to ensure a safe, attractive, and enjoyable living environment for the resident of the facility and in accordance with current Federal, State, and local standards governing the facility . 3.1-11

Based on record review and interview, the facility failed to complete discharge Minimum Data Set (MDS) assessments for 2 of 19 MDS's reviewed. (Residents 14 and 25) Findings include: 1. The clinical record for Resident 14 was reviewed on 12/09/24 at 10:23 A.M. The resident's census indicated they were admitted to the facility on [DATE] and discharged with no anticipated return on 07/01/24. The MDS listings lacked a completed discharge assessment. 2. The clinical record for Resident 25 was reviewed on 12/09/24 at 10:26 A.M. The resident's census indicated they were admitted to the facility on [DATE] and discharged with no anticipated return on 07/01/24. The MDS listings lacked a completed discharge assessment. During an interview on 12/09/24 at 10:52 A.M., the MDS Coordinator indicated if a resident discharged from the facility then a discharge assessment should be completed. The discharge assessments for residents 14 and 25 had been missed and should have been completed. The current facility policy titled, Resident Assessment Instrument, with a revised date of September 2021, was provided by the Director of Nursing on 12/09/24 at 2:07 P.M. The policy indicated, .The Assessment Coordinator is responsible for ensuring that the Interdisplinary Assessment Team conduct timely resident assessments . 3.1-31(d)

Based on observation, interview, and record review, the facility failed to prevent a skin impairment for 1 of 17 residents reviewed for quality of care. (Resident 3) Findings include: During and observation on 12/06/24 at 1:47 P.M., Resident 3 was assisted with peri care. The resident had a bandage to the right bottom of the buttock. The dressing was clean and dry. The bandage was dated 12/06/24. The clinical record for Resident 3 was reviewed on 12/05/24 at 11:46 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 11/08/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, stroke, anemia, hemiplegia/hemiparesis, and depression. The resident was always incontinent of bowel and bladder. A Progress Note, dated 10/23/24 at 12:53 A.M., indicated a Certified Nurse Aide (CNA) had reported an open area to the resident's upper right posterior thigh from the brief. The area measured 2.5 centimeters (cm) X (by) 1.0 cm X 0.2 cm. The area was cleansed and covered with a foam dressing. Wound Care was notified, and they were awaiting orders. A Wound MD Note, dated 10/23/24, indicated the resident had a non-pressure wound to the right buttock from brief trauma. The wound measured 0.6 cm X 3 cm X 0.1 cm. A treatment order was initiated, daily. A Wound MD Note, dated 11/27/24, indicated the resident had a non-pressure wound to the right buttock. The wound measured 0.8 cm X 1 cm X 0.1 cm. The treatment remained the same. A Care Plan, with a start date of 10/24/24, indicated the resident had a non-pressure injury to her right buttock that included the following interventions that started on 10/24/24: - administer medications per the physician's order, - contact the physician as needed, - encourage 100% of meal and fluid consumption, - encourage and assist with turning and repositioning every two hours as needed, - observe for signs and symptoms of infection, - treatments per the physician's order, and - weekly skin assessments. During an interview on 12/09/24 at 9:32 A.M., CNA 7 indicated the resident required total staff assistance with all care. She was incontinent of bowel and bladder and had a wound on the back side of her right leg. During an interview on 12/09/24 at 9:42 A.M., the Infection Preventionist/Wound Nurse, indicated the wound MD had classified the wound to the resident as trauma from the brief. She believes it was a trauma from friction of the brief not being placed properly or the resident was wearing the wrong size brief that day. The staff were not in-serviced on any brief placement or correct brief sizing. During an interview on 12/09/24 at 9:47 A.M., CNA 8 indicated the resident required a mechanical lift for transfers, was a total assist with care, was incontinent. The resident had a wound under her right buttock. She thought the wound was from the resident's brief not being positioned right. She was unsure if there was education on correct brief placements. During an interview on 12/09/24 at 10:04 A.M., the Director of Nursing (DON) indicated she believed the residents wound was from how the staff were applying the resident's brief. The resident was followed by the Wound MD. She was unsure if any staff were in-service related to brief placement, and she would not have updated the care plan with any interventions related to the brief placement or size. During an interview on 12/09/24 at 10:09 A.M., CNA 9 indicated if she needed to get residents more briefs because they were out in their room, she would look to see what size they had on. She had never had to get a resident more briefs because the night shift always put them in the resident's closets. During an interview on 12/09/24 at 10:13 A.M., the Facility Central Supply indicated if a resident ran out of briefs in their room, then the staff would go by what size the resident had on them. There was not a list saying what size brief residents wore for the staff working the floor. When a resident came to the facility the CNAs would measure them and let her know what size brief they needed and then she would order them. If a resident changed sizes, then she would be updated by the CNAs. She was never aware that Resident 3 needed new brief sizes and had not order her a different size in the last 6 months. The current facility policy titled, Urinary Continence and Incontinence-Assessment and Management, with a revised date of September 2021, was provided by the DON on 12/10/24 at 11:10 A.M. The policy indicated, .The staff and practitioner will appropriately screen for, and manage individuals with urinary incontinence .A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin . The current facility policy titled, Perineal Care, with a revised date of February 2018, was provided by the DON on 12/10/24 at 11:10 A.M. The policy indicated, .The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . 3.1-37(a)

Based on observation, record review and interview, the facility failed to ensure the proper dose was administered related to priming the needel for the insulin kwikpens and following the physician's order for 2 of 2 resident's observed for pharmacy services. (Residents 160 and 56) Findings include: 1. During an observation on 12/5/24 at 11:00 a.m., LPN (Licensed Practical Nurse) 10 obtained Resident 160's blood sugar by glucometer. The blood sugar reading was 263 mg/dL (milligrams per deciliter). The LPN applied the needle to the Humalog kwikpen and dialed the pen to 3 units. She did not prime (dial the kwikpen to 2 units and press to remove air) the needle prior to administering 3 units of Humalog into the resident's right upper arm. During an interview on 12/5/24 at 11:15 a.m., LPN 10 indicated she had administered 4 units, then corrected herself and confirmed she had only administered 3 units of insulin to the resident. The LPN planned to administer another unit. During an observation on 12/5/24 at 11:20 a.m., LPN 10 applied the needle to the Humalog kwikpen. The LPN administered 1 more unit into Resident 160's right upper arm. She did not prime the needle prior to administering 1 unit of Humalog. The physician's order, dated 11/20/24, indicated staff were to administer the resident's Humalog kwikpen per sliding scale: If the resident's blood sugar level was 150 to 199 mg/dL give 2 units; 200 to 249 mg/dL give 3 units; 250 to 299 mg/dL give 4 units; 300-349 mg/dL give 5 units; 350 to 400 mg/dL give 6 units; 400 mg/dL plus give 7 units, subcutaneously before meals and at bedtime related to diabetes mellitus. 2. During an observation on 12/5/24 at 11:27 a.m., LPN 10 entered Resident 56's room. The resident indicated he had self obtained a high blood sugar reading. The LPN indicated she would have to obtain the blood sugar reading herself by glucometer. The blood sugar reading was 518 mg/dL when the LPN obtained the reading. The LPN indicated she would administer a total of 12 units of insulin. The LPN obtained the resident's lispro kwikpen and attempted to dial the 12 units. There was only 5 units left. She injected the 5 units of lispro into the resident's left upper arm, without priming the kwikpen needle. During an observation on 12/5/24 at 11:45 a.m., LPN 10 obtained Resident 56's lispro kwikpen from the refrigerator. She applied the needle to the kwikpen and dialed the remaining 7 units. The LPN did not prime the needle prior to administering the lispro into the resident's left upper arm. The physician's order, dated 10/14/24, indicated staff were to administer 7 units of the resident's lispro kwikpen subcutaneously before meals related to type 1 diabetes mellitus. The physicians' order, dated 11/2/24, indicated staff were to administer the resident's lispro kwikpen per sliding scale: If the resident's blood sugar was 150 to 225 mg/dL give 1 unit; 226 to 301 mg/dL give 2 units; 302 to 377 mg/dL give 3 units; 378-453 mg/dL give 4 units; 454 to 529 mg/dL give 5 units, subcutaneously before meals and at bedtime related to type 1 diabetes mellitus. During an interview on 12/5/24 at 11:51 a.m., LPN 10 indicated she did not prime the needle prior to administration. She should prime the needle with 5 units to make sure the resident received all of their insulin, in case there was air in the needle. During an interview on 12/5/24 at 1:58 p.m., the DON (Director of Nursing) indicated the staff should follow the physician's orders when administering insulin. She felt the insulin kwikpens did not require priming, as that was already built in. The Instructions For Use Humalog Kwikpen injection, for subcutaneous use 3 mL [milliliters] single-patient-use pen (100 units per mL), last copyrighted in 2023, included, but was not limited to, . Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units . The Insulin Administration policy, revised September 2014, included, but was not limited to, . 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order . Steps in the Procedure (Insulin Injections via Syringe) . 8. Check the order for amount of insulin . 12. Double check the order for the amount of insulin . 3.1-25(b)(9)

Based on interview and record review, the facility failed to ensure residents meal consumptions were documented, per the plan of care, for 2 or 3 residents reviewed for medical records. (Resident B and Resident C) Findings include: 1. The clinical record for Resident B was reviewed on 10/11/24 at 12:27 p.m. The resident's diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease and depression. The care plan, dated 7/1/20, indicated the resident required setup assistance with meals and to monitor/document percentage eaten. Review of the August 2024 meal consumption record indicated the resident's following meal consumptions were not documented on the following dates: - On 8/01/24, the resident's consumption for dinner was not documented. - On 8/02/24, the resident's consumption for dinner was not documented. - On 8/05/24, the resident's consumption for dinner was not documented. - On 8/06/24, the resident's consumption for dinner was not documented. - On 8/07/24, the resident's consumption for lunch was not documented. - On 8/09/24, the resident's consumption for dinner was not documented. - On 8/14/24, the resident's consumption for breakfast and lunch were not documented. - On 8/15/24, the resident's consumption for breakfast and lunch were not documented. - On 8/18/24, the resident's consumption for lunch was not documented. - On 8/25/24, the resident's consumption for breakfast and lunch were not documented. - On 8/30/24, the resident's consumption for breakfast and lunch were not documented. Review of the September 2024 meal consumption record indicated the resident's following meal consumptions were not documented on the following dates: - On 9/02/24, the resident's consumption for breakfast and lunch were not documented. - On 9/03/24, the resident's consumption for breakfast and lunch were not documented. During an interview on 10/15/24 at 2:35 p.m., CNA (Certified Nursing Aide) 5 indicated all resident meals should be documented in the system. 2. The clinical record for Resident C was reviewed on 10/11/24 at 1:20 p.m. The resident's diagnoses included, but were not limited to, dementia, depression and left sided hemiplegia and hemiparesis. The care plan, dated 10/21/22, indicated the resident required set up assistance will meals and to monitor/document percentage eaten. Review of the August 2024 meal consumption record indicated the resident's following meal consumptions were not documented on the following dates: - On 8/01/24, the resident's consumption for dinner was not documented. - On 8/02/24, the resident's consumption for dinner was not documented. - On 8/05/24, the resident's consumption for dinner was not documented. - On 8/07/24, the resident's consumption for lunch was not documented. - On 8/09/24, the resident's consumption for dinner was not documented. - On 8/11/24, the resident's consumption for dinner was not documented. - On 8/12/24, the resident's consumption for breakfast and lunch were not documented. - On 8/14/24, the resident's consumption for lunch was not documented. - On 8/15/24, the resident's consumption for breakfast and lunch were not documented. - On 8/25/24, the resident's consumption for breakfast and lunch were not documented. - On 8/30/24, the resident's consumption for breakfast and lunch were not documented. Review of the September 2024 meal consumption record indicated the resident's following meal consumptions were not documented on the following dates: - On 9/02/24, the resident's consumption for breakfast and lunch were not documented. - On 9/03/24, the resident's consumption for breakfast and lunch were not documented. - On 9/06/24, the resident's consumption for breakfast and lunch were not documented. - On 9/08/24, the resident's consumption for dinner was not documented. - On 9/09/24, the resident's consumption for breakfast and lunch were not documented. - On 9/10/24, the resident's consumption for breakfast, lunch, and dinner were not documented. - On 9/13/24, the resident's consumption for dinner was not documented. - On 9/14/24, the resident's consumption for dinner was not documented. - On 9/15/24, the resident's consumption for lunch and dinner were not documented. - On 9/16/24, the resident's consumption for breakfast, lunch, and dinner were not documented. - On 9/19/24, the resident's consumption for breakfast and lunch were not documented. - On 9/22/24, the resident's consumption for breakfast and lunch were not documented. - On 9/24/24, the resident's consumption for dinner was not documented. - On 9/25/24, the resident's consumption for lunch was not documented. - On 9/28/24, the resident's consumption for dinner was not documented. Review of the October 2024 meal consumption record indicated the resident's following meal consumptions were not documented on the following dates: - On 10/01/24, the resident's consumption for breakfast, lunch, and dinner were not documented. - On 10/02/24, the resident's consumption for breakfast and lunch were not documented. - On 10/03/24, the resident's consumption for breakfast, lunch, and dinner were not documented. - On 10/04/24, the resident's consumption for dinner was not documented. - On 10/07/24, the resident's consumption for breakfast and lunch were not documented. - On 10/08/24, the resident's consumption for lunch was not documented. - On 10/09/24, the resident's consumption for breakfast and lunch were not documented. - On 10/10/24, the resident's consumption for breakfast and lunch were not documented. - On 10/13/24, the resident's consumption for breakfast and lunch were not documented. On 10/15/24 at 11:26 a.m., the Director of Nursing provided a current copy of the document titled Nutrition (Impaired).Unplanned Weight Loss - Clinical Protocol: dated 9/2017. It included, but was not limited to, The nursing staff will .document the .dietary intake of residents in a format which permits comparisons over time On 10/15/24 at 3:15 p.m., the Infection Preventionist provided a current copy of the document titled Preparing the Resident for a Meal dated 9/2010. It included, but was not limited to, The purpose of this procedure is to prepare the resident .in order to help make meal time pleasant for the resident .Documentation .The date and time .How the resident tolerated the procedure This Citation relates to Complaint IN00442568 3.1-50(a)(1)

Based on interview and record review, the facility failed to ensure appropriate interventions were implemented, in a timely manner, for a resident (Resident B) who was at a moderate risk for pressure ulcers, which resulted in a stage 2 pressure ulcer (partial thickness skin loss of the epidermis, dermis, or both) of the right heel that progressed to an unstageable pressure ulcer (localized area of tissue necrosis which develops when soft tissue is compressed for extended periods of time), an unstageable pressure ulcer of the left outer ankle, a deep tissue injury (injury to the soft tissue under the skin due to pressure) of the right lateral foot, a stage 2 pressure ulcer to the right buttock, and an unstageable pressure ulcer of the coccyx for 1 of 3 residents reviewed for pressure ulcers. Findings include: The clinical record for Resident B was reviewed on 10/19/21 at 11:20 a.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/9/21 MDS (Minimum Data Set) admission assessment indicated the resident required an extensive two person physical assistance with bed mobility. The Braden Observation Tool, dated 7/9/21, indicated a moderate risk for pressure ulcers as the resident was occasionally moist, bedfast, had very limited mobility, probably inadequate nutrition, and a problem with friction and shearing. The 7/7/21 admission assessment indicated a surgical incision to the right hip and a reddened area to right buttock. The admission note, dated 7/7/21 at 3:45 p.m., indicated the resident had 4 x 4's on her heels and ankles as a preventive measure and had no reported open areas. The care plan, dated 7/21/21, indicated the resident was at risk for skin breakdown and to administer medications as ordered, encourage adequate food intake, encourage the resident to get out of bed for a few hours each day, and to turn and reposition every 2 hours and upon resident request. The weekly skin assessment, dated 7/29/21, indicated an open area to the right buttock. The nurses note, dated 8/4/21 at 8:00 a.m., indicated the resident had a stage 2 pressure ulcer on the right heel and an unstageable pressure ulcers to the left outer ankle. The care plan, dated 8/4/21, indicated the resident had a pressure ulcer to right heel and to observe for signs/symptoms of infection, healing, and pain and to complete treatments as ordered. Review of the weekly wound sheets for the stage 2 of the right heel, acquired on 8/4/21, indicated the following measurements: 8/05/21 - 2 cm (centimeters) in length, 2 cm in width with a depth of 0.1 cm 8/10/21 - 2.5 cm in length, 2.7 cm in width with no depth 8/18/21 - 3 cm in length with a width of 2.7 cm (area reclassified as an unstageable pressure ulcer) 8/24/21 - 3 cm in length with a width of 3.5 cm 8/30/21 - 2.5 cm in length with a width of 2.9 cm 9/08/21 - 3.4 cm in length with a width of 2.5 cm 9/14/21 - 3 cm in length with a width of 2.8 cm 9/20/21 - 3.5 cm in length with a width of 2.5 cm 9/27/21 - 3 cm in length with a width of 3 cm 10/5/21 - 3.4 cm in length with a width of 3 cm Review of the weekly wound sheets for the unstagebale pressure ulcer of the left outer ankle, acquired on 8/4/21, indicated the following measurements: 8/05/21 - .5 cm in length with a width of 0.4 cm 8/10/21 - no change 8/18/21 - no change 8/24/21 - no change 8/30/21 - 0.2 cm in length with a width of 0.2 cm 9/08/21 - area healed The physician order, dated 8/17/21, indicated the resident was to have heel boots to bilateral heels at all times. The care plan, dated 8/18/21, indicated the resident had a deep tissue injury to the right lateral foot and to observe for signs and symptoms of healing/pain and to complete treatments as ordered. Review of the weekly wound sheets for the deep tissue injury of the right lateral foot, acquired on 8/18/21, indicated the following measurements: 8/18/21 - 0.6 cm in length with a width of 0.5 cm 8/24/21 - no change 8/30/21 - no change 90/8/21 - no change 9/14/21 - no change 9/20/21- 0.6 cm in length with a width of 0.2 cm 9/27/21- 1.5 cm in length with a width of 0.5 cm 10/5/21 - 0.8 cm in length with a width of 0.6 cm Review of the weekly wound sheets for the stage 2 pressure ulcer of the right buttock, acquired 7/28/21 as an abrasion, indicated the following measurements: 9/08/21 - 4 cm in length with a width of 4.5 cm 9/14/21 - 2.5 cm in length with a width of 3.5 cm 9/20/21 - 1.5 cm in length with a width of 0.5 cm 9/27/21 - 1 cm in length with a width of 1 cm 10/5/21 - area healed The physician order, dated 9/14/21 at 1:05 p.m., indicated the resident was to have a low air loss mattress. The care plan, dated 9/15/21, indicated the resident had a pressure area to coccyx and to monitor for signs of healing and pain and to complete treatments as ordered. Review of the weekly wound sheets for the unstageable pressure ulcer of the coccyx, acquired 9/15/21, indicated the following measurements: 9/20/21 - 5 cm in length with a width of 3 cm 9/27/21 - 2.7 cm in length with a width of 2 cm 10/5/21 - 5 cm in length with a width of 3.5 cm During an interview on 10/20/21 at 10:01 a.m., the Director of Nursing indicated, from her understanding, the resident had the heel wound on admission, but it was not documented and that they put heel boots on the resident. The resident refused to get out of bed, would not get up, and kept saying she wanted to die. She would not eat or drink and was getting new areas every week. They tried to get the family to put the resident on hospice due to her decline, but they would not. The clinical record lacked any other implemented wound prevention interventions, physician evaluation/wound progression documentation, documentation of resident refusal of care, a plan of care related to refusals of care, or any documented conversations with the family with regards to hospice until 9/22/21. On 10/22/21 at 2:30 p.m., the Director of Nursing provided a current copy of the document titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated April 2018. It included, but was not limited to, Monitoring .During visits, the physician will evaluate and document the progress of wound healing .physician will guide the care plan .when wounds are not healing .or new wounds develop despite existing interventions .Current approaches should be reviewed for whether they remain pertinent This Federal tag relates to Complaint IN 316 3.1-40(a)(1)

Based on record review, interview and observation the facility failed to ensure the hand brakes were functioning properly for 1 of 2 residents reviewed using a sliding board from the bed to the wheelchair who sustained a fall,when the brakes failed,with a fractured femur above the knee and 11 stitches to the right foot. (Resident B) This deficient practice had the potential to affect 59 of 73 residents who utilize wheelchairs with hand brakes. Findings include: During the initial tour on 8/11/11 between 8:15 a.m. and 9 a.m., Resident B was resting in her bed. LPN #1 indicated Resident B was alert and oriented x 3. 1 person assist with activities of daily living. The resident went out to the hospital on [DATE] after a fall. She had a cracked femur above the knee and 11 stitches under her toes on the right foot. The CNA (certified nurse assistant) Assignment Sheet indicated the resident was on a functional maintenance plan which included, but was not limited to a sliding board for transfers. The clinical record for Resident B was reviewed on 8/12/11 at 10:30 a.m. The resident's [DIAGNOSES REDACTED]. Nurses Notes included, but were not limited to: 8/9/11 9:30 a.m. "CNA approached this nurse to tell me res was on the floor. Upon entering room res lying on back with pillow under her head. Blood noted between 1st, 2nd & 3rd toes on R foot. Head to toe assesment (sic) completed c/o (complains of) pain in her R knee. res was transferring between bed & w/c using sliding board, both brakes were locked. CNA present with res as she was sliding down the board w/c rolled backwards causing resident to fall with her R leg twisting in an angle at her knee joint. Denies hitting her head... The resident was sent out to the ER for eval and treat. The resident returned to the facility at 5:30 p.m. "11 stitches from toes on R foot in 10 days..." On 8/12/11 at 11 a.m., in interview with the DON, she indicated the resident was on a sliding board for a transfer from the bed to the chair. CNA #1 was with the resident. The wheelchair was not the residents, but a communal chair from physical therapy. The brakes disengaged during the transfer. The brakes malfunctioned. One end of the sliding board slipped cut her foot. Wheelchairs are to be checked every week when cleansed by the 3rd shift. A fall details report provided by the DON on 8/12/11 at 12:10 p.m., included, but was not limited to: Nurse's Note of what happened written by LPN #2 entered by LPN#3 on 8/9/11 at 14:38 (2:38 p.m.): " resident was transferring from bed to w/c (wheel chair) using sliding board. both (sic) brakes were locked on w/c. As resident was sliding down board, w/c rolled backward causing resident to fall. her (sic right leg twisted under her at the knee. complained (sic) of knee pain. left (sic) on floor due to possible fracture. sent (sic) to (named) hospital ER (emergency room ) for eval and treat." On 8/12/11 at 2:45 p.m., the (named) hospital faxed the xray of the femur, thigh 2 views which included, but was not limited to: "Impression: Non displaced obliquely oriented fracture involving the distal metadiaphysis of the right femur." On 8/12/11 at 11:30 a.m., in interview with CNA #1, she indicated the resident was getting into the wheelchair using a slide board. The chair was borrowed as another aide brought it from the therapy department. She locked the wheelchair, using a gait belt with the slide board as the resident was transferring the wheelchair rolled back the resident fell to the floor. The wheelchair was locked when I checked it by rolling it back and forth. I put a pillow under her head and ran to get the nurse. On 8/12/11 at 11:35 a.m., in interview with the Therapy Manager, she indicated the wheelchairs are checked to make sure the brakes are working. The facility aides on 3rd shift sign off the brakes are checked. On 8/12/11 at 11:40 a.m., in interview with the Maintenance Director, he indicated the brakes had to be replaced on the wheelchair used during the fall. He does not have the wheelchairs on a routine maintenance program. On 8/12/11 at 2:45 p.m., the DON provided the facility policy and practice for wheel chair cleaning, revised June 6, 2011, which included, but was not limited to: "Wheelchair brakes should be kept free of debris and to prevent a loose fit when the chair is locked. wiping regularly with a damp cloth will prevent this. During the wheelchair cleaning, the nursing staff are to evaluate the wheelchair for cracks, or areas that need replaced or repaired. The wheelchair brakes are to be set and tested for braking ability. if the wheelchair is fit with auto locking brakes these are to be viewed and verified that they work correctly. In the event the brakes are found to be loose or faulty the wheelchair is to be removed from use, taken off the unit and stored in the maintenance work shop. A work order is to be filled out and the wheelchair is to remain out of use until returned by the maintenance department and is safe to use again. On 8/12/11 at 2:45 p.m., the DON provided a copy of the safety Inspection/Troubleshooting manufacturers instructions, faxed to the facility on [DATE] at 1:30 p.m., which included, but were not limited to: "Every six months or as necessary, take your wheelchair to a qualified technician for a thorough inspection and servicing. Regular cleaning will reveal loose or worn parts and enhance the smooth operation of your wheelchair. To operate properly and safely, your wheelchair MUST be cared for just like any other vehicle. Routine maintenance will extend the life and efficiency of your wheelchair.. 4.1 Safety Inspection Checklist Inspect/Adjust Initially: Ensure that the wheelchair rolls straight (no excessive drag or pull to one side). Inspect for loose or missing hardware on frame and cross braces. Inspect for bent frame or cross braces. Check that the wheel locks DO NOT interfere with tires when rolling. Check that the wheel lock pivot points are free of wear and looseness. Check that the wheel locks are easy to engage. Ensure that the wheel locks prevent the wheelchair from moving when engaged...Inspect the seat and back for loose or broken hardware. Inspect the back cane hand grips for wear/looseness/deterioration. Inspect/Adjust Weekly: Ensure that the wheel locks prevent the wheelchair from moving when engaged....If equipped, check that the quick-release axles lock properly. Lubricate if necessary. WARNING After any adjustments, repair or service and before use, make sure all attaching hardware is tightened securely. Otherwise injury or damage may result...Suggested Maintenance Procedures 1. Before using your wheelchair, make sure all nuts and bolts are tight. 2. Check all parts for damage or wear and replace. 3. Check all parts for proper adjustment...5. Periodically adjust wheel locks in correlation to tire wear. On 8/12/11 between 3 and 4 p.m. the personnel files were reviewed. CNA #1 was hired on 6/9/10. Review of the skills check list completed on lacked reference to the use of a slide board. On 8/12/11 at 3:55 p.m., in interview with the Staff Development Coordinator, she indicated CNA #1 had not been trained in the use of a slide board. Training was the responsibility of the therapy department. Training for specialized equipment any assistive devices for the resident would be done by therapy. On 8/12/11 at 10:30 a.m., the clinical record for Resident B was reviewed. A Functional Maintenance Care Plan for Resident B for Rehabilitation Inservice dated 2/26/10 included, but was not limited to Topic: Mover and safe use of sliding board with bed to mobilized w/c transfer. Pt. requires contact guard assist for transfer after full s/u (set up) of board. Surface to transfer to should be lowered." Documentation was lacking the CNA had been trained in the procedure. On 8/12/11 at 4:20 p.m., the DON provided a current list of 59 of 73 residents who utilized a wheelchair with hand brakes. On 8/12/11 at 4:20 p.m., the DON provided page 55 of the Wheelchair manufacturers instructions which included, but were not limited to: "WARNING If wheel locks do not hold the occupied wheelchair in place, contact a qualified technician; otherwise injury or damage may occur." 3.1-45(a)(2)