Every finding on record at Willowdale Village

Based on interview and record review, the facility failed to ensure physician notification for a resident's change of condition for 1 of 5 residents reviewed for unnecessary medications. A resident's physician was not notified following insulin being held due to low blood sugar. (Resident 5)Findings include:On 2/11/26 at 11:08 A.M., Resident 5's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus.The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/31/25, indicated a moderate cognitive impairment, and use of insulin. Physician orders included, but were not limited to: insulin aspart U-100 solution; 100 unit/mL (milliliters); amount to administer: 6 units, dated 7/15/25 through 1/16/26. The order did not include parameters to hold the insulin. A current insulin use care plan, last revised 12/31/25, indicated but was not limited to the following interventions:Document abnormal findings and notify physician, dated 3/25/25.Medications as ordered, dated 3/25/25. Resident 5's Medication Administration Record (MAR) from November 2025 through January 2026 indicated the following dates insulin aspart was held with no note that the physician was notified: 11/1/25 7 A.M. 11/4/25 5 P.M. 11/10/25 5 P.M. 11/13/25 5 P.M. 11/15/25 5 P.M. 11/16/25 5 P.M. 11/17/25 5 P.M. 11/18/25 7 A.M. 11/20/25 5 P.M. 11/26/25 7 A.M. and 5 P.M. 11/27/25 12 P.M. 11/28/25 7 A.M. 11/30/25 12 P.M. 12/3/25 5 P.M. 12/4/25 5 P.M. 12/6/25 12 P.M. 12/7/25 5 P.M. 12/8/25 5 P.M. 12/11/25 5 P.M. 12/13/25 5 P.M. 12/15/25 5 P.M. 12/17/25 7 A.M. 12/18/25 5 P.M. 12/19/25 7 A.M. and 5 P.M. 12/21/25 12 P.M. 12/22/25 7 A.M. and 12 P.M. 12/23/25 7 A.M. 12/27/25 7 A.M. 12/28/25 7 A.M. 12/29/25 5 P.M. 12/31/25 7 A.M. 1/2/26 5 P.M. 1/3/26 7 A.M. 1/4/26 7 A.M. 1/8/26 5 P.M. 1/11/26 7 A.M. and 5 P.M. 1/14/26 5 P.M. Resident 5's clinical record lacked notification to the physician that insulin had been held. On 2/12/26 at 11:33 A.M., Licensed Practical Nurse (LPN) 5 indicated Resident 5's insulin had been held using nursing judgement if they considered the blood sugar too low. She indicated the physician should have been notified each time the insulin was held and documented in their clinical record. She indicated at some point in January, the staff relayed information to the physician that Resident 5's blood sugar was running low in the mornings, and the insulin aspart order was changed to include parameters to hold if the blood sugar was less than 80. On 2/13/26 at 8:56 A.M., the Director of Nursing (DON) and Regional Support indicated notification to the physician had not been found in Resident 5's clinical record related to holding insulin. On 2/13/26 at 10:15 A.M., the Administrator provided a current Resident Change of Condition policy, last revised 11/2028, that indicated It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place . All symptoms and unusual signs will be documented in the medical record and communicated to the attending physician promptly 3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure services of a Registered Nurse (RN) were available at least 8 consecutive hours in a 24 hour period, 7 days a week for 2 of 7 days reviewed for nurse staffing. (11/29/24, 11/30/24) Findings include: On 12/11/24 at 9:50 A.M., the daily nursing schedules were provided for the week of 11/27/24 through 12/3/24 and reviewed. The schedules indicated there was an RN that worked from 6:00 P.M. to midnight (6 consecutive hours) on Friday, 11/29/24 and lacked RN coverage on Saturday, 11/30/24. During an interview on 12/16/24 at 12:10 P.M., the Director of Nursing (DON) indicated there was not RN coverage for those dates but there should have been 8 hours of consecutive RN coverage every day. On 12/16/24 at 1:10 P.M., a current RN Coverage Policy was requested. The DON indicated they did not have a policy, but they would follow the regulations. 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 1 of 1 residents reviewed for Transmission Based Precautions (TBP). Staff failed to don (put on) personal protective equipment (PPE) prior to entering a contact isolation room. (Resident 16) Findings include: During an observation on 12/11/24 at 8:45 A.M., the following sign was observed on Resident 16's door, STOP CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands (hand sanitizer or hand washing) before entering and when leaving the room. Put on gloves before room entry. Discard gloves before room exit. Put on a gown before room entry. Discard gown before room exit .Use dedicated or disposable equipment . During an interview on 12/11/24 at 8:46 A.M., the Infection Preventionist (IP) indicated Resident 16 had a contact precautions sign on the door due to a diagnosis of extended-spectrum beta-lactamase (ESBL bacteria) in her urine. During an observation on 12/11/24 at 12:13 P.M., Housekeeper 4 entered Resident 16's room and grabbed hangers. Housekeeper 4 failed to don PPE before she entered the room. During an observation on 12/11/24 at 12:14 P.M., CNA (Certified Nurse Aide) 2 failed to don PPE before she brought Resident 16 a meal tray. CNA 2 then exited the room, failed to sanitize hands, grabbed packets off the top of the meal cart, and then re-entered Resident 16's room without donning PPE. During an observation on 12/11/24 at 12:17 P.M., CNA 2 exited Resident 16's room, failed to sanitize hands, pushed the meal cart down the hall, and delivered a meal tray to Resident 14. During an observation on 12/12/24 at 11:51 A.M., LPN (Licensed Practical Nurse) 6 failed to don PPE prior to entering Resident 16's room when she administered medications. During an interview on 12/16/24 at 9:40 A.M., the Housekeeping Supervisor indicated all housekeeping staff should don a gown and gloves before they enter a contact isolation room. During an interview on 12/16/24 at 11:05 A.M., the IP indicated all staff should have had a gown and gloves on before they entered the contact isolation room. On 12/16/24 at 11:29 A.M., the IP provided a current Standard and Transmission-Based Precautions (Isolation) Policy, revised 4/24/24, that indicated, CONTACT PRECAUTIONS: .put on gown and gloves upon entry to room . 3.1-18(b)(2) 3.1-18(l)

Based on interview and record review, the facility failed to insure care plan conferences were completed quarterly for 4 of 10 residents reviewed for care plans. (Resident 2, Resident 3, Resident 15, Resident 22) Findings include: 1. On 12/20/23 at 9:22 A.M., Resident 3's clinical record was reviewed. Resident 3 was admitted on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus and dysphagia. The most recent quarterly MDS (minimum data set) Assessment was completed on 9/20/23. Resident 3's cognitive level was moderately impaired, and required extensive assistance for mobility and eating, and total dependence for toileting and bathing. Care plan conferences during the past 12 months were held on 3/3/23, 3/31/23, and 7/5/23. 2. On 12/20/23 at 10:07 A.M., Resident 22's clinical record was reviewed. Resident 22 was admitted on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus and dementia. The most recent quarterly MDS Assessment was completed on 11/18/23. Resident 22's cognitive level was moderately impaired, and required extensive assistance for mobility and transfers, maximal assistance for toileting, and was dependent on staff for bathing. Care plan conferences during the past 12 months were held on 5/31/23 and 12/18/23. 46882 3. On 12/20/23 at 10:59 A.M., Resident 15's clinical record was reviewed. Diagnosis included, but were not limited to, chronic obstructive pulmonary disease, unspecified dementia, Type II diabetes mellitus, anxiety and major depressive disorder. The most recent quarterly MDS Assessment, dated 11/4/23, indicated Resident 15 had severe cognitive impairment, required extensive assistance of two for bed mobility and toilet use, and was totally dependent on two staff members for transfers, and one staff member for bathing. Resident 15's most recent care plan conference was completed on 8/31/23. The clinical record lacked a care plan conference, or an invitation to one since 8/31/23. During an interview on 12/21/23 at 1:10 P.M., the administrator indicated she was unable to find a care plan conference or an invitation to one after 8/31/23 in Resident 15's clinical records. 45933 4. During an interview on 12/19/23 10:11 A.M., Resident 2 indicated she had not received a care plan conference. On 12/20/23 at 9:33 A.M., Resident 2's clinical record was reviewed. The most recent significant change MDS Assessment, dated 11/15/23 indicated Resident 2 had a moderate cognitive impairment. Resident 2 failed to receive a care plan conference between 6/16/23 and 12/21/23. The care plan conference form indicated Resident 2 received an observation on 12/20/23 and the form was completed on 12/21/23. During an interview on 12/21/23 at 10:07 A.M., the Social Services Director indicated care plan conferences should be completed quarterly or if there is a significant change, and the facility completed the care plan conferences when the resident was due for a MDS Assessment. She indicated several residents failed to receive their care plan conferences as they should have. She further indicated that the observation date on the form was when the form was opened and the completed date was when the care plan conference was completed with the facility. On 12/21/23 at 12:34 P.M., the Infection Preventionist provided the Comprehensive Care Plan Policy, revised 8/2023 that indicated, Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MDS assessment. 3.1-35(c)(2)(C)

Based on interview and record review, the facility failed to ensure a communication process with hospice personnel was developed and implemented, including how the communication will be documented between the LTC (long term care) facility and the hospice provider, and to ensure that the needs of the resident were addressed. The clinical record lacked documentation of ongoing communication between facility staff and hospice staff for 1 of 1 residents reviewed for hospice. (Resident 3) Findings include: On 12/20/23 at 9:22 A.M., Resident 3's clinical record was reviewed. Resident 3 was admitted on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus and dysphagia. The most recent quarterly MDS (minimum data set) Assessment was completed on 9/20/23. Resident 3's cognitive level was moderately impaired, and required extensive assistance for mobility and eating, and total dependence for toileting and bathing. Current physician orders included, but were not limited to, [admission to] (hospice company) with diagnosis of COPD (chronic obstructive pulmonary disease) dated 3/27/23. During an interview on 12/21/23 at 11:41 A.M., LPN 12 indicated Resident 3 did not have a hospice communication binder, or any other source of communication, and hospice would verbally communicate any changes or hand write any new orders on a telephone order sheet. During an interview on 12/21/23 at 12:01 P.M., the DON (director of nursing) indicated nurses working the floor do not have access to (hospice company) charting system, and medical records has to print (hospice company) notes from their charting system and upload them in to the patient's chart in the facility's charting system, and that should be done each time hospice has completed a visit. The DON was unable to provide documentation that any notes had been uploaded from (hospice company) charting system to the facility's charting system. During an interview on 12/21/23 at 12:29 P.M., the Hospice Nurse indicated all of the charting completed by hospice is entered into their charting system, was not accessible by floor nurses but was accessible by administrative staff, and when hospice faculty are in the facility they verbalize any changes of Resident 3 to the nurse working the floor at that time. On 12/19/23 a document titled Hospice Services Agreement, dated 2/11/15, was provided. This document served as a contract between the facility and Resident 3's current contracted hospice company, and indicated 2. Responsibilities of the Facility: (f) Maintain an accurate medical record that includes all services and events provided. Required documentation provided by Hospice will be included in a designated area/section. A current hospice policy, dated 1/2016 revised 8/19, was provided by the DON on 12/21/23 at 2:20 P.M. and indicated Recommend using the Hospice Initiation observation in Matrix for documentation. 3. For resident's who have elected the hospice benefit, there will be e. Hospice documentation available at the facility.

Based on observation, interview, and record review the facility failed to ensure proper storage of medications in 1 of 2 medication carts. The narcotic box was not locked in the medication cart. (West Hall) Finding includes: On 12/20/23 at 7:23 A.M., the narcotic box in the [NAME] Hall Medication Cart was observed unlocked. On 12/20/23 at 9:56 A.M., the narcotic box in the [NAME] Hall Medication Cart was observed unlocked. During an interview on 12/20/23 at 10:00 A.M., Registered Nurse (RN) 20 indicated the narcotic box should be locked. During an interview on 12/20/23 at 10:10 A.M., RN 35 indicated narcotic boxes in the medication cart should be locked anytime the nurse was not in it. On 12/21/23 at 10:15 A.M., a current Controlled Substance Policy, dated November 2015, was provided by the Administrator and indicated . 1. All controlled substances prescribed for all residents must be double locked in a secure container in the community . 3.1-25(m)

Based on observation and interview, the facility failed to ensure infection control practices were in place for 2 of 2 residents observed during incontinence care. Staff failed to sanitize hands between dirty to clean tasks, staff touched items with their gloves before perineal care was performed, and staff washed hands using a 3 second lather. (Resident G, Resident D) Findings include: 1. During an observation on 6/28/23 at 7:19 A.M., CNA (Certified Nurse Aide) 17 and CNA 19 performed incontinence care on Resident G. CNA 17 and CNA 19 donned gloves. CNA 17 used her gloved hands and used the remote to raise the bed up. CNA 19 used her gloved hands to move the bedside table, opened the door of the closet and grabbed a brief, opened a drawer and grabbed barrier cream. CNA 17 removed the straps on the brief and wiped the resident with 2 wipes with the same gloves. Then, Resident G was rolled to her left side and CNA 19 wiped the resident with 3 wipes and removed the soiled brief and applied barrier cream. At that time, Resident G voided. CNA 19 removed gloves and failed to sanitize or wash hands before new gloves were donned. CNA 19 wiped resident and applied barrier cream. CNA 17 and CNA 19 removed gloves and pulled the resident up in the bed using the draw sheet, covered Resident G up with her blankets, CNA 19 opened a drawer and put the wipes in it. CNA 19 washed hands using a 3 second lather. 46882 2. On 6/28/23 at 8:11 A.M., CNA 13 and CNA 15 performed incontinence care on Resident D. Upon entering the room, both aides washed their hands at the sink and put gloves on. CNA 13 went to the right side of the bed and pulled the bedside table away from the resident and pulled the privacy curtain. CNA 15 went to the left side of the bed, pulled the privacy curtain and using the bed controller lowered the head of the bed. Neither CNA changed gloves before starting incontinence care. While Resident D was lying on her back, CNA 13 unfastened the brief. Resident D turned to her left side. CNA 15 held the resident while CNA 13 pulled the brief down, used two wipes to clean her back side and removed the soiled brief. CNA 13 threw the brief and wipes in the trash bag, removed her gloves, went to the sink to wash her hands and put on clean gloves. CNA 15 put a clean brief under Resident D, had her turn to her back, cleaned the front perineal area with two wipes, placed the wipes in the trash bag, pulled the clean brief up, removed gloves, and went to the sink to wash her hands. CNA 13 fastened the brief. Resident D turned to her left side. CNA 13 covered the resident with blankets, gave her the call light, pushed the curtain back and raised the head of the bed. CNA 13 removed her gloves and put them in the trash bag, went to the sink, and washed her hands. CNA 15 removed the trash bag from the trash can, tied it in a knot and put a clean trash bag into the trash can. CNA 13 carried the trash bag out of the room. During an interview on 6/29/23 at 8:31 A.M., the (IP) Infection Preventionist indicated hands should be lathered for 40 seconds, and the total handwashing time should be 60 seconds. The IP indicated that staff should perform hand hygiene from dirty to clean tasks. The IP indicated she would expect staff to change gloves if they touched items before performing care. On 6/28/23 at 9:11 A.M., a current Hand Hygiene Policy, revised 12/2021, provided by the IP, indicated .Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a resident. Before moving from work on a soiled body site to a clean body site on the same resident This Federal tag relates to complaints IN00411185 and IN00411241. 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure medications were labeled with an open date, resident's physician, dosage, prescription number, and pharmacy information for 1 of 1 medication carts and 1 of 2 medication storage rooms reviewed. (Resident 26, Resident 2, Resident 19, Resident 4, Resident 20, Resident 22 Resident 17, Resident 13) Findings include: On 1/10/20 at 11:45 [NAME]M., the medication storage room was observed with QMA 8. 1. In the sink, the following was observed. a. Two bottles of [MEDICATION NAME] (a stool softener) and two bottles of Refresh eye drops (lubricating eye drops) for Resident 26. b. One bottle of [MEDICATION NAME] for Resident 2. c. One bottle of Latanoprost eye drops (eye drops to treat [MEDICAL CONDITION]) and one bottle of Immodium (an anti-diarrheal medication) for Resident 19. d. One over-the-counter bottle of Calcium plus Vitamin D (a supplement), one bottle of [MEDICATION NAME] (a medication that dilates the blood vessels), one container of [MEDICATION NAME] ear drops (a medication to remove ear wax), and one bottle of Brimonide eye drops (a medication to treat [MEDICAL CONDITION]) for Resident 4. e. One bottle of Milk of Magnesia (an antacid and laxative medication) and one bottle of biscadoyl (a laxative medication) for Resident 20. f. Mi- Acid acid relief (an antacid medication) for Resident 22. g. One bottle of [MEDICATION NAME] (a long acting insulin), open date 11/15/19 for Resident 17. h. One bottle of Immodium, one bottle of Milk of Magnesia for Resident 13. 2. A container of equate lubricating eye drops and anti-itch cream was stored in the medication room without a resident's name. 3. A vial [MEDICATION NAME] Skin Test solution, open date 12/10/19 was stored in the refrigerator. 4. The temperature log lacked documented temperature for 1/3/20, 1/7/20, 1/8/20, and 1/9/20. On 1/10/20 at 11:56 P.M., QMA 8 indicated she was unsure why the medications were stored in the sink, who the unlabeled medications belonged to, and night shift was supposed to take the temperatures for the refrigerator in the medication storage room. On 1/10/20 at 12:30 P.M., the Regional Nurse Consultant provided the current Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles policy, revised 4/5/19. At that time, the policy was reviewed and included, but was not limited to: Facility should ensure that medications and biological's are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezer of sufficient size to prevent overcrowding 3.1-25(l)(1) 3.1-25(l)(2) 3.1-25(o)

Based on observation, interview, and record review, the facility failed to ensure food was discarded after the use by date and meals were served in a sanitary manner for 2 of 2 kitchen observations and 1 of 2 meal observations. Food was stored after the use by date and hand hygiene was not performed between room meal service. (CNA 3, Resident 2) Findings include: 1. On 1/6/19 at 8:25 [NAME]M., during the initial tour of the kitchen, the following was observed: a. A container, labeled squash with a use by date of 1/5/20. b. A container, labeled chicken soup with a use by date of 1/5/20. c. A wet cloth was observed sitting on the counter by the dish washer. 2. On 1/6/20 at 12:09 P.M., during the noon meal, the following was observed. d. CNA 3 entered Resident 23's room to serve the resident their lunch tray. CNA 3 exited the room, returned to the cart of lunch trays and retrieved a tray for Resident 26. CNA 3 entered Resident 26's room, sat the lunch tray on the bedside table, adjusted the bedside table, and exited the room. CNA 3 retrieved a tray from the cart of lunch trays for Resident 7. CNA 3 entered Resident 7's room, sat the tray on the table, moved a cup on the table, touched the handle of the walker, and exited the room. CNA 3 retrieved a lunch tray for Resident 127 and took the tray to Resident 127's room. CNA 3 adjusted a chair in the resident's room, moved a chair, exited the room, and sanitized her hands. On 1/10/20 at 9:40 [NAME]M., CNA 6 indicated when serving room meal trays, staff should sanitize after serving every room tray. 3. On 1/9/20 at 10:35 [NAME]M., the kitchen was observed. A container of tomato soup was observed in the refrigerator dated 1/2/20 and use by 1/7/20. On 1/9/20 at 11:15 [NAME]M., the Dietary Manager indicated the tomato soup had been labeled incorrectly. The Dietary Manager indicated the tomato soup was stored uncooked so it was good for six days. The Dietary Manager indicated if an item was cooked, it was good for three days. On 1/10/20 at 10:29 [NAME]M., the Director of Nursing provided the current Labeling and Dating policy, dated 5/2018. The policy included, but was not limited to: 3 days: Processed meats and any items that has been cooked and cooled should be kept no longer than 3 days. Label with the date of storage and the date of discard-add 2 days to today's date. Examples: chili, soups, chicken breasts, ham, bologna, salami, cooked vegetables, cooked potatoes . 4. During the main dining room lunch service on 1/6/20 at 12:23 P.M., RN 1 was observed squeezing a mustard packet onto Resident 2's cheeseburger. The mustard dropped from RN 1's painted artificial nail onto the cheeseburger and was served to the resident. During an interview on 1/10/20 at 9:57 [NAME]M., the DON (Director of Nursing) indicated artificial nails can be worn by staff, and was not sure what the policy was for serving food with artificial nails. On 1/10/20 at 10:08 [NAME]M., a copy page 16 of the employee handbook was provided (not dated), and indicated .Fingernails are to be kept moderately short and clean; this includes artificial nails. In addition, artificial nails are not allowed within the dietary department of the facilities . 3.1-21(i)(3) 3.1-21(i)(2)

Based on observation and interview, the facility failed to provide a safe and sanitary environment for 4 of 16 rooms observed. Grab bars were loose in bathrooms and a bathroom wall was cracked exposing loose plaster. (resident room [ROOM NUMBER], resident room [ROOM NUMBER], resident room [ROOM NUMBER], resident room [ROOM NUMBER]) Findings Include: On 1/7/20 at 9:30 [NAME]M. room [ROOM NUMBER] was observed. In the bathroom, the grab bar next to the toilet was observed to be loose and unstable. On 1/9/20 at 8:30 [NAME]M. the same was observed. The bathroom was shared by three residents. On 1/7/20 at 8:55 [NAME]M. room [ROOM NUMBER] was observed. In the bathroom, the grab bar next to the toilet was observed to be loose and unstable. On 1/9/20 at 8:36 [NAME]M. the same was observed. The bathroom was shared by three residents. On 1/7/20 at 8:57 [NAME]M. room [ROOM NUMBER] was observed. In the bathroom, the lower wall was observed to be cracked and loose plaster was exposed. On 1/9/20 at 8:35 [NAME]M. the same was observed. The bathroom was shared by three residents. On 1/7/20 at 10:21 [NAME]M. room [ROOM NUMBER] was observed. In the bathroom, the grab bar next to the toilet was observed to be loose and unstable. On 1/9/20 at 8:31 [NAME]M. the same was observed. The bathroom was used by one resident. On 1/9/20 at 8:50 [NAME]M. Maintenance 11 indicated that the grab bars in rooms 8,13, and 29 needed to be tightened, or possibly replaced, as they were the older grab bars. Maintenance 11 indicated that the bathroom wall in room [ROOM NUMBER] needed to be patched. On 1/9/20 at 11:03 [NAME]M. the Regional Nurse Consultant provided a policy dated 2/2012 titled, 'Maintenance Department' which that indicated that the maintenance department was responsible for maintaining optimal conditions to maintain a safe and healthy environment. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure comprehensive care plans were implemented for 4 of 12 residents reviewed. Pressure relieving boots were not worn, and residents' feet were not floated. (Resident 16, Resident 9, Resident 17, Resident 13) Findings include: 1. On 1/6/20 at 2:12 P.M., Resident 16 was observed with RN 10. Resident 16 was observed not wearing pressure relief boots on either foot. RN 10 indicated the pressure relief boots should be on the resident's feet. On 1/8/20 at 9:09 [NAME]M., Resident 16 was observed with CNA 6 and RN 1. Resident 16 was lying in bed. Resident was not wearing pressure relieving boots on either foot. RN 1 indicated the pressure relieving boots should be on Resident 16's feet. On 1/7/20 at 12:18 P.M., Resident 16's clinical record was reviewed. A Significant Change MDS (Minimum Data Set) assessment, dated 11/20/19, indicated Resident 16 had severe cognitive impairment, was dependent on two persons for bed mobility, and was at risk for pressure ulcers. The Care Plans included, but were not limited to:Resident is at risk for skin breakdown, initiated on 10/30/17. The interventions included, but were not limited to: Pressure relieving boots to bilateral feet at all times, initiated 11/6/19. A physician's orders [REDACTED]. 2. During an observation on 1/6/20 at 9:28 [NAME]M., Resident 9 was lying in bed with eyes closed. He was not wearing boots on his feet, and feet were lying against the mattress. During an observation on 1/8/20 at 10:20 [NAME]M., Resident 9 was lying in bed. He did not have boots on his feet. During an observation on 1/8/20 at 10:39 [NAME]M., Resident 9 was lying in bed. His feet were not floated, and did not have boots on his feet. At that time, RN 10 pulled the sheet back to reveal the resident's feet resting in direct contact with the mattress. RN 10 pulled the pillow under the resident's ankles and indicated the feet were supposed to be floated at all times. RN 10 went to the closet, pulled out a pair of blue boots, and indicated Resident 9 should wear the boots as well. During an observation on 1/9/20 at 8:46 [NAME]M., Resident 9 was observed lying in bed with blue boots on his feet. On 1/7/20 at 12:12 P.M., Resident 9's clinical record was reviewed. The most recent quarterly MDS (Minimal Data Set) Assessment indicated resident was cognitively intact, [DIAGNOSES REDACTED]. Resident 9's current orders included, but were not limited to, float heels while in bed, initiated 7/24/19. Resident 9's clinical record lacked an order related to floating heels or wearing boots. 3. During an observation on 1/6/20 at 9:28 [NAME]M., Resident 17 was lying in bed with a pillow under his knees. His heels were rested on the mattress. During an observation on 1/6/20 at 1:21 P.M., LPN 2 and MDS Coordinator assisted Resident 9 to move up in the bed. At that time, a pillow was observed behind his knees, and feet were rested on the mattress. During an observation on 1/8/20 at 9:15 [NAME]M., QMA 8 pulled Resident 17's cover sheet away from his feet. Resident 17's feet were rested in direct contact with the mattress. QMA 8 indicated at that time Resident 17's feet should be floated at all times. At that time, Resident 17 indicated he had bad circulation in his feet. During an observation on 1/8/20 at 11:06 [NAME]M., RN 10 removed the sheet from Resident 17's feet, and both feet were rested in direct contact with the mattress. RN 10 floated the feet by pulling the pillow under the ankles. Resident 17 indicated at that time don't hurt my feet. That heel on my left side really hurts. Sometimes it swells. RN 10 indicated the left heel was not boggy or red at that time. During an observation on 1/9/20 at 8:51 [NAME]M., Resident 17 was lying in bed with feet elevated with a pillow. On 1/9/20 at 9:58 [NAME]M., Resident 17's clinical record was reviewed. The most recent quarterly MDS Assessment indicated a slight cognitive impairment, [DIAGNOSES REDACTED]. Resident 17's current orders included, but were not limited to float heels while in bed, initiated 10/31/16. Resident 17's current care plan for risk for skin breakdown included the intervention, but was not limited to elevate heels when in bed, initiated 8/16/16. 4. On 1/7/20 at 9:15 [NAME]M. Resident 13 was observed asleep in bed wearing non-skid socks on both feet. Pressure relieving boots were not observed on Resident 13. On 1/8/20 at 9:13 [NAME]M. Resident 13 was observed in bed sleeping wearing non-skid socks on both feet. No pressure relieving boots were observed on Resident 13's feet. On 1/7/20 at 8:37 [NAME]M. Resident 13's clinical record was reviewed. The most recent quarterly MDS (minimum data set), dated 10/8/19, indicated Resident 13 had cognitive impairment and required maximum assistance for transfers and activities of daily living. [DIAGNOSES REDACTED]. A current care plan, revised on 12/2/19, indicated that Resident 13 was at risk for skin breakdown and had some sensory impairment .that limits ability to feel pain/discomfort in lower extremities. The interventions included, but were not limited to, Pressure relieving boots to bilateral lower extremities while in bed, initiated 6/27/19. physician's orders [REDACTED]. On 1/8/20 at 11:01 [NAME]M. CNA 6 indicated that Resident 13 should wear pressure relieving boots while in bed along with a supportive cushion between the knees. CNA 6 indicated that Resident 13's pressure relieving boots were located in the closet at that time. On 1/9/20 at 11:14 [NAME]M. a policy for developing, updating and following the resident's care plan was requested, but the policy not provided. The Regional Nurse Consultant indicated that it was the facility's policy to follow the care plan for each resident. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure residents received necessary respiratory care and services in accordance with professional standards of practice, oxygen concentrator filters were not cleaned for 2 of 3 residents reviewed for respiratory care. (Resident 15, Resident 24) Findings include: 1. During an observation on 1/8/20 at 10:25 [NAME]M., the oxygen concentrator in Resident 15's room had white dust caked on the filter located on the side of the machine. During an observation and interview on 1/8/20 at 10:43 [NAME]M., the Director of Nursing (DON) was made aware the filter for Resident 15's oxygen concentrator was caked with white dust. The DON indicated she would check the physician's orders [REDACTED]. The clinical record for Resident 15 was reviewed on 1/8/20 at 10:08 [NAME]M. The record indicated the [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Oxygen at 1.5 lpm (liters per minute) per nasal cannula . A physician's orders [REDACTED].Change oxygen tubing and humidity Once a Day on Tue (Tuesday) . The physician's orders [REDACTED]. A care plan titled, Resident has potential for impaired gas exchange related to: [MEDICAL CONDITIONS] and chronic [MEDICAL CONDITION]. Resident becomes visibly short of breath with exertion and when lying flat in bed r/t (related to) [MEDICAL CONDITION] and [MEDICAL CONDITION]. She utilized oxygen continuously to maintain SaO2 (oxygen levels) WNL (with in normal range), though chooses to remove at times per her preference, and requires extensive to total assist with ADLs (activities of daily living) d/t (due to) becoming short of breath ., was initiated on 4/30/2016, last reviewed and revised on 12/23/19 at 10:01 [NAME]M., and interventions included, but were not limited to, the following: . .Start Date: 07/21/2017 .APPROACH: Oxygen . Start Date: 04/30/2016 .APPROACH: Monitor oxygen sat rates as needed/ordered . The care plan lacked documentation for instructions on how and when to clean Resident 15's oxygen concentrator. 2. During an observation on 1/08/20 at 10:29 [NAME]M., Resident 24 was observed in his bed asleep while wearing his oxygen nasal cannula. The filter for his oxygen concentrator was visible with caked, white dust. Resident 24's clinical record was reviewed on 1/8/20 at 11:30 [NAME]M. The record indicated the [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Oxygen at 2 liters per nasal cannula . A physician's orders [REDACTED].Change oxygen tubing and humidity Once a Day on Sun (Sunday) . During an interview on 1/9/20 at 8:58 [NAME]M., the Director of Nursing indicated the filters on the oxygen concentrator should have been scheduled for routine cleaning. During an interview on 1/10/20 at 9:05 [NAME]M., the Director of Nursing indicated the facility did not have a policy for the maintenance of oxygen concentrators, but the facility would follow the manufactures recommendations. The Director of Nursing indicated the filters should be kept clean. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure treatments were consistent with residents needs for 1 of 2 residents reviewed for skin conditions. Orders were not updated after a wound was healed. (Resident 16) Finding includes: On 1/7/20 at 12:18 P.M., Resident 16's clinical record was reviewed. A Significant Change MDS (Minimum Data Set) assessment, dated 11/20/19, indicated Resident 16 had severe cognitive impairment, was at risk for pressure, and had no unhealed pressure ulcers. The physician's orders [REDACTED]. 11/26/19- Cleanse area to L (left) buttock with wound cleanser, pat dry. Skin prep periwound. Cover with calcium alginate. Cover with [MEDICATION NAME]. Once A Day Every Other Day; 10:00 PM-06:00 AM The Progress Notes included, but were not limited to: 11/26/19 at 12:52 P.M., Moisture associated skin damage noted to residents left buttock Area cleansed with wound cleanser, patted dry, skin prep applied to periwound, calcium alginate applied and covered with a [MEDICATION NAME] dressing. 12/5/19 at 6:56 P.M., Dressing to left buttock clean, dry, and intact 12/6/19 at 10:58 [NAME]M., Dressing to the resident's left buttock, covered, dry, and intact . A Weekly Summary, dated 12/5/19, indicated Resident 16 had no areas of skin impairment. The (MONTH) 2019 TAR (Treatment Administration Record) indicated the dressing to Resident 16's wound was changed on 12/5/19, 12/7/19, 12/9/19, 12/11/19, 12/13/19, 12/15/19, 12/17/19, 12/19/19, 12/21/19, 12/23/19, 12/25/19, 12/27/19, 12/29/19, and 12/31/19. The (MONTH) 2020 TAR indicated the dressing to Resident 16's wound was changed on 1/2/20, 1/4/20, and 1/6/20. On 1/8/20 at 9:09 [NAME]M., Resident 16 was observed with RN 1, LPN 2, CNA 6, and the DON. A dressing was observed on Resident 16's left buttock. LPN 2 removed the dressing and no wound was observed. On 1/8/20 at 9:45 [NAME]M., LPN 2 indicated there was calcium alginate on the [MEDICATION NAME] dressing at the time she removed it. The DON indicated Resident 16's wound had healed on 12/5/19. The DON indicated the Nurse Practitioner was aware the area had healed but thought the dressing change orders had been missed. On 1/10/20 at 9:00 [NAME]M., the DON indicated she had notified the Nurse Practitioner verbally on 12/5/19 that Resident 16's wound had healed. The DON indicated the order for the dressing change did not get changed. On 1/10/20 at 10:29 [NAME]M., the DON provided the current Skin Management Program policy, revised 4/2018. The policy included, but was not limited to: When Alteration in Skin Integrity Has Healed . Discontinue treatment orders 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident assessment was completed for 1 of 1 residents reviewed for self-administration of treatments and medications. A resident self-administered treatments and medications without an assessment to determine their capability. (Resident 4) Finding includes: During an observation of medication administration for Resident 4 on 1/9/20 at 9:50 [NAME]M., the following medications were located on the resident's bedside table: One tube of [MEDICATION NAME] mouth cream, one bottle lubricating eye drops, one tube of Vagacil, one container of Simply Saline nasal spray, and one tube of anti-itch cream. During an interview and chart review on 1/9/20 at 10:01 [NAME]M., RN 1 indicated Resident 4 had an assessment completed to enable self-administration of Pro Air Inhaler and [MEDICATION NAME] Eye, but Resident 4 did not have an assessment completed for the saline nasal spray, eye drops and creams which were located on her bedside table. The clinical record for Resident 4 was reviewed on 1/9/20 at 10:58 [NAME]M. The record indicated the [DIAGNOSES REDACTED]. A physician's order dated 8/1/19 read as follows: .Saline Nasal Mist .1 spray in each nostril .prn nasal congestion . No physician's orders were documented for the tube of Vagisil, one bottle of lubricating eye drops, one tube of [MEDICATION NAME] mouth cream, and one tube of anti-itch cream. A care plan initiated on 7/11/19 titled, Resident chooses to self-administer medication: Pro Air Inhaler and [MEDICATION NAME] Eye Drops, was last reviewed on 12/5/19 and read as follows: .GOAL: Res. will adequately and safely administer medications . APPROACH: Complete .Medication Self Administration Request/Evaluation quarterly and as needed .Start Date: 12/05/2019 . APPROACH: Keep medications out of reach of other residents .Start Date: 12/05/2019 APPROACH: Provide education to resident on proper use of medication .Start Date: 7/11/2019 APPROACH: IDT to complete Medication Self-Administration Evaluation Observation .Start Date: 7/11/2019 APPROACH: Notify MD of any changes .Start Date: 7/11/2019 APPROACH: Will re-evaluate as needed .Start Date: 7/11/2019 The care plan lacked documentation for the self-administration of lubrication eye drops, creams and saline nasal spray. A policy titled, Self Administration of Medications, last updated on 01/2015, was provided by the Regional Consultant, reviewed on 1/9/20 at 10:07 [NAME]M., and read as follows: .A Physician order will be obtained specifying the resident's ability to self-administer medication and, if necessary, listing which medications will be included in the self-administration plan .The licensed nurse will instruct the resident regarding proper administration of medication .all medication will be maintained in a secure location in the resident's room . During an interview on 1/9/20 at 10:30 [NAME]M., the Director of Nursing indicated the medications positioned on Resident 4's bedside table were provided by the resident's family. 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure accuracy of the MDS assessments for 3 of 16 residents reviewed. Bed rails were coded incorrectly as restraints. (Resident 21, Resident 15, Resident 26) Findings include: 1. During an observation on 1/6/20 at 9:54 [NAME]M., Resident 21 was observed standing in front of her wheelchair where she indicated she did not feel well today. Resident 21 turned and walked into the bathroom. No positioning rails were observed on the bed at that time. The clinical record for Resident 21 was reviewed on 1/7/20 at 10:10 [NAME]M. Resident 21 was admitted on [DATE]. The record indicated Resident 21's [DIAGNOSES REDACTED]. The Significant change MDS (Minimum Data Set) assessment, dated 12/13/19, indicated Resident 21 experienced mild cognitive impairment and that bed rails were used daily as restraints. The physician's orders [REDACTED].Activity Level: Up Ad Lib with assistance using 4 wheeled walker or wheelchair . The physician's orders [REDACTED].Bilateral positioning rails to aid in bed mobility d/t (due to) weakness. During an interview 1/09/20 at 12:59 P.M., LPN 10 indicated Resident 21 ambulated with a walker whenever she was in her room and that Resident 21 also used a wheelchair. 2. On 1/7/20 at 11:55 [NAME]M., Resident 15's clinical record was reviewed. The most recent MDS (Minimum Data Set) assessment (quarterly) dated 11/12/19 indicated that bed rails were being utilized as restraints. Resident 15's current orders lacked an order for [REDACTED]. Resident 15's [DIAGNOSES REDACTED]. 3. On 1/6/20 at 12:09 P.M., Resident 26 was observed to be sitting in a recliner in her room. No restraints were observed. On 1/7/20 at 11:55 [NAME]M., Resident 26's clinical record was reviewed. The original Quarterly MDS (Minimum Data Set) assessment, dated 12/19/19, indicated physical restraints of bed rails were used daily. During an interview on 1/7/20 at 9:30 [NAME]M., the Administrator indicated there were no residents residing in the building who required restraints. The administrator indicated the MDS coordinator had incorrectly coded Resident 21, Resident 15, and Resident 26 as having the need for restraints. On 1/10/19 at 9:47 [NAME]M., the MDS Coordinator indicated the facility followed the RAI (Resident Assessment Instrument) regarding MDS assessments. 3.1-31(d)

Based on interview and record review, the facility failed to provide a Notice of Medicare Non-Coverage form in a timely manner for a resident whose payer source was changing for 1 of 3 records reviewed. (Resident 4) Finding includes: On 1/7/20 at 12:38 P.M. the clinical record for Resident 4 was reviewed and indicated that services ended on 10/13/19 and that Resident 4 was discharged on [DATE]. An unsigned Notice of Medicare Non-Coverage form was found in Resident 4's record. On 1/8/20 at 8:04 [NAME]M. the BOM (Business Office Manager) indicated that Resident 4 was discharged on [DATE] and was notified via phone on 10/14/19 that services had ended. The BOM indicated that the Notice of Medicare Non-Coverage form was mailed to Resident 4 on 10/14/19, but the facility never received a returned, signed form. On 1/9/20 at 9:39 [NAME]M. the Regional Nurse Consultant provided an undated policy titled 'Checklist/Instructions for issuing a Notice of Medicare Non-Coverage (NOMNC)/ Determination On Continued Stay' that stated NOMNC for must be issued no later than two days (48 hours) before the proposed end of services. 3.1-4(f)(2)

Based on observation, interview, and record review, the facility failed to ensure completed staffing sheets were posted daily for 5 of 5 days during the survey. Findings include: On 1/6/20 at 8:30 [NAME]M., the staff posting sheet posted behind the nurses station was for date 12/13/19. On 1/10/20 at 9:35 [NAME]M., staff posting sheets were provided for the following dates: 12/30/19 12/31/19 1/1/20 1/2/20 1/3/20 1/4/20 1/5/20 1/6/20 1/7/20 1/8/20 Each staff posting sheet indicated the date and number of hours worked for each shift (day, evening, night). Disciplines included licensed nursing staff, and unlicensed nursing staff. Specific hours were not included in the postings. During an interview on 1/10/20 at 10:58 [NAME]M., the DON (Director of Nursing) indicated staffing sheets were posted daily on day shift, and other shifts added the hours to them at the beginning of their shifts. She indicated the staffing sheet was supposed to be posted daily. On 1/10/20 at 9:35 [NAME]M., a current posted nurse staffing policy, dated 7/2019, was provided and indicated .The facility must post the following information at the beginning of each shift . The current date . The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift . (hours and shifts) should be included in the Posted Nurse Staffing Data form .

Based on observation, interview, and record review, the facility failed to ensure proper food storage was maintained during 1 of 2 kitchen observations and a cleaning schedule was followed during 2 of 2 kitchen observations. Food was not labeled and dated in freezers and refrigerators, dust had accumulated around the 3 compartment sink, and a sticky residue was present on the kitchen floor. Findings include: 1. During an observation on 2/4/19 at 8:55 A.M., an opened bag of frosting or icing was being stored in a Ziploc bag in freezer 1. The Ziploc bag had no label or open date. 2. During an observation on 2/4/19 at 9:05 A.M., a salad mix was being stored in a Ziploc bag in Refrigerator 3. No label or date was marked on the bag. 3. During an observation on 2/4/19 at 9:07 A.M., a chopped green food (appeared to be green peppers) was stored in a Ziploc bag in freezer 3. The Ziploc bag had no label or date. 4. During an observation on 2/4/19 at 9:15 A.M., a sticky substance adhered to the bottom of shoes while touring the kitchen. 5. During an observation 2/6/19 12:25 P.M., a sticky substance adhered to the bottom of shoes while observing the kitchen. An accumulation of dust was observed on the wall and on piping near the 3 compartment sink. During record review on 2/8/19 at 12:00 P.M., daily cleaning schedules indicated the morning cooks failed to document any daily cleaning tasks as completed for 6 of 31 days reviewed. Afternoon cooks failed to document any daily cleaning tasks as completed for 11 of 31 days reviewed. Morning dietary aids failed to document any daily cleaning tasks as completed for 5 of 31 days reviewed. Afternoon dietary aides failed to complete daily cleaning tasks as completed for 7 of 31 days reviewed. During an interview on 2/4/19 at 9:20 A.M., the DM (Dietary Manager) indicated food stored in Ziploc bags should be labeled and dated. On 2/5/19 at 9:15 A.M., the DON (Director of Nursing) supplied a policy dated, 11/2017, titled, Food Storage. The policy stated, .Foods should be covered or wrapped tightly, labeled and dated. On 2/8/19 at 9:40 A.M., the DM supplied a facility policy titled, Cleaning Floors, Tables, and Chairs, dated, 7/2015. The policy stated, Kitchen floors will be swept and cleaned after each meal. 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure that allegations of abuse were identified and reported to the state survey agency immediately for 4 of 7 abuse allegations reviewed. (Resident 4, Resident 13, Resident 29, unidentified resident) Findings include: 1. On 2/5/19 at 1:53 P.M., the facility grievances were reviewed. A Concern/Grievance Form, dated 6/5/18 regarding Resident 4 included, but was not limited to: daughter reported her mom was made by 3 staff members to clean up her feces on the floor On 2/6/19 at 11:43 A.M., the reportable incidents were reviewed. The allegation was not reported to the State Survey Agency. On 2/6/19 at 2:24 P.M., the Administrator indicated she had contacted the daughter of the resident and the story was different from the initial grievance form and therefore the incident was not reported. 2. On 2/6/19 at 11:43 A.M., a reportable incident, dated 12/12/18 at 6:01 A.M., included an allegation of verbal abuse regarding Resident 13 was received through the compliance hotline. The Corporate Compliance hotline intake information indicated the allegation was received on 12/11/18, no time listed. On 2/6/19 at 2:21 P.M., the Administrator indicated the corporate compliance had contacted her via telephone to report the allegation of abuse. On 2/8/19 at 1:30 P.M., the Administrator indicated the call had come into the compliance hotline at 6:01 A.M., the administrator was notified at 6:08 A.M., and the incident was reported at 6:15 A.M. 3. On 2/6/19 at 11:43 A.M., a reportable incident, dated 11/5/18 at 1:01 P.M., included an anonymous allegation of inappropriate tone of voice received through the compliance hotline. The anonymous caller did not identify any affected residents. The Primary Issue via the hotline indicate Resident Rights Violation. The allegation included, but was not limited to: one girl in particular is so loud as well as rude to the people and I once seen her yelling at a lady because it looked like she had a (sic) accident in the dining hall and all other employees just ignored it when I felt so bad for the lady being scolded . The allegation was not identified by the compliance hotline as abuse, nor was it reported to the state survey agency until 11/8/18 at 9:34 A.M. On 2/6/19 at 3:16 P.M., the Administrator indicated the corporate compliance hotline is through a third party. The Administrator indicated that depending on what was said during the phone call it was sent to different areas at their home office. The Administrator further indicated the home office then forwarded the information to the facility. The Administrator indicated she did not know why the incident was not flagged as an abuse allegation, but the facility investigated it as an abuse allegation. The Administrator indicated she was unsure whether to report the allegation to the state survey agency, but she finally did three days later. 4. On 2/6/19 at 11:43 A.M., a reportable incident, dated 7/11/18 at 1:10 P.M., included an allegation of a visitor telling a Resident 29 to be quiet and shut up. The State Agency intake information indicate the allegation was not reported to the State Survey Agency until 7/12/18 at 3:24 A.M. On 2/5/19 at 1:09 P.M., during the Resident Council Group meeting, 11 residents indicated they would notify the administrator of an allegation of abuse. On 2/4/19 at 10:00 A.M., the Administrator provided the Abuse Prohibition, Reporting, and Investigation policy, revised 6/2018. The policy included, but was not limited to: Identification: Abuse includes: Staff to resident abuse of any type, resident to resident abuse of any type, and visitor to resident abuse Reporting/response: The Executive Director will ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin, and misappropriation of resident property are reported immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the Long Term Care Division of the Indiana State Department of Health via the Gateway portal 3.1-28(c)

Based on observation, interview, and record review, the facility failed to ensure kitchen staff followed recipes for 6 of 6 pureed meals observed. Kitchen staff failed to measure ingredients in accordance with the dietician signed recipes. Findings include: During an observation on 2/6/19 at 11:05 A.M., Cook 3 prepared 6 pureed meals. Cook 3 indicated preparing chicken tenders, macaroni and cheese, and a Scandinavian vegetable mix. The recipe binder was observed sitting on the preparation table, it was not opened during the pureed food process. Meals were prepared as follows: Chicken tenders - Cook 3 added 6 chicken tenders to the food processor, added 1 and 1/2 teaspoons of chicken base, about 2 and 1/4 cups of water, and used about half of a 1/3 cup of food thickener. Scandinavian blend - Cook 3 ladled 6 - 4 oz scoops of Scandinavian vegetable mix to the food processor. Cook 3 then added about, 2 ounces (not measured) of butter, then added more butter, added about 10 ml of water, and then added about 1/4 of a 1/3 cup of thickener. Macaroni and cheese - Cook 3 used a #10 scoop (3 ounces) to add 6 scoops of macaroni and cheese to the food processor. Cook 3 then added an unmeasured amount of milk from a gallon milk jug, about 1/4 of a 1/3 cup of thickener, and then again added about 1/2 of a 1/3 cup of thickener. During record review on 2/6/19 at 2:30 P.M., recipes indicated the following measurements should be used to prepare the noted pureed meals (measurements calculated for 6 servings): Chicken tenders (permission given by Registered Dietician to use recipe for chicken livers) - 6 servings chicken (tenders), 1 and 1/3 teaspoons of chicken base, 1 and 4/5 cups of water, and 1/5 cup of food thickener. Scandinavian blend - 3 cups Scandinavian vegetables, 2 and 2/5 tablespoons of butter, and 4/5 cup of food thickener. Macaroni and cheese - 2 and 2/5 cups of macaroni and cheese, 1/5 cup of milk, and 9/10 teaspoon of food thickener. During an interview on 2/8/19 at 9:44 A.M., the DM (Dietary Manager) indicated kitchen staff should follow the menu when preparing pureed meals. On 2/8/19 at 12:50 P.M., a facility policy dated, 11/2016, titled, Menu Planning, was provided by the DM. The policy stated, Regular and therapeutic menus are written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended dietary allowances . Menus are written to include meals at regular times, in amount consistent with each resident's nutritional needs. 3.1-20(i)(4)

Based on observation, interview, and record review, the facility failed to ensure a dependent resident admitted without pressure ulcers was provided effective interventions to prevent the development of an unstageable pressure ulcer on the left lateral foot and a stage 3 pressure ulcer on the bottom of left foot for 1 of 2 residents who met the criteria for review of pressure ulcers. This deficient practice resulted in Resident 21 experiencing one stage 3 pressure ulcer and one unstageable pressure ulcer to the left foot. (Resident 21) Findings include: During an observation on 1/3/18 at 10:05 A.M., Resident 21 was assisted out of bed by CNA 6 and LPN 15 at which time a black surgical shoe was placed on her left foot. One Z - Boot (pressure relieving boot) was observed on the resident's chair. Resident 21 was then taken to the dining room for breakfast. During an observation on 1/4/18 at 9:15 A.M., Resident 21 was observed sitting in a wheelchair at a dining room table wearing a blue boot on her left foot. During an observation on 1/4/18 at 2:25 P.M., Resident 21 was observed in the dining room wearing a blue boot on left foot. During an observation on 1/5/18 at 9:10 A.M., Resident 21 was observed sitting in the hall wearing her black surgical walking shoe on her left foot. During an observation on 1/8/18 at 11:00 A.M., Resident 21 was observed sitting in a wheelchair wearing a black surgical shoe on her left foot. During an observation on 1/9/18 at 6:40 A.M., Resident 21 was observed in bed asleep on her left side. CNA 6 removed the blankets which covered Resident 21's feet. Resident 21 wore a blue boot on her left foot only and her right medial foot was observed resting on the mattress. The clinical record of Resident 21 was reviewed on 1/4/18 at 11:00 A.M. The clinical record indicated Resident 21 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 21 experienced cognitive impairment, needed the extensive assistance of 2 staff for bed mobility and transfers, and was at risk for developing pressure ulcers. A Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] indicated Resident 21 was at risk to develop a pressure ulcer. A progress note dated 11/16/17 at 10:51 A.M. read as follows: .L foot L side wound area examined by ADNS (Assistant Director of Nurses Services) and nurse. Dark sunken area, with reddened peri wound. Res expressed tenderness when area is touched .Noted swivel wheel on L side of w/c has bolt that touches res L foot at times. Bolt padded to prevent irritation . A Care Plan for Resident 21 dated 11/17/17 was provided by the acting DON on 1/8/18 at 2:41 P.M., and it included, but was not limited to: .Resident has impaired skin integrity: Pressure Ulcer: Left foot. Resident has decreased strength and mobility with dx [MEDICAL CONDITIONS] .can't always communicate need to be turned or repositioned . Approach Start Sate: 12/04/2017 .Avoid pressure to left foot . Approach Start Date: 12/28/2017 .Z-flo boot to left foot when in bed . Approach Start Date: 12/28/2017 .Boots to BLE at all times while in bed . Approach Start Date: 1/05/2018 .Surgical shoe left foot when up in w/c (wheelchair) . Approach Start Sate: 11/17/2017 .Turn and reposition approximately every 2 hours . Approach Start Sate: 11/17/2017 .Pressure reducing/redistribution mattress on bed . Approach Start Sate: 11/17/2017 .RD (Registered Dietician) Supplements as ordered . Approach Start Sate: 11/17/2017 .Wound healing vitamins as ordered . Approach Start Sate: 11/17/2017 .Supplement as ordered . The care plan, .Resident has impaired skin integrity ., lacked documentation with regards to floating Resident 21's feet prior to the development of the left foot pressure wound on 11/16/17. The care plan also lacked documentation, between 11/16/17 (when the pressure ulcer to the left foot developed) and 12/26/17, as to a specific intervention or interventions which would avoid pressure to Resident 21's left foot while in bed. A recap of the physician's orders [REDACTED]. Dated 4/4/17 .Apply skin prep to bilateral heels daily as prevention . Dated 12/4/17 .Limit time upon L (left) foot and avoid pressure Dated 12/21/17 - 12/28/17 .Dressing to left foot stay on dry and intact. Surgical shoe on when up in w/c (wheelchair) . Dated 12/21/17 - 12/21/17 .Leave dressing to left foot on and keep dry. No showers. Keep shoe/boot on while up in w/c. Dated 12/26/17- 1/4/18 (D/C Date) .Fluidized boots on BLE @ all times when in bed. check placement q (every) shift . Dated 12/26/17 - 1/4/18 (D/C Date) .Surgical shoe on left foot @ (at) all times when up in w/c . Dated 1/4/18 - 1/5/18 (D/C Date) .Surgical shoe to left foot for transfers and ambulation . Dated 1/4/18 - 1/5/18 (D/C Date).Z-flex fluidized to left foot Special Instructions: To be worn at all times except for ambulation and transfers . Dated 1/5/18 .Surgical shoe to be worn when up in w/c and for transfers to left foot . Dated 1/5/18 .Z-Flex boot to be worn at all times when in bed . A progress note dated 11/16/17 at 10:51 A.M. read as follows: .L foot L side wound area examined by ADNS (Assistant Director of Nurses Services) and nurse. Dark sunken area, with reddened peri wound. Res expressed tenderness when area is touched .Noted swivel wheel on L side of w/c has bolt that touches res L foot at times. Bolt padded to prevent irritation . A progress note dated 12/18/17 at 2:21 P.M., read as follows: .Daughter here and states res (resident) is developing wound on sole of L foot. Area on sole 3 cm x 1 cm, pale gray, peri wound reddened. Tx (treatment) done to area on upper outer side wound, drsg (dressing) applied to sole .Res laying (sic) in bed with feet on pillow .wound center notified . A progress note dated 12/21/17 at 10:57 A.M. read as follows: .Res returned to facility at this time. MN/O (new orders) received to leave dressing as is, do not get wet, shoe/boot on when in w/c . A progress note dated 12/23/17 at 5:12 P.M. read as follows: . Has worn special foam boot all awake hours this day . The Treatment Administration Record (TAR) for November 2017 included, but was not limited to, the following: 1. .Apply skin prep to bilateral heels daily as prevention . Order dated 4/4/17. 2. .L side L foot wound, cleanse with wound cleaner, pat dry. Apply small patch of Therahoney. Skin prep to peri wound. Cover with [MEDICATION NAME] Gentle .Once a day . Ordered 11/16/17 through 11/29/17 The Treatment Administration Record (TAR) for December 2017 included, but was not limited to, the following: 1. .Apply skin prep to bilateral heels daily as prevention .04/04/2017 . 2. .Surgical shoe on L foot @ all times when up in w/c . Intervention started day shift on 12/27/17. 3. .Fluidized boots on BLE (both lower extremities) @ all times when in bed . Interventions started night shift on 12/26/17. 4. .12/21/17 .Keep shoe/boot on when up in w/c . Intervention started night shift on 12/23/17. The Treatment Administration Record (TAR) for January 2017 included, but was not limited to the following: 1. .Surgical shoe on left foot @ all times when up in w/c . Order dated 12/26/17 and was discontinued on 1/5/18. 2. .Fluidized boots on (unable to read letter) LE @ all times when in bed .light blue air boots . Order dated 12/26/17 and was discontinued on 1/5/18. 3. .Surgical shoe to be worn when up in w/c and for transfers to Left foot Every Shift . Order dated 1/5/18. 4. .Z-Flex to be worn at all times when in bed . Order dated 1/5/18 2. .Z-Flex boot to be worn at all times when in bed . Intervention started night shift on 1/5/17. A laboratory report dated 11/6/17 indicated Resident 21's lab values (blood levels) were as follows: Total protein was low at 5.9 g/dl (grams per deciliter). The normal range for protein is 6.4 - 8.2 g/dl. [MEDICATION NAME] was low at 3.0 g/dl. The normal range for [MEDICATION NAME] is 3.5 - 5.0 g/dl. The laboratory report dated 1/2/18 indicated Resident 21's lab values (blood levels) were as follows: Total protein was low at 6.1g/dl. The normal range for protein is 6.4 - 8.2 g/dl. [MEDICATION NAME] was low at 2.8 g/dl. The normal range for [MEDICATION NAME] is 3.0 - 4.8 g/dl. The WOUND CARE CENTER RECORD dated 12/1/17 read as follows: .Ulcer type .Pressure .(Size in cm) .Length 0.9 . Width 0.6 .Depth . Obs Area 54 The Physicians orders from the Wound Care Clinic for 12/1/17 indicated the pressure ulcer was located on the left lateral foot. Special Instructions: read as follows: .*Plan for TCPO2 (Transcutaneous oxygen tension) .*Z-Flex fluidized boot L foot . The Z- Flex fluidized boot was not implemented until 12/29/17 The WOUND CARE CENTER RECORD dated 12/8/17 read as follows: .Ulcer type .Pressure .(Size in cm) .Length 1.2 . Width 1.2 .Depth 0.1 .Area 1.44 .Stage Unstageable .Thickness .Full . The Physicians orders from the Wound Care Clinic for 12/8/17 indicated the unstageable pressure ulcer was located on the left lateral foot .limit time on L foot, Avoid pressure. Special Instructions: read as follows: .*(Facility Name) to *Please get Z-Flex fluidized boot for pt (patient) to wear at nighttime while sitting or lying in bed . The Z- Flex fluidized boot was not implemented until 12/29/17 The WOUND CARE CENTER RECORD dated 12/21/17 read as follows: Wound 1 .Ulcer type .Pressure .(Size in cm) .Length 0.8 . Width 0.6 .Depth 0.2 .Area 0.48 .Thickness .Full . Wound 2 .L Plantar foot Ulcer type .Pressure .(Size in cm) .Length 0.7 . Width 1.8 .Depth 0.1 .Area 1.26 .Thickness .Full .New . The Physicians orders from the Wound Care Clinic for 12/21/17 indicated Resident 21 had an unstageable pressure ulcer on the left lateral foot and a Stage 3 pressure ulcer on the plantar (bottom) surface of the left foot. The pressure reduction and prevention measures were ordered to do the following: .Limit time on L foot, Avoid pressure .Surgical shoe L foot . Special Instructions: read as follows, .*(Facility Name) to get pt a Z-Flex fluidized boot for pt to wear when sitting or lying . The WOUND CARE CENTER RECORD dated 12/28/17 read as follows: Wound 1 .L lateral foot .Ulcer type .Pressure .(Size in cm) .Length 0.9 . Width 0.8 .Depth 0.1 .Area 0.72 .Thickness .Full . .Daughter states pt has received z_flex fluidized boots on 12/25/17 Wound 2 .L Plantar foot Ulcer type .Pressure .100% [MEDICATION NAME] The pressure reduction and prevention measures were ordered to do the following: .Limit time on L foot, Avoid pressure .Surgical shoe L foot . Special Instructions: read as follows: .*Pt to continue wearing Z-Flex boot when sitting or lying . The WOUND CARE CENTER RECORD dated 1/5/18 read as follows: Wound 1 .L lateral foot .Ulcer type .Pressure .(Size in cm) .Length 0.7 . Width 0.7 .Depth 0.1 .Area 0.49 .Thickness .Full . Wound 2 .L Plantar foot Ulcer type .Pressure .100% [MEDICATION NAME] The pressure reduction and prevention measures were ordered to do the following: .Limit time on L foot, Avoid pressure .Z-Flex boot while in bed .Surgical shoe L foot . A wound care center note was provided on 1/10/18 at 9:15 A.M. by RN 22. The Transcutaneous oxygen tension report read as follows: .Oxygen pressures reached 5mmHg to the dorsal left foot .Greater than 40 is predictive of wound healing. Based on these findings, tissue oxygenation appears to be adequate for wound healing . A purchase order dated 12/18/17 was provided by the Regional Nurse on 1/10/18 at 12:00 P.M., and indicated that an inflatable air boot with a hand pump had been ordered on [DATE]. A purchase order dated 12/27/17 was provided by the Regional Nurse on 1/10/18 at 12:00 P.M., and it indicated a Z - Flex Heel protection boot had been ordered on [DATE]. During an interview on 1/9/17 at 12:15:P.M., CNA 6 indicated Resident 21 should wear the black boot when seated in her wheelchair and should wear the blue boot while in bed. CNA 6 indicated she had the Z-Flex boot for about a week. During an interview on 1/9/17 at 12:30 P.M., the Director of Nursing (DON) indicated there had been an order from the wound care clinic on 12/1/17 for a Z- Boot for Resident 21's left foot. The DON indicated the Z-Boot was not ordered by the facility until 12/18/17 because there was a miscommunication between the wound care clinic and the facility as to who was responsible for obtaining the Z-Boot. The DON indicated that on 12/18/17 that Resident 21's daughter brought to the facility's attention the information that her mother had developed a second pressure ulcer on the plantar surface of her left foot and that Resident 21 did not have a Z-Boot and that the facility was responsible for purchasing the boot. The DON indicated she called the wound care clinic on 12/18/17 and clarified the order. The Z-Boot was ordered that day. The DON further indicated the Z-Boot arrived on 12/21/17. The DON indicated there had been some confusion as to when the Z-Boot was supposed to be worn and when the surgical shoe was supposed to be worn. The order was clarified on 1/5/18 when Resident 21 went to the wound care clinic for an appointment. The wound care clinic clarified the order as follows: Resident 21 was supposed to wear the Z-Boot while in bed and the surgical shoe was supposed to be worn when Resident 21 was seated in a chair. The DON indicated the intervention in place between 11/16/17 (when the pressure ulcer developed on the left foot) and 12/21/17 (when the Z-Boot arrived) was to turn and reposition the resident every 2 hours, skin prep to bilateral heels, and the wound treatments ordered by the physician. During an interview on 1/10/18 at 12:01 P.M., the Regional Nurse indicated a pressure relieving boot had been ordered on [DATE], but it was determined to be the wrong type of boot when it arrived. A second pressure relieving boot was ordered on [DATE]. A Policy and Procedure for SKIN MANAGEMENT PROGRAM was provided on 12/16/15 at 2:53 P.M. by RN 11. The procedure read as follows: .3. Interventions will be initiated based upon the individual's risk factors to include, but not limited to, the following: .Redistribute pressure ( .protecting or off loading heels, ect .) . STAGES OF PRESSURE ULCERS, AMDA - 2008, the following was included: Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Unstageable: Full thickness tissue loss in which the base of the ulcer covered by slough ( yellow, tan, green or brown) and /or eschar (tan, brown or black) in the wound bed 3.1-40(a)

A. Based on observation, interview, and record review, the facility failed to ensure services were provided to prevent falls, in that, a resident identified as being a risk to fall experienced a fall for 1 of 3 residents, who met the criteria for review of falls. This deficient practice resulted in Resident #36 experiencing a left wrist fracture. (Resident #36) B. Based on observation, interview, and record review, the facility failed to ensure a resident received adequate supervision and/or interventions were properly implemented and/or provided to prevent falls for a resident identified as being a high risk for falls for 1 of 3 residents who met the criteria for review of falls. (Resident #26). Findings include: A 1. On 09/17/15 at 8:30 A.M., Resident #36 was observed in a hallway, sitting in a wheelchair. Resident #36 was observed, at that time, to have a bruise under the left eye and a cast to the left upper extremity. During an interview 09/17/14 at 8:40 A.M. LPN #11 indicated Resident #36 had attempted to stand and ambulate independently, experienced a fall, and broke her arm sometime in the previous 10 days. The clinical record of Resident #36 was reviewed on 09/17/14 at 1:00 P.M. The record indicated the [DIAGNOSES REDACTED]. The Annual MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #36 experienced severe cognitive impairment, balance deficits, and no behaviors. The MDS further indicated Resident #36 required the extensive assistance of two staff for transfers and had a history of [REDACTED]. A Fall /Injury Assessment: Prevention and Management Care plan dated 05/02/14 for Fall/Injury Risk included, but was not limited to, an intervention dated 05/02/14 for ".. general supervision..." The revised care plan dated 06/26/14 identified a new intervention of, "... increased supervision..." The most recent Quarterly MDS assessment dated [DATE] indicated Resident #36 experienced severe cognitive impairment, balance deficits, and behaviors. The MDS further indicated Resident #36 required the extensive assistance of two staff for transfers and had a history of [REDACTED]. A Physician's Progress note dated 07/16/14 indicated, "..She does have a history of dementia...recently she had increased falls..." A Nurse's note dated 09/03/14 at 12 :00 P.M., indicated, "Spoke to therapy re: resident significant decline in ambulation. Resident shakey (sic) and walking with knees bent..." A Nurse's note dated 09/03/14 at 9:30 P.M., indicated, "Resident up and down all evening. Would not lie or sit over 5-10 minutes at time. Res toileted and redirect numerous times. Resident has spoken jibberish (sic) frequently. ..." A Nurse's note dated 09/04/14 at 5:45 P.M., indicated, "Res lying sideways in bed, attempted to kick nurse when attempting to give medications..." A Nurse's note dated 09/04/14 at 8:00 P.M., indicated, "... Resident agitated..." A Nurse's note dated 09/09/14 at 4:00 A.M. indicated, "Res has been up pacing/wandering in halls since beginning of shift. Res states I don't know what to do, I am afraid, looking for her sons. attempts to redirect resident unsuccessful. Resident given snack, warm milk, books to read. 1 on 1 care. Resident also given Tylenol for general discomfort. Res very restless staff will assist res (resident) to bed but she gets up within 1-2 minutes. Resident does the same when sitting in lobby-staff will get her to sit down-but she gets up within 1-2 minutes. unable to keep resident attention with any activity. Wanderguard (a door-locking device) is in place and functioning. no exit seeking noted." A Nursing note dated 09/09/14 at 2:55 P.M., indicated, "...This nurse setting (sic) at nurses (sic) station, heard noise in front lobby. Looked up and saw resident lying on floor on her stomach. Head turned to the right side and touching the wallboard..." A Care Conference Note dated 09/10/14 indicated, "Resident was assisted to the lounge area with 1 CNA. Seated in a chair moments later the resident got up out of chair. Lost her balance and fell ...noticeable malformation of the left wrist. NP (Nurse Practitioner) notified ... anti-anxiety medication administered after after (sic) pain med, distraction, diversion and 1-1 was unsuccessful..." A FNP (Family Nurse Practitioner) Progress note dated 09/11/14 displaced left dist (distal) radius fx (fracture). Closed reduction with left arm cast placement. Elevate as much as possible..." During an interview on 09/18/14 at 10:30 A.M., RN #10 indicated Resident #36 experienced a recent fall and incurred a fractured left wrist. RN #10 further indicated, at that time, Resident #36 experienced agitation, confusion, and/or decreased safety awareness for several days prior to the fall. During an interview on 09/19/14 at 11:15 A.M. the HFA (Health Facilities Administrator) indicated a CNA had assisted Resident #36 to a stationary chair outside of the DON's office, served Resident #36 a snack, and turned away from Resident #36 and continued to pass snacks to the other residents in the dining room. The HFA then indicated she was walking from behind the nurse's station towards her office and a nurse was seated at the nurse's station. The HFA further stated, at that time, Resident #36 was "...extremely impulsive and high risk to fall..." and indicated no one could get to the resident in time to prevent the fall. During an interview on 09/19/14 at 2:00 P.M., the DON (Director of Nursing) indicated Resident #36 experienced a fall on 09/09/14 and further indicated, at that time, Resident #36 was not supervised closely enough in the dining room to prevent the fall. B1. On 9/17/14 at 10:30 A.M., Resident #26 was observed her room lying in bed. The clinical record for Resident #26 was reviewed on 9/19/14 at 8:34 A.M., [DIAGNOSES REDACTED]. The facility Interdisciplinary team notes included: Fall #1 occurred on 2/5/14, Resident found on restroom floor, she had been incontinent of bowel and bladder and had removed the clothing on her bottom half. The immediate intervention added was Imodium (an anti diarrheal medication). Fall # 2 occurred on 2/5/14, Resident found on restroom floor had been incontinent of bowel and bladder. Immediate intervention added was Imodium. Fall #3 occurred on 2/9/14, Resident was sitting in a glider rocker and slid with seat cushion to floor. The immediate intervention added was Resident #26 was not to be placed in the rocker anymore. Fall #4 occurred on 2/19/14 Resident fell out of glider rocker in dining room. The immediate intervention was staff education not to place Resident #26 in the rocker anymore and dycem was placed under seat cushion. Fall #5 2/27/14 Resident fell in room attempting to ambulate from wheel chair to a recliner without assistance. The immediate intervention was to add a self release seat belt to the wheel chair. Fall #6 occurred on 4/1/14. Resident #26 was found sitting on the floor in her room beside the bed. The immediate intervention was adding non skid strips to floor. The Nursing progress notes include: Fall #7 occurred on 7/10/14. Resident #26 found lying on side beside bed. The immediate intervention was to place a pillow under her right side. Fall #8 occurred on 8/31/14. Resident #26 was found lying on floor on her left side. The immediate intervention was to provide an electric bed so it could be placed in the lowest position. The care plans include, but were not limited to, an ADL (activities of daily living)/ MOBILITY CARE PLAN imitated 2/28/14 which indicated Resident #26 will transfer with one assist. A "FALL/INJURY ASSESSMENT: PREVENTION AND MANAGEMENT PLAN OF CARE" was imitated 2/28/14 related to a history of falls, dementia and Alzheimer's. Interventions include, but were not limited to, increased supervision, educated resident/responsible party as needed and scheduled toileting all dated 2/28/14. Also included were low air loss mattress undated, pillow to right side while in bed added 7/11/14 and an electric bed dated 8/31/14. The Director of Nursing was interviewed on 9/22/14 at 9:20 A.M. in regards to the falls. She indicated Resident #26 was not on a toileting program at the time of the first fall because of her cognition. She indicated Resident #26 was at risk for falls. She indicated she was aware that Resident #26 had fallen twice out of the glider in the dining room and that staff were educated not to use it after the second fall. She further indicated that Resident #26 falls from bed were due to Resident #26 having decreased safety awareness and being able to get up from the bed. The Falls and Injuries Policy and Procedure provided by the ADON (Assistant Director of Nursing) on 09/19/14 at 8:31 A.M. indicated, "... provide an environment that is free from hazards over which the center has control and provides supervision... to each resident to prevent avoidable accidents...Hazards refer to elements of the resident environment that have potential cause of injury or illness. "Hazards over which the center has control" are hazards where reasonable efforts could influence the risk resulting in injury. "Free of accident hazards as much as possible" refers to being free of accident hazards over which the center has control...Supervision/Adequate Supervision...Adequate supervision is defined by the type and frequency of supervision, based on the individual resident assessed needs and identified hazards in the resident environment. Supervision may vary resident to resident and time to time for the same resident. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure effective interventions were provided for a dependent resident, in that, a resident admitted without a pressure ulcer later developed a pressure ulcer for 1 of 1 resident who met the criteria for review of pressure ulcers. This practice of failed interventions resulted in Resident #23 experiencing a deep tissue injury wound that progressed to a stage 3 pressure ulcer. (Resident #23) Findings include: During an observation on 09/22/14 at 12:13 P.M., Resident #23 was in the dining room sitting in her wheelchair with her left foot elevated. The clinical record of Resident #23 was reviewed on 09/19/14 at 2:15 P.M. The record indicated the [DIAGNOSES REDACTED]. The Admission Assessment for Resident #23 dated 01/10/14 (Returned from hospital after L [MEDICAL CONDITION]) read as follows, "...Psychiatric:...some memory loss...SKIN: some [MEDICAL CONDITION]" Documentation as to the location of the [MEDICAL CONDITION] was lacking. The physician's orders [REDACTED]. The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #23 experienced cognitive impairment, required the extensive assistance of two plus staff for bed mobility (how resident moves to and from lying position, turn side to side, and position body while in bed or alternate sleep furniture), was at risk for the development of pressure ulcers, and had no pressure ulcers upon readmission from the hospital. A Braden Risk assessment dated [DATE] indicated Resident #23 "...Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently..." and was a moderate risk for the development of pressure areas. A Resident Lifting, Transferring and Repositioning Data Collection Form dated 1/9/14, read as follows, "...1. Resident's level of assistance:...Total Dependence...4. Resident's level of cooperation: Unpredictable or varies...resident whose behavior changes frequently should be considered "unpredictable", not cooperative or unable to follow simple commands...7...b. Repositioning...2 (staff) or 3 (staff) for repositioning in bed. A Skin Grid-Pressure report provided by the DON (Director of Nursing) on 09/22/14 at 2:40 P.M., included, but was not limited to, an entry dated 02/11/14 which indicated, "...Deep tissue...(suspected) DEEP TISSUE INJURY Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear)...1.8 X 1.2 X 0.1 cm (centimeters)...color B (black - (escar))..." A Skin Grid-Pressure report provided by the DON (Director of Nursing) on 09/22/14 at 2:40 P.M., read as follows, "...STAGING DESCRIPTIONS...UNSTAGEABLE Full thickness loss in which the base of the ulcer is covered by ...eschar (tan, brown, black) in the wound bed..." physician's orders [REDACTED].M.) read as follows, "...Stage 3 Pressure Ulcer to L (left) distal Achilles complicated by diabetes,[MEDICAL CONDITION](hypertension, hx (history of [MEDICAL CONDITIONS] and [MEDICAL CONDITION]" A Progress Note dated 2/11/2014 07:10 A.M., indicated "...Resident abed ( in bed) without pressure relief boots in place...Pressure area 1.8 x (by) 1.2 x 0.1 cm (centimeters) to lt (left) Achilles Cleansed with wound cleaner et (and) skin prep applied...Provider Orders: Cleanse with wound cleaner et (and) apply skin prep bid x 2 weeks et reeval.(reevaluate)...Date Notified: 2/11/14...Time Notified: 09:25 AM...Nurses Notes: Additional Comments Resident instructed to leave boots in place while abed (in bed)..." A Nurse's Note dated 2/11/14 at 1:45 P.M. indicated, "...Total depend (dependent) with transfers...New area found on L (left) Achilles...N.O. (new orders) DC (discontinue) Teds (compression stockings). Apply skin prep BID x (times) 14 d (days) et (and) eval. 2 asst (assistance) with ADL's (activities of daily living)..." A physician's orders [REDACTED].@ (at) Wound Clinic eval (evaluation) et (and) tx (treatment) L (left) ankle..." Care Plan Skin integrity Assessment: dated 1/10/14 read as follows "prevention and treatment plan of care ...moderate risk (13-14) ...protect heels...goal Will remain free of open areas...care plan dated 2/11/14 protect elbows and heels as needed. 10/9/13" A Physical Therapy Note dated 2/12/14 read as follows. "Education with staff about importance of donning foam boots when pt (patient) is in bed to avoid further skin breakdown on heel." During an interview on 9/22/14 at 4:15 P.M., Occupational Therapy Assistant #5 indicated a physical therapist would educate staff if they noticed a resident was not wearing protective boots or if a staff member made a referral indicating the resident was not wearing their foam boot. During an interview on 9/23/14 at 10:10 A.M., the Director of Nursing (DON) indicated Resident #23 was at risk of developing a pressure ulcer upon returning from the hospital. The DON further indicated Resident #23 found the foam boots uncomfortable and would remove them herself. The DON indicated Resident #23 would reach down and loosen the straps and remove her right boot, then use her right foot to push down on the left boot until it was off her foot. The DON indicated she had educated Resident #23 about keeping the boots on. No new interventions were added to the care of Resident #23 when the staff were made aware the resident was removing her own protective boots 3.1-40(a)(1)

Based on interview and record review, the facility failed to ensure a resident with a walking boot did not develop 6 pressure sores, of which 3 were unstageable, beneath the walking boot for 1 of 1 residents reviewed for pressure sores with boot type devices. Resident # 33 Findings include: On 8/7/13 at 2 P.M., the clinical record of Resident #33 was reviewed. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set Assessment) dated 5/20/13 indicated the following for the resident: moderately impaired cognition; extensive assistance for bed mobility, transfers and personal hygiene; "yes" for pressure ulcer risk; currently had no pressure ulcers. Nurses notes dated 5/13/13 at 7 P.M. indicated the following for the resident: "...new admit...from (name of hospital)...non wt (weight) bearing of rt (right) foot d/t (due to) fx (fracture) of foot and toe. Boot cast applied...no [MEDICAL CONDITION] to BLE (bilateral lower extremities) noted. Toes of rt foot warm with < 3 sec (second) cap (capillary) refill..." A "Skin Integrity Assessment: Prevention and treatment Plan of Care" was dated 5/14/13 and included, but was not limited to, the following: "Braden Risk Assessment Score: 18. At risk 15 - 18...Very high risk (score of 9 or below)...Frequent turning...protect heels, manage...friction and shear...pressure reduction support surfaces..." Interventions included, but were not limited to, the following: "...protect elbows and heels if being exposed to friction and shear...inspect the skin for s/s (signs and symptoms) of breakdown...provide padding for casts, braces, splints..." Nurses notes dated 6/12/13 at 1 P.M., indicated the resident "LOA (leave of absence) to appt (appointment) at (name of Foot and Ankle Physician)." Nurses notes were reviewed from 5/13/13 to 6/12/13 and documentation was lacking of the circulatory status being checked twice a day to the right foot on all days, with the exception of 5/27/13. A physician progress notes [REDACTED]. At time went to (name of hospital emergency room )...Placed in walking boot...placed in nursing home...patient still in walking boot...there are, however, numerous dark red pressure sores due to cast being too tight. None have ulcerated as of yet..." A facility nursing progress note dated 6/12/13 at 2:30 P.M., indicated the following: "...noted several pressure areas to right foot: 1. Right side mid foot unstageable (full thickness tissue loss in which the base of the ulcer is covered by...eschar (tan, brown or black) in the wound bed...measuring 1.3 cm (centimeters) x 2.2 cm with eschar. 2. Right side of foot near pinkie toe measuring 2.1 cm x 1.7 cm, unstageable with eschar; 3. Bottom of great toe stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence) measuring 0.3 cm x 0.2 cm; 4. Top of right foot near bunion stage 1, measuring 0.2 cm x 0.4 cm; 5. Left top of right foot stage 1 measuring 0.3 cm x 0.4 cm; 6. Left side of right foot bunion unstageable measuring 1.8 cm x 1.7 cm." On 8/8/13 at 8:07 A.M., the Physical Therapy (PT) Director was interviewed. She indicated the resident was admitted on [DATE], with a boot type device on her right foot. The PT Director indicated the resident was NWB (non weight bearing) to her right foot initially and required total assistance for transfers on admission. The PT Director indicated the resident began Physical Therapy on 5/14/13. She indicated upon admission, the resident had a walking type boot on her right foot that was capable of being removed, although there was no order to do so. The PT Director indicated Physical Therapy did "nothing with the boot." She indicated the resident was seen at the foot and ankle specialist on 6/12/13 and the resident was discharged home on[DATE]. On 8/8/13 at 8:50 A.M. the DON was interviewed. She indicated the boot to the right leg, covered the leg from just below the knee to the foot, with the area from the base of the toes to the tips of the toes being exposed. She indicated there were velcro straps on the boot so the boot could have been removed. The DON indicated there was no order to take the boot off or to leave it on, no order directing staff what to do with the boot. The DON indicated staff should have checked the toes for warmth and blanching and should be done at least twice a day. The DON indicated this should be documented in nurses notes and /or the treatment administration record (TAR). The DON indicated when the resident returned on 6/12/1, she had an order to wear street shoes and leave the boot off. The resident was discharged home on[DATE]. On 8/9/13 at 9:40 A.M., the DON (Director of Nursing) was interviewed. She indicated when the resident returned to the foot and ankle specialist on 6/12/13 and had the walking boot initially removed, the facility was made aware of the pressure sores to the resident's right ankle. The DON indicated at the time, they saw they had an opportunity for improvement. She indicated they did a detailed analysis of the resident and/or her stay at the facility from admission to 6/12/13. The DON indicated the analysis revealed the facility did not have a copy of discharge instructions from the emergency room and/or did not have a physician order [REDACTED]. She indicated when team members went to the resident's room, they didn't see the boot as it was covered by a sheet. The DON indicated on admission, the resident's Braden Skin Risk assessment indicated she was a low risk to develop pressure sores. The DON indicated the nurses did not remove the resident's walking boot as there was no order to remove the boot. She indicated at the time, the facility should have had orders to address care and monitoring of the boot and right extremity. She indicated the nurse performing the weekly skin assessments did not remove the boot because there was no order to do so. The DON indicated at the time, nursing staff should have documented the presence of the walking boot, and notified the physician for clarification on the care and/or removal of the boot, skin care parameters On 8/9/13 at 10 A.M., the DON was interviewed. She indicated the facility should have monitored the circulatory status of the resident's right foot, while the boot was in place. She indicated this would include, but was not limited to, the warmth of the toes, capillary refill (applying pressure to the nail beds to assess circulation of the extremity) of the toe nail beds and [MEDICAL CONDITION]. The DON indicated the circulatory status of the foot should have been monitored on the day and evening shift. She indicated this would be documented in the nurse ' s notes. The DON indicated when the resident saw the foot and ankle specialist on 6/12/13, it was noted the resident had [MEDICAL CONDITION]. She indicated the resident had traveled to the physician's office so had her leg down, thus contributing to the [MEDICAL CONDITION] noted by the specialists. 3.1-40(a)(1)