Every finding on record at Woodmont Health Campus

Based on interview and record review, the facility failed to ensure a resident's right to privacy for 1 of 3 resident's reviewed for resident rights. An employee took an unauthorized video of a cognitively impaired resident with a personal cell phone. (Resident C) This deficient practice was corrected on May 11, 2026, prior to the start of the survey, and was therefore past noncompliance.Finding includes:Review of facility reported incidents on 6/11/26 at 10:30 A.M., a reported incident dated 5/5/26 at 5:03 P.M. indicated CNA 4 was taking a video in the hallway of Resident C. The video was approximately five seconds long and was taken on the employee's personal cell phone. Review of Resident C's clinical record indicated the resident's diagnoses included but were not limited to cognitive communication deficit, abnormal posture, abnormalities of gait and mobility, lack of coordination, and major depression. The most recent annual Minimal Data Set (MDS) dated [DATE], indicted the resident had severe cognitive impairment. An interview on 6/11/26 at 11:15 A.M., the Activity Director indicated that only the Activity Staff and certain facility leaders are authorized to photograph or video residents who have given consent. The Activity Director indicated CNA's and nurses are not authorized to take photographs or videos of the residents while providing care and if she were to see a staff member doing so, she would ensure the photograph or video was deleted immediately. The Activity Director indicated she has had to ask staff to delete an unauthorized video or photograph of a resident. On 6/11/26 at 12:10 P.M., the Facility Administrator supplied a facility policy titled Cell Phones, Cameras, and Electronic Devices Policy, dated 10/3/25. The policy included, This policy is designed to maintain excellent customer service, comply with healthcare regulations, and protect residents' rights to privacy and confidentiality. It is of utmost importance to avoid taking or using photographs or making recording that might be demeaning, humiliating or could potentially cause emotional or mental abuse to a resident . The Company prohibits unauthorized use of personal cell phones, cameras and electronic devices in work areas in the health campus . Unauthorized taking . of photographs and/or recordings . is prohibited .The deficient practice was corrected on 5/11/2026 after the facility implemented a systemic plan that included the following actions: an action plan included in-service review of policies for Electronic Devices including cell phone, photo, video and Social Media, additional in-service for HIPPA was included for all staff, and the on going monitoring of staff. This citation relates to intakes 2997844 and 3032233. 410 IAC 16.2-3.1-3(t)

Based on interview and record review, the facility failed to ensure pharmaceutical services were available to provide physician prescribed routine medications to 2 of 3 residents reviewed for pharmacy services. Physician prescribed routine medications were not administered due to the medications being unavailable at the facility. (Resident B, Resident C)Findings include:1. During an interview on 3/13/26 at 10:35 A.M., Resident B indicated that staff had informed her on more than one occasion that they were out of her routine medications. During record review on 1/9/25 at 11:20 A.M., Resident B's diagnoses included but were not limited to, heart failure, kidney failure, type II diabetes, anemia, Systemic Inflammatory Response Syndrome (SIRS), and acute upper respiratory infection. Resident B's physician orders included, but were not limited to:- Carboxymethylcellulos sodium 0.5% (artificial tears), administer one drop in each eye three times a day, started 2/23/26.- Ferrous sulfate (iron supplement) 325 milligrams (mg) once a day, started 12/31/25.- Insulin Lispro pen (fast acting insulin) 100 units/milliliter (sliding scale) before meals, started 2/23/26.- Ipratropium-albuterol solution for nebulization (medication to treat breathing difficulties) 0.5 mg - 3 mg / 3 ml every four hours, started 2/1/26.- Methylprednisolone (steroid )4 mg three times a day, started 2/5/26. Resident B's Medication Administration Record (MAR) for February 2026 indicated the resident did not receive the prescribed medications due to the medications being unavailable on the following dates:- Carboxymethylcellulos sodium 0.5%, administer one drop in each eye three times a day - 2/24/26 (6:00 P.M. - 10:00 P.M.)- Ferrous sulfate 325 milligrams (mg) once a day - 2/16/26- Insulin lispro pen 100 units/milliliter (sliding scale) before meals - 2/25/26 (6:30 A.M. - 9:00 A.M)- Ipratropium-albuterol solution for nebulization 0.5 mg - 3 mg / 3 ml every four hours - 2/8/26 (8:00 A.M.)- Methylprednisolone 4 mg three times a day - 2/7/26 (6:00 A.M. - 10:00 A.M.)2. During record review on 3/13/26 at 11:00 A.M., Resident C's diagnoses included, but were not limited to, type II diabetes, heart failure, and kidney failure. Resident C's physician orders included, but were not limited to:- Cyancobalamin (vitamin B-12) 1,000 micrograms (mcg) once a day, started 1/29/26.- Novolog FlexPen (fast acting insulin) U-100 insulin 100 units/ml - administer 8 units three times a day, started 1/15/26. Resident B's Medication Administration Record (MAR) for January 2026 indicated the resident did not receive the prescribed medications due to the medications being unavailable on the following dates:- Cyancobalamin (vitamin B-12) 1,000 micrograms (mcg) once a day - 1/30/26- Novolog FlexPen U-100 insulin 100 units/ml - administer 8 units three times a day - 1/15/26 (6:00 P.M. - 10:00 P.M.)On 3/13/26 at 3:36 P.M., the Administrator supplied a facility policy titled, Medication Administration - General Guidelines, dated 01/2018. The policy included, .The facility has sufficient personnel and a medication distribution system to ensure safe administration of medications without unnecessary interruptions . 2. Medications are administered in accordance with written orders of the prescriber .This citation relates to Intake 2723125. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(a)

Based on interview and record review, the facility failed to ensure residents were free of significant medications errors for 1 of 3 residents reviewed for pharmacy services. A resident received a double dose of insulin and received another resident's medications. (Resident C) Finding includes:During record review on 3/13/26 at 11:00 A.M., Resident C's diagnoses included, but were not limited to, type II diabetes, heart failure, kidney failure, anxiety, and depression. Resident C's most recent annual Minimum Data Set (MDS) assessment, dated 2/2/26, indicated the resident had no cognitive impairment and received insulin, antidepressant, diuretic, anticoagulant, hypoglycemic, and anticonvulsant medications during a seven day look back period. Resident C's nurses progress notes included but were not limited to:12/1/25 at 3:25 P.M. - Time of occurrence: 11/30/25 at 12:30 P.M. - Medication Error. Resident was given insulin twice by two different nurses. Resident received Novolog 10 units twice due to it was not clicked off on the Medication Administration Record (MAR) and nurse was unaware that the insulin had already been administered by another nurse. Resident C's January 2026 MAR indicated routine evening medications were held due to the resident's condition on 1/16/26. An order to monitor neuro-check assessments was started on 1/16/26 at 8:30 P.M. An Event Report, dated 1/16/26 at 7:14 P.M., indicated a medication error was made involving Resident C. The resident received Xanax (anti-anxiety) 0.5 milligrams (mg), atorvastatin (anti-hyperlipidemia) 40 mg, Aricept (a medication used to treat dementia) 10 mg, metoprolol (anti-hypertensive) 25 mg, Remeron (anti-depressant) 7.5 mg, Singulair (anti-asthmatic) 10 mg, ranolazine (a medication to treat chronic chest pain) 500 mg, and ropinirole (anti-Parkinson's) 1 mg. A description of the error included, wrong resident and wrong medication. Reason for error included, wrong resident.During an interview on 3/13/26 at 11:25 A.M., LPN 4 indicated she administered Resident C's medications on the evening of 1/16/26. LPN 4 indicated she mistakenly administered Resident C's roommate's medications to Resident C. During an interview on 3/13/26 at 1:30 P.M., QMA 6 indicated nursing staff should use the five rights when administering medications. Nursing staff should ensure the correct resident, correct medication, correct dose, correct route, and correct time by checking orders in the resident's record. On 3/13/26 at 3:36 P.M., the Administrator supplied a facility policy titled, Medication Administration - General Guidelines, dated 01/2018. The policy included, .The facility has sufficient personnel and a medication distribution system to ensure safe administration of medications . B. Administration . 7) Residents are identified before medication administration. Methods of identification include a. Checking photograph attached to medical record. b. Calling the resident by name . c. Having the resident verify his/her last name d. If necessary, verifying resident identification with other facility personnel .This citation relates to Intake 2723125. 410 IAC (Indiana Administrative Code) 16.2-3.1-48(c)(2)

Based on observation, interview, and record review, the failed the obtain the temperature of the food prior to serving the residents for 1 of 1 plating observations. Finding includes:During an observation of plating on 8/28/25 at 6:02 A.M., [NAME] 17 utilized tongs and scoops to place the food items on the plates to serve the residents.During an interview on 8/28/25 at 6:06 A.M., [NAME] 19 indicated a computerized system was used to log the temperatures of the food items. At that time, she pulled up the temperature log on the computerized system, and the log was blank. [NAME] 17 continued plating and indicated temperatures should have been obtained by [NAME] 21. At that time, [NAME] 21 indicated the Dietary Manager should be in the facility at any time, and refused to answer on if the temperature of the food was obtained.On 6/28/25 at 6:09 A.M., the Dietary Manager entered the kitchen and looked on the computerized system to find the temperature log. At that time, he talked to [NAME] 21, and then indicated that [NAME] 17 had to stop plating food, and he began to take the temperature of all food items (oatmeal, gravy, scrambled eggs, sausage links, puree eggs, and mechanical meat).On 8/29/25 at 11:56 A.M., Clinical Support 1 provided a current Food Safety and Handling policy, reviewed 6/2016 that indicated, .reaching proper temperatures within an appropriate time period can help ensure that food is safest to eat. Cooks must know the proper temperatures.3.1-21(a)(2)

Based on interview and record review, the facility failed to clarify a Resident's code status for 1 of 1 residents reviewed for advanced directives. A resident's current Physician's Order did not match the signed Indiana Physician Orders for Scope of Treatment form, and staff was unaware of Resident's wishes. (Resident 56)Finding includes:On 8/29/25 at 11:17 A.M., Resident 56's daughter visited while Resident 56 was asleep in bed. At that time, the daughter indicated Resident 56 did not want to be intubated.On 8/27/25 at 10:16 A.M., Resident 56's clinical record was reviewed. Diagnosis included, but were not limited to, metastatic stage 4 cancer.Resident 56's admission Minimum Data Set (MDS) assessment was in progress and had not been completed.Physician Orders included, but were not limited to the following: CODE STATUS: No chest compressions. May intubate, dated 8/22/25A current POST form indicated, Limited Additional Interventions.Do not intubate, signed 8/22/25Resident 56's clinical record lacked a care plan related to code status.During an interview on 8/29/25 at 11:19 A.M., Registered Nurse (RN) 23 indicated if Resident 56 coded, he wished to be intubated.During an interview on 8/29/25 at 11:31 A.M., Clinical Support 1 indicated Resident 56's code status was Do Not Resuscitate (DNR) which indicated he should not be intubated.On 8/29/25 at 11:56 A.M., Clinical Support 1 provided a current Guidelines for Advanced Directives policy, revised 9/26/24, that indicated, . 1. Advanced Directives will be reviewed with resident and/or resident representative by the Admissions Representative or designee at time of admission. A member of the IDT will review and/or updated quarterly and PRN thereafter. 2. The resident or representative will advise the admissions representative/designee regarding wishes for end of life directives and code status.6. The nursing staff will confirm the desired code status and obtain an order from the physician. Verbal Wishes if witnessed by 2 people will be honored until an order is officially obtained . The DNR form will be completed documenting these desires and scanned into the medical record.3.1-4(l)(5)

Based on observation. interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised for 1 of 2 residents reviewed for urinary tract infections (UTI), 1 of 3 residents reviewed for pressure ulcers, and 2 of 5 reviewed for unnecessary medications. Residents who were not on antianxiety medication and no longer had a UTI had care plans that were not removed and a resident with multiple pressure ulcers did not have wound specific care plans. (Resident 6, Resident 18, Resident 45, Resident 1)Findings include:1. On 8/27/25 at 8:04 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, severe dementia with psychotic disturbance and adjustment disorder. The most recent quarterly Minimum Data Set (MDS) assessment, dated 8/7/25, indicated Resident 6's cognition was severely impaired and she was taking an antipsychotic, antidepressant, diuretic and opioid medication. Current Physician's Orders lacked an order for an antianxiety medication. Current Care Plans included a Risk for Adverse Consequences related to Antianxiety Medication Care Plan, last reviewed 8/22/25. 2. On 9/2/25 at 10:23 A.M., Resident 18's clinical record was reviewed. Diagnoses included, dementia with behaviors and depression. The most recent quarterly MDS assessment, dated 7/18/25, indicated Resident 18 was cognitively intact and taking an antipsychotic, antiplatelet, hypoglycemic, anticonvulsant, and antidepressant medication. Current Physician's Orders lacked an order for an antianxiety medication. Current Care Plans included a Risk for Adverse Consequences related to Antianxiety Medication Care Plan, last reviewed 8/1/25. On 9/2/25 at 10:26 A.M., Clinical Support 2 indicated Resident 6 and Resident 18 were no longer on antianxiety medications and the care plans should have been removed. 3. On 8/27/25 at 9:27 A.M., Resident 45's clinical record was reviewed. Diagnoses included, but were not limited to, stroke and neurogenic bladder. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/30/25, indicated a moderate cognitive impairment, and an indwelling urinary catheter. Physician orders included, but were not limited to: Bactrim DS (sulfamethoxazole-trimethoprim) (an antibiotic) tablet; 800-160 mg; amt: 1 tablet; oral for UTI, dated 8/1/25 through 8/11/25. Macrobid (nitrofurantoin monohyd/m-cryst) (an antibiotic) capsule; 100 mg; amt: 100 mg; oral twice A Day, dated 8/20/25 through 8/27/25. A current care plan for urinary tract infection (UTI) was initiated and last reviewed 8/4/25. On 7/28/25, a urinalysis was obtained that identified a UTI. A progress note, dated 8/1/25, indicated antibiotic orders were received for UTI for Resident 45 to begin that evening. An Interdisciplinary Team (IDT) note, dated 8/4/25, indicated a ten day antibiotic course had been initiated for UTI. A care plan was initiated the same day. On 8/20/25, a urinalysis was obtained that identified a UTI. A progress note, dated 8/20/25, indicated antibiotic orders were received for UTI. An IDT note, dated 8/25/25, indicated a seven day antibiotic course had been initiated for UTI. The UTI care plan was not discontinued after the UTI on 8/1/25, and was not revised for the UTI identified on 8/20/25. On 8/29/25 at 1:01 P.M., Clinical Support 2 indicated a UTI care plan would be expected to be resolved 2-3 days after completion of an antibiotic. 4. On 8/27/25 at 9:21 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, heart failure and renal failure. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/31/25, indicated a moderate cognitive impairment, and two unstageable pressure ulcers present upon admission. Resident 1 was admitted to the facility on [DATE]. A current pressure ulcer care plan, dated 6/19/25 and last reviewed 8/15/25, indicated a pressure area to the sacrum as well as the left hip. The two areas were combined on one care plan. On 8/29/25 at 9:04 A.M., the Assistant Director of Nursing (ADON) indicated Resident 1's left hip pressure ulcer was healed on 8/13/25. On 8/29/25 at 12:56 P.M., the Administrator provided a current Comprehensive Care Plan policy, dated 5/22/18, that indicated The comprehensive care plan should be reviewed no less than quarterly and revised to reflect changes in the resident's condition as they occur 3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 2 of 3 residents reviewed for nutrition and 1 of 4 residents reviewed for urinary tract infections (UTI) and pressure ulcers. Weights were not monitored and discontinuation of contact precautions were not completed as ordered, a dressing was not initialed or dated, staff documented treatments completed on a pressure ulcer that had been healed, and a nurse signed off on a treatment that another staff member completed. (Resident 45, Resident 1, Resident 8)Findings include: 1. On 8/27/25 at 12:45 P.M., Resident 8's clinical record was reviewed. Diagnoses included, but was not limited to, diabetes mellitus type II, chronic kidney disease (CKD), hypertension, lymphedema, edema, obesity (morbid), and dementia with psychotic disturbance. The most recent quarterly MDS assessment, dated 5/16/25, indicated Resident 8's cognition was moderately impaired, was 232 pounds (lbs), 5 foot 6 inches tall, no known weight loss or gain, and was totally dependent on staff for transfers (used a Hoyer lift). Physician's Orders, included, but were not limited to, obtain monthly weight on resident, ordered 8/12/24 and discontinued 7/14/25. The current Physician's Orders did not include an order to weigh the resident. Current Care plans included, but were not limited to, the following: Resident has experienced a significant weight loss, last reviewed 8/13/25, with an intervention to weigh as ordered. Resident has been identified as morbidly obese in the past, related to Body Mass Index [BMI] classification and diagnoses, last reviewed 8/13/25, with an intervention to obtain weight as ordered/needed. Resident has CKD related to renal failure, last reviewed 8/13/25, with an intervention to monitor weight per order. The following weights on Resident 8 were documented from 1/15/25 to present: 1/15/25 1:48 P.M., Weight: 226.4 lbs 2/5/25 9:15 A.M., Weight: 223.8 lbs 3/2/25 11:01 A.M., Weight: 228.5 lbs 3/5/25 4:09 P.M., Weight: 230.5 lbs 4/2/25 10:03 A.M., Weight: 234.9 lbs 4/5/25 1:56 P.M., Weight: 234.9 lbs 5/1/25 3:26 P.M., Weight: 232.4 lbs 6/2/25 9:42 A.M., Weight: 231.5 lbs 7/3/25 11:07 A.M., Weight: 227.2 lbs 7/10/25 9:11 A.M., Weight: 261.4 lbs (Resident gained 34.2 lbs) 7/14/25 7:42 P.M., Weight: 241.9 lbs (this was a re-weigh from 7/10/25. Resident gained 14.2 lbs in 11 days and the clinical record lacked documentation about what was done.) 7/29/25 8:36 P.M., Weight: 240.7 lbs 7/30/25 1:59 P.M., Weight: 242.3 lbs 7/31/25 time not noted, Weight: 242.3 lbs 8/5/25 at 3:15 P.M., Weight: 230.4 lbs (resident lost 11.9 lbs) Progress notes from July 1, 2025, to present included, but were not limited to, the following: 7/13/25 Nutrition Note: Questioning the accuracy of the current weight of 261.4 lbs on 7/10/25. Recommend to re-weigh. 7/14/25 IDT Note: Recommended re-weigh of resident (from 7/10/25) due to apparent entry error. 7/28/25 Nutrition Note: Resident's last few weights appear to be inconsistent. Recommend to re-weigh for 3 days to establish a baseline. 7/29/25 Interdisciplinary (IDT) note: Dietitian Recommendation: Get weight for 3 days to establish baseline. 8/7/25 Nutrition Weight Monitoring note: According to staff, the 7/10 weight of 261.4 lbs was an error. Recommended to invalidate. The current reason for weight loss was unknown. Per staff, she had no illness or fluid overload. Her baseline weight appears to be around 230 lbs. Will continue to monitor. On 8/28/25 at 12:45 P.M., Resident 8 was observed getting weighed by Certified Nurse Aide (CNA) 3 and CNA 5 with a Hoyer lift. Both CNAs washed their hands and put on gloves. CNA 3 zeroed the scale, Resident 8 was lifted out of her wheelchair, and indicated the resident weighed 229.8 lbs. CNA 3 indicated they weigh the residents, tell the nurse, and the nurse puts the weight in the clinical record. On 8/28/25 at 12:15 P.M., the Director of Nursing (DON) and Clinical Support 1 indicated that weights were being done monthly. They were not aware of the weight variations and were unsure of why. On 8/28/25 at 12:55 P.M., Registered Nurse (RN) 48 indicated she would get the weight from the CNA and put it in the clinical record. But, if it's more than two to 3 lbs different than the previous weight or seems out of the normal range, she has them reweigh the resident. If it's still up more than 3 lbs in 24 hours or more than 5 lbs in a week, then she would assess the resident to see if she could figure out why. It could have been that the resident was not weighed correctly, was retaining fluid, or constipation. She would notify the physician, family, and the DON. The weights should be monitored closely every time a weight was entered. On 8/29/25 at 9:13 A.M., the Administrator indicated she was unsure why the resident's weights were varying so much. She indicated they recently looked at the Hoyer lift scales and was unsure when they had been serviced last but they did learn recently that there were different batteries for the scale than the main battery that runs the Hoyer lift. She provided an invoice for the last service in May of 2025. 2. On 8/27/25 at 9:27 A.M., Resident 45's clinical record was reviewed. Diagnoses included, but were not limited to, stroke and neurogenic bladder. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/30/25, indicated a moderate cognitive impairment and use of an indwelling catheter. Current physician orders included, but were not limited to: Contact precautions related to MRSA (methicillin-resistant Staphylococcus aureus) (a type of staph bacteria) in urine. May discontinue when MRSA has cleared, dated 8/4/25. A current urinary tract infection (UTI) care plan, initiated and last revised 8/4/25, indicated use of contact precautions. A urine culture reported 8/3/25 indicated MRSA in the urine. A progress note, dated 8/20/25, indicated a new order for a urinalysis to ensure MRSA was clear and to remove from contact isolation. A urine culture reported on 8/22/25 did not indicate MRSA in the urine. On 8/29/25, the Infection Preventionist (IP) indicated that staff had Resident 45 do a follow-up urine to make sure the MRSA was cleared, and then contact precautions should have been discontinued. 3. On 8/27/25 at 9:21 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, heart failure and renal failure. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/31/25, indicated a moderate cognitive impairment, significant weight loss, and two unstageable pressure ulcers present on admission. Current physician orders included, but were not limited to: Daily weight, dated 7/25/25. Wound Vac to sacral and left hip wound, change Monday, Wednesday, and Friday, dated 6/11/25 through 8/25/25. Resident 1's Medication Administration Record (MAR) for July 2025 through August 2025 included the following dates the resident's weight was not completed: 7/27/25 (not available during shift) 8/6/25 with no reason listed 8/7/25 with no reason listed 8/8/25 with no reason listed 8/25/25 (unavailable) Resident 1's MAR indicated the wound vac to the sacral and left hip wound was changed every Monday, Wednesday, and Friday as ordered. Resident 1's MAR indicated the wound vac to the sacral and left hip wound was changed on 8/25/25 by Registered Nurse (RN) 9. On 8/27/25 at 12:17 P.M., Resident 1 was observed with a dressing to the sacrum. The dressing was not initialed or dated. On 8/29/25 at 9:04 A.M., the Assistant Director of Nursing (ADON) indicated Resident 1's wound to the left hip was healed on 8/13/25, and as a result, the wound vac to the left hip was discontinued on 8/13/25 as well. She indicated earlier that day, she had discontinued the wound vac to the sacrum was discontinued, and a regular dressing was placed on the area. On 8/29/25 at 11:20 A.M., RN 9 indicated that on 8/25/25, she did not actually change Resident 1's wound vac, only confirmed with the ADON that she had done it. She then signed off on the MAR that it had been done. She indicated at that time that she did not see the wound vac or the area and did not know what it looked like. On 8/29/25 at 12:59 P.M., Qualified Medication Aide (QMA) 7 indicated the aides were responsible for obtaining resident weights and would usually get them before breakfast unless the resident requested otherwise. If the resident was unavailable, they would then pass the information on to the next shift to get. On 8/29/25 at 11:56 A.M., the Administrator provided a current non-dated RN job description that indicated Provide direct nursing care and provide clinical supervision of patient care staff working with residents assigned on your unit to provide direct care . Administer and document medication and treatments per the physician's order and accurately record all care provided. On 8/29/25 at 11:56 A.M., the Administrator provided a current Weight Monitoring policy, last revised 5/10/24, that indicated Review of missing weights . Daily weights as ordered . Review of error weights, daily, in CCM a. Re-weighs as needed b. Correct weights as needed c. Invalidate weights as needed. 3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident received ordered treatment and services to promote healing and prevent new ulcers from developing for 1 of 3 residents reviewed for pressure ulcers. A wound specific care plan was not developed, treatment orders were not followed, wound assessments were not completed accurately, and Enhanced Barrier Precautions (EBP) were not used when providing wound care. (Resident 6)Finding includes:On 8/27/25 at 8:04 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, severe dementia with psychotic disturbance and pressure ulcer.The most recent quarterly Minimum Data Set (MDS) assessment, dated 8/7/25, indicated Resident 6's cognition was severely impaired, was dependent on staff assistance for toileting, substantial to maximum assistance (staff performs over half the effort) for bed mobility and transferring, and had one facility-acquired unstageable pressure ulcer. Current physician's orders included, but were not limited to, the following:EBP with wound care, ordered 8/25/25lidocaine ointment 5 %, apply topically to wounds on bilateral feet prior to wound treatment on left lower extremity (LLE) wound measured 5.4 cm x 6.4 centimeters (cm) and right lower extremity (RLE) wound measured 2 cm x1.5 cm daily, ordered 8/20/25Right lateral foot: cleanse the wound with normal saline, pat dry, apply skin prep to peri-wound (around wound bed), apply Santyl Ointment (a prescription medication used to help remove dead tissue from a chronic wound bed, like ulcers, to keep the wound bed clean and promote healing), cut Calcium Aliginate ( a highly absorbent, biodegradable dressing that promotes wound healing by absorbing exudate and forming a moist get) to size of wound bed and apply over Santyl Ointment, and cover with dry dressing daily and as needed. Therapy to change Monday through Friday and nursing staff to change on holidays and weekends, ordered 8/27/25 Left heel: cleanse wound with normal saline, pat dry, apply skin prep to peri-wound, apply Santyl, and cover with Allevyn LIFE heel dressing daily and as needed. Therapy to change dressing Monday through Friday and nursing staff to change on holidays and weekends, ordered 8/27/25Left lateral first metatarsal: apply skin prep to the area and apply Allevyn LIFE dressing BID, 8/27/25 The current physician's orders lacked an order for the Santyl Ointment dosage and application instructions.A current Pressure Ulcer Care Plan, last revised 6/19/25, indicated the resident had a pressure ulcer to the right bottom of her foot. The left heel was resolved. Interventions included, but were not limited to, assess and record the condition of the skin surrounding the pressure ulcer, provide treatment per medical doctor (MD) and notify MD if treatment is not effective, observe for and report signs of pain and infection of the wound (drainage amount, color, smell, and type of drainage, swelling around the wound, skin around the wound feeling warm or appearing red, and the edges of the wound may be separating), and perform weekly skin assessmentsA current EBP Care Plan, initiated and last reviewed 8/25/25, indicated the resident required EBP (gown and gloves) during wound care.Resident 6's clinical record lacked a wound-specific care plan for the left heel and the left foot first metatarsal pressure ulcers.On 8/28/25 at 12:21 P.M., all weekly skin assessments and wound care notes were requested and provided by Clinical Support 1. They included the following measurements and wound observations: Wound 1: right lateral foot wound6/15/25 1.2 cm x 1.2 cm (depth could not be measured), skin surrounding the wound were pink/normal and blanchable, without exudate and tunneling, and no wound odor was present. Stage: unstageable (a full-thickness pressure wound where the base is completely covered by slough and/or eschar. The true depth cannot be determined until the covering is removed) and suspected deep tissue pressure injury (A localized area of intact skin that is deep red, purple, or maroon. A blood-filled blister may be present. The tissue may be preceded by pain, or feeling firm, mushy, or boggy)6/18/25 1.2 cm x 1.2 cm (depth could not be measured), no exudate or odor present. Stage: unstageable- deep tissue.6/25/25 1.0 cm x 1.2 cm (depth could not be measured), no exudate or odor present. No stage noted.7/9/25 1.5 cm x 1.5 cm x 0.2 cm, no exudate or odor present. Slough tissue was present, and the skin surrounding the wound was pink/normal. No stage noted.7/16/25 1.5 cm x 1.5 cm (depth could not be measured), no exudate present, and well-defined wound edges. Stage: unstageable -slough and/or eschar.7/22/25 2.3 cm x 2.6 cm x 0. 00 cm (The wound observations were not completed. Stage: suspected deep tissue)7/29/25 0.90 cm x 1.30 cm x 0.00 cm (The wound observations were not completed. Stage: suspected deep tissue)8/5/25 1.4 cm x 1.0 cm x 0.00 cm (The wound observations were not completed. Stage: suspected deep tissue)8/12/25 1.52 cm x 1.48 cm x 0.00 cm (The wound observations were not completed. Stage: suspected deep tissue)8/19/25 1.86 cm x 1.69 cm x 0.00 cm (The wound observations were not completed. Stage: suspected deep tissue)8/26/25 1.8 cm x 1.8 cm x 0.3 cm (The wound observations were not completed. Stage: suspected deep tissue)Wound 2 Left Heel: 8/19/25 5.41 cm x 6.39 cm x 0 cm (The wound observations were not completed. Stage: Unspecified Ulcer Suspected deep tissue)8/26/25 1.84 cm x 1.9 cm x 0.1 cm (The wound observations were not completed. Stage: Unspecified Ulcer Suspected deep tissue)wound 3: left foot lateral first metatarsal 8/26/25 1.0 cm x 0.74 cm x 0 cm. The wound observations were not completed, but had the comment, Area is dark purple and intact, redness noted to peri wound, being seen by PT [physical therapy] and WCC [Wound Care Certified Nurse], treatment in place. Stage: Unspecified Suspected deep tissueThe clinical record lacked documentation of a new event or a skin occurrence for wounds 2 and 3.During an interview on 8/28/25 at 12:21 P.M., the Assistant Director of Nursing (ADON)/WCC indicated the resident was being treated for her right lateral foot wound, then developed the left heel wound, and now has the wound starting on her left first metatarsal. The skin on her left first metatarsal was still intact, and they were hoping to keep it intact. Therapy is doing debridement on the other wounds Monday through Friday because they have some slough on both of them, and then our nurses do it on weekends and holidays. The weekly skin assessments were in the clinical record under the resident's documents and filled out by the nurses once a week. They would to in when therapy did her treatment so it's only done once. They will check off in the medication or treatment record that the assessment was completed. If there are new wounds, there should be an event or a skin occurrence put in the clinical record. The incoming Infection Preventionist (IP) and I make wound rounds every Tuesday. So we would go in, observe the wound, take the pictures, and then PT 1 actually did the debridement.On 8/29/25 at 1:00 P.M., Physical Therapist (PT) 1 indicated she did the wound care for Resident 6 during the week when she was here, but nursing staff would do it otherwise, and they got measurements on Tuesdays. She indicated she would not do the debridement procedure of the wounds on her right lateral foot and the left heel if the resident didn't tolerate it. Yesterday, the resident did not tolerate it, so she did not do it. Resident 6 was in the therapy room behind a privacy curtain, sitting in her wheelchair with her legs up on a therapy wedge with a towel covering it. PT 1 sat on the floor on the resident's right side. PT 1 applied Anti-Bacterial Hand Rub (ABHR) and put on gloves, but did not put on a gown to perform the wound care. First, PT 1 performed care on the right lateral foot. She removed the dressing from her right foot, dated 8/28/25. There was no drainage on the dressing. The wound did not have signs of infection, the edges of the wound were white, and it had white slough in the wound bed. The wound was not measured at that time. She sprayed the wound bed with wound cleanser, not normal saline as ordered. Then, she put Lidocaine 5% ointment on a gauze pad and taped it over the wound on her foot. She removed her gloves, applied ABHR, and put her gloves back on. Next, PT 1 performed care on the resident's left heel. She removed the foam dressing and kerlix gauze, dated 8/28/25. The wound did not have signs of infection, the edges of the wound were white, and it had white slough in the wound bed. The wound was not measured at that time. She sprayed the wound bed with wound cleanser, not normal saline as ordered. Then, she put Lidocaine 5% ointment on a gauze pad and taped it over the wound on her foot. She removed her gloves, applied ABHR, and put her gloves back on. Lastly, PT 1 performed care on the resident's left foot first metatarsophalangeal (MTP) joint (the joint that connects the base of your big toe to the rest of the foot). The wound did not have a dressing over it. It was purple in the middle with redness around it. The skin was intact. She wiped the area with skin prep. PT 1 did not apply an Allevyn LIFE (bandage with foam center to cover wound) dressing to the wound. She took off her gloves, applied ABHR, and put her gloves back on. After 10 minutes, PT 1 started again with the wound on Resident 6's right lateral foot. She removed the lidocaine and gauze. She sprayed the wound bed with wound cleanser again. She took a debriding tool and scraped a scant amount of slough from the wound bed. The resident pulled her foot away, and she said it hurt. PT stopped the debridement procedure. With the same gloves she was using, she cut the calcium alginate pad, put Santyl ointment on it. She wiped with a skin prep pad around the wound and covered it with a bandage dated 8/29. She took off her gloves, applied ABHR, and put her gloves on. Next, she took off the lidocaine and gauze pad from the left heel wound, sprayed it with wound cleanser, and debrided it a scant amount. PT 1 requested that another staff member come over to hold the resident's left foot up. She applied ABHR and put on gloves, but did not have a gown on. She held the left foot with her left hand fingers over the purplish colored wound on the first metatarsal. With the same gloves she used to try to debride the wound, PT 1 put Santyl ointment on a foam heel pad and placed that on the left heel, wrapped with kerlix gauze, taped it in place, and dated it 8/29. With the same gloves on, she put on the resident's socks. During an interview on 9/2/25 at 10:15 A.M., the ADON/WCC indicated the treatments on pressure ulcers should be done as ordered, normal saline was not the same as wound cleanser, and EBP should be used when performing wound care. At that time, a current EBP policy was requested but not provided during the duration of the survey.On 9/2/25 at 11:41 A.M., a current Wound Guidelines Policy, revised 4/9/25, was provided by Clinical Support 1 and indicated, . to provide weekly documentation guidelines of wound measurements and condition. If skin alteration occurs post-admission, follow the steps below:a. Appropriate wound incident is completed by an RN/LPN [Registered Nurse/Licensed Practical Nurse] in EHR [electronic health record] b. Complete the incident for each impaired area and assessment of the wound. Document description of wound using: a. Length (12 o'clock to 6 o'clock) b. Width (3 o'clock to 9 o'clock) c. Depth deepest area of wound bedd. Exudates e. Color f. Odor g. Wound margins h. Surrounding tissue i. Tunneling and/or undermining if applicable . Re assessment/measurement weekly or with significant change in wound, noting the current treatment, medical interventions provided, and comments as needed in progress notes and wound management or with a follow-up encounter weekly in [wound software name] . On 9/2/25 at 11:41 A.M., Clinical Support 1 indicated they do not have a policy to follow orders, but it would be their policy to do so.3.1-40(a)

Based on observation, interview, and record review, the facility failed to provide adequate supervision and prevent falls for 1 of 3 residents reviewed for accidents. Fall interventions were not in place for a resident with multiple falls and neurological (neuro) checks were not fully completed after unwitnessed falls. (Resident 5)Findings include:During an observation on 8/27/25 at 12:55 P.M., Resident 5 was in the recliner with regular white socks on.On 8/27/25 at 8:56 A.M., Resident 5's clinical record was reviewed. Diagnoses included, but was not limited to, fracture of right pubis, hypertension, anxiety disorder, and depression.The most recent quarterly Minimum Data Set (MDS) assessment, dated 8/6/25, indicated Resident 5 was cognitively intact and substantial to maximal assistance of staff (staff performs more than half the effort) for transfers and toileting, and Resident 6 had a fall with fracture in the last 6 months.Resident 5's Physician's Orders included, but was not limited to the following:Call don't fall sign in the bathroom, dated 8/25/25Non-skid strips on the bathroom floor, dated 8/25/25Resident 5's care plan included, but was not limited to, Resident is at risk for falls, dated 1/25/25. Current interventions included, but were not limited to the following:Non-skid strips to the bathroom floor, dated 7/5/25Call don't fall sign in the bathroom, dated 8/15/24Provide non-skid footwear, dated 1/25/24Resident 5's fall history for the last 3 months included the following:Fall 17/3/25 at 12:25 A.M., Staff responded to call light. Resident noted on bathroom floor, incont of urine, bare foot and no assistive device.The facility failed to complete the following neuro checks related to that fall:-every hour times 4 hours neuro check on 7/3/25 at 6:30 A.M.-every 4 hours times 5 on 7/3/25 at 10:30 A.M. and 2:30 P.M.Fall 27/24/25 at 1:12 A.M., This nurse heard someone yelling for help. Upon opening the door to the room, resident was found on floor between her bed and roommate's bed. Roommate was yelling for help. Full body assessment done. Shortening of RLE (right lower extremity). No ROM (range of motion) at this time RLE.Fall 38/26/25 at 2:50 P.M., Responded to CNA (certified nursing aide) claiming resident was found sitting on the floor in their bathroom. Found resident sitting on the floor in front of toilet facing the door.The facility failed to complete the following neuro checks related to that fall:-every 30 minutes times 4 hours on 8/26/25 at 5:00 P.M.-every 1 hour times 4 hours on 8/26/25 at 8:00 P.M.During an interview on 8/27/25 at 1:00 P.M., CNA 15 indicated current fall interventions included to lock the wheelchair in front of the resident and provide the call light.During an interview on 8/27/25 at 1:02 P.M., Licensed Practical Nurse (LPN) 11 looked on the clinical record and indicated current fall interventions include a call don't fall sign in the bathroom, non-skid strips to the bathroom floor, and ensure that the wheelchair is next to the bed. She further indicated neuro checks should be completed after an unwitnessed fall every 15 minutes times 4, then every 30 minutes times 4, followed by every hour times 4, then every 4 hours times 4. At that time, LPN 11 was unable to locate a call don't fall sign in the bathroom.On 8/29/25 at 8:52 A.M., Qualified Medication Aide (QMA) 7 and CNA 15 assisted Resident 5 to the bathroom. Resident 5 was barefoot during the transfer. At that time, QMA 7 asked if Resident 5 had been wearing non-skid socks throughout the day, and CNA 15 indicated that she had not.During an interview on 8/29/25 at 10:00 A.M., Clinical Support 1 indicated neuro checks should be completed, and care plan interventions should be implemented at all times.On 8/29/25 at 11:56 A.M., Clinical Support 1 provided a current Fall Management Program Guidelines policy, reviewed 12/17/24, indicated, .4. Any order received from the physician should be noted and carried out. 5. The resident care plan should be updated to reflect any new or change in interventions. At that time, a current Guidelines for Neurological Checks policy, reviewed 12/17/24, indicated, .Neuro-checks for 24 hours should be completed.3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 1 of 5 residents (Resident 31) observed during the medication pass. There were 25 opportunities for error observed with 3 medication errors, resulting in a medication error rate of 12 percent.Finding includes:On 8/28/25 at 7:27 A.M., Licensed Practical Nurse (LPN) 43 was while they prepared and administered medications to Resident 31. They used Anti-bacterial Hand Rub (ABHR) prior to setting up medications. They measured out 10 milliliters (mL) of Docusate Sodium into a medication cup. They put the Tradjenta and Levothyroxine into another medication cup and the Metoprolol Succinate Extended Release (ER) in another. They crushed all the medications, keeping the Metoprolol separated. They labeled that medication cup with BP. They proceeded to mix the crushed medications in both cups with a spoonful of pudding. They took the medications and vitals machine into the resident's room, took her blood pressure (126/55) with the machine, washed their hands, and then administered the medications to the resident using seperate spoons. On 8/28/25 at 8:00 A.M., Resident 31's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, hypothyroidism, constipation, and hypertension. Current Physician's Orders included, but were not limited to, the following medications:May crush meds or open capsules as needed unless contraindicated, refer to Do not crush list, ordered 4/20/22docusate sodium 50 milligram (mg)/5 mL (for constipation), give 10 mL once by mouth (po) daily, ordered 8/6/25Tradjenta 5 mg tablet (for blood sugars), give one po once daily, ordered 8/21/25Metoprolol Succinate Extended Release (ER) 24 hr 25 mg tablet (for blood pressure), give one po once daily. Hold if systolic blood pressure is less than 110., ordered 8/8/25levothyroxine 50 microgram (mcg) tablet (for thyroid hormone replacement), give one po once daily from 6:00 A.M. to 10:00 A.M. at least 30-60 minutes before food or other medications, ordered 8/19/25During an interview on 8/28/25 at 8:25 A.M., the pharmacist at (facility pharmacy) was contacted and indicated these medications (Tradjenta, levothyroxine, and Metoprolol) should not be crushed and in addition, the levothyroxine should not be given with food or other medications. He indicated crushing the medications could disrupt the mechanism, the absorption, and how well the medications worked. On 8/28/25 at 12:15 P.M., the Director of Nursing (DON) and Clinical Support 1 indicated residents should have an order to crush medications. Clinical Support 1 indicated nurses should refer to the Do Not Crush list in the narcotic book on each medication cart for reference. They were to provide a copy of Do Not Crush list and indicated they would have to refer to the list to see if the medications could be crushed. For the levothyroxine, they usually have documentation that the resident doesn't want it administered early and the doctor confirming it would be ok to have with food and other medications instead of not taking at all. They were to provide the documentation. On 8/28/25 at 12:55 P.M., Registered Nurse (RN) 48 indicated she was not sure about a Do Not Crush medication list. At that time, she indicated it was usually in the order not to crush the ones that can't be.On 8/28/25 at 12:59 P.M., the 100 Hall Cart 1, 100 Hall Cart 2, and the 200 Hall Cart 2 narcotic books were observed and did not have a Do Not Crush list in the book or on the cart itself.On 8/29/25 at 8:52 A.M., the DON indicated they misspoke yesterday during the interview and they don't have a Do Not Crush list. The policy was what said they should not crush Metoprolol. They did not have documentation from the physician indicating it was ok to give levothyroxine with other medications and food. They had notified the physician and were waiting on clarification for all medications regarding the crushing and administration of levothyroxine with other medications and food.On 8/29/25 at 9:04 A.M., a current Medication Administration Policy, revised November 2018, was provided by Clinical Support 1 and indicated, . Medications are administered as prescribed in accordance with good nursing principles and practices . Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient personnel and a medication distribution system to ensure safe administration of medications. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines. a. Long-acting or enteric coated medications should not be crushed; an alternative should be sought . For residents able to swallow or who have difficulty swallowing, tablets which can be appropriately crushed may be ground coarsely and mixed with the appropriate vehicle so that the resident receives the entire dose ordered. Please consult with the product literature or Do Not Crush lists which the facility may have or with the pharmacist if there is a question about medications to be crushed . The need for crushing medications is indicated on the resident's orders and the MAR so that all personnel administering medications are aware of this need and the Consultant Pharmacist can advise on safety issues and -alternatives, if appropriate, during medication regimen reviews . 3.1-48(c)(1)

Based on interview and record review, the facility failed to ensure antibiotic use protocols were followed to monitor antibiotic use. Residents received an antibiotic prior to obtaining culture results, and received an antibiotic without an indication for 2 of 2 residents reviewed for urinary tract infections (UTI). (Resident 45, Resident 1)Findings include:1. On 8/27/25 at 9:27 A.M., Resident 45's clinical record was reviewed. Diagnoses included, but were not limited to, stroke and neurogenic bladder. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/30/25, indicated a moderate cognitive impairment, and an indwelling urinary catheter. Physician orders included, but were not limited to:Macrobid (nitrofurantoin monohyd/m-cryst) (an antibiotic) capsule; 100 mg; amt: 100 mg; oral for UTI, dated 6/25/25 through 6/27/25. levofloxacin (an antibiotic) tablet; 500 mg; amt: 500mg; oral for UTI, dated 6/27/25 through 7/4/25. Macrobid (nitrofurantoin monohyd/m-cryst) capsule; 100 mg; amt: 100 mg; oral twice A Day, dated 8/20/25 through 8/27/25. A current care plan for urinary tract infection (UTI) was initiated and last reviewed 8/4/25. Interventions included, but were not limited to, administer medications and treatments as ordered. A progress note, dated 6/25/25, indicated a new order for Macrobid was given for Resident 45, however the urine culture we still pending. The note indicated would wait for the culture result to see if the antibiotic prescribed would be resistive or not to the organism indicated. A progress note, dated 6/25/25, indicated a new order was received to start Resident 45 on Cipro (an antibiotic) for seven days for UTI. Physician was updated that an order had already been received for Macrobid. Received order to continue with Macrobid until culture was back. A progress note on 6/27/25 indicated a new order for a different antibiotic and the Macrobid was stopped for UTI. A urine culture report, dated 6/27/25, indicated the organism pseudomonas aeruginosa in the urine. The report did not list Macrobid as resistant or susceptible to the organism, and Cipro was listed as resistant. A progress note, dated 8/20/25, indicated a new order to repeat a UA (urinalysis) and C&S (culture and sensitivity). A progress note, dated 8/20/25, indicated a new order was received for Macrobid 100mg twice a day for seven days for UTI with culture pending. A urine culture report, dated 8/22/25, indicated the culture was completed on 8/22/25. On 8/29/25 at 3:01 P.M., the Infection Preventionist (IP) indicated waiting for a urine culture to come back prior to starting on an antibiotic was hit or miss with the physicians. 2. On 8/27/25 at 9:21 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, heart failure and renal failure. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/31/25, indicated a moderate cognitive impairment, and an indwelling urinary catheter.Physician orders included, but were not limited to:Urinalysis w/ Microscopic, Culture if Indicated, dated 6/17/25Urine culture, dated 6/17/25.Macrobid (nitrofurantoin monohyd/m-cryst) (an antibiotic) capsule; 100mg; amt: 100mg; oral, twice a day, dated 6/21/25 through 6/27/25. A urine culture, dated 6/18/25, indicated no uropathogens isolated. No organism was found. On 8/29/25 at 3:01 P.M., the Infection Preventionist (IP) indicated that on 6/17/25, Resident 1 had symptoms, and a positive urinalysis, but the culture did not grow anything. She indicated the resident was treated based on symptoms and UA results. At that time, the urinalysis and symptom form was provided. The form indicated the date of infection as 6/17/25, and date of review 7/1/25. The only symptom listed was increased lethargy related to yeast infection. The form also indicated UTI criteria was not met. On 8/28/25 at 10:45 A.M., the Administrator provided a current Antibiotic Stewardship policy, dated 11/10/17, that indicated Optimize the treatment of infections by ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic. Reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use

Based on observation, interview, and record review, the facility failed to ensure posted nurse staffing forms were accurate for 4 of 6 days during the survey. Census information was not correct on the forms. Finding includes:On 8/27/25 at 12:43 P.M., a posted nurse staffing form was observed at the nurses station. The facility census was listed as 46. At that time, the Administrator indicated the current census was 54.On 8/28/25 at 1:02 P.M., a posted nurse staffing form was observed at the nurses station. The facility census was listed as 46. At that time, the Administrator indicated the current census was 55.On 8/29/25 at 9:10 A.M., a posted nurse staffing form was observed at the nurses station. The facility census was listed as 46. At that time, the Administrator indicated the current census was 55.On 9/2/25 at 8:40 A.M., a posted nurse staffing form was observed at the nurses station. The facility census was listed as 46. At that time, the Administrator indicated the current census was 56. On 9/2/25 at 8:45 A.M., the Administrator indicated the scheduler was responsible for posting the staffing form, and the nurses on the floor were responsible for verifying its accuracy daily. On 9/2/25 at 10:00 A.M., a posted nurse staffing policy was requested and not provided.

Based on observation, interview, and record review, the facility failed to maintain infection control practices to help mitigate the spread of COVID-19. Staff failed to complete proper hand hygiene, touched resident furnishings without performing hand hygiene, and placed a dirty glove on top of a medication cart during 2 of 3 observations of care. (Resident C, Resident D) Findings include: 1. During an observation on 10/29/24 at 10:49 A.M., CNA 7 was providing urostomy care and incontinence care for Resident C. CNA 7 indicated Resident C required Enhanced Barrier Precautions due to the urostomy. Following urostomy care, CNA 7 removed Resident C's soiled brief and provided peri-care. CNA 7 then removed both gloves and completed a 10 second handwashing. CNA 7 then applied new gloves and placed a new brief on the resident. CNA 7 indicated they had forgotten to apply a pad around the urostomy insertion site. CNA 7 removed gloves and completed a 12 second handwashing. CNA 7 applied new gloves and placed a pad around the ostomy insertion site. CNA 7 then removed and disposed of gloves, pulled the trash bag from the bin next to the resident's bed, grabbed the resident's privacy curtain with bare hands and pulled the curtain to the side, then entered the resident's bathroom to complete hand hygiene. 2. During an observation on 10/29/24 at 11:05 A.M., RN 4 completed glucose monitoring for Resident D. RN 4 completed hand hygiene, donned gloves, pricked Resident D's finger with a lancet drawing a drop of blood from the finger, then checked the resident's blood sugar level with a glucometer. RN 4 instructed Resident D to grab a tissue for her finger, then RN 4 removed one glove as she exited the resident's room, carrying the glucometer in the other hand. RN 4 then placed one used glove on a medication cart in the hall, placed the glucometer on the medication cart, removed the other glove, and then threw both gloves in the trash on the medication cart. RN 4 then completed hand hygiene. RN 4 proceeded to ask a resident across the hall if they would like a pain medication. During an interview on 10/29/24 at 12:30 P.M., CNA 7 indicated that staff should wash hands with a scrub time of 20 seconds. CNA 7 indicated she was counting during hand hygiene and counted between 15-20 seconds during all handwashing, then stated she may have been counting fast. On 10/29/24 at 11:20 A.M., the Director of Nursing (DON) supplied a facility policy titled, Guideline for Handwashing/ Hand Hygiene, dated 2/9/17. The policy indicated, .3. Health Care Workers (HCW) shall use hand hygiene at times such as: .c. Before/after having direct physical contact with residents. d. After removing gloves, worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc . Procedures 1. Hand Washing a) Turn on water . b) wet hands with running water. Apply liquid soap and work into lather. c) Wash well for at least 20 seconds . This citation relates to complaint IN00441635. 3.1-18(b) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure storage of food in a safe and sanitary manner and failed to follow proper sanitation for 2 of 2 kitchen observations. Food items were observed unlabeled and open to air. The dishwasher did not reach the proper rinse temperature. Temperature logs were not completed correctly. (Kitchen) Findings include: 1. On 7/21/24 at 9:10 A.M., a box of beef patties and a box of chicken breasts were observed open to air and not labeled in the walk in freezer. On 7/22/24 at 9:34 A.M., a box of beef patties was observed open to air and unlabeled in the walk in freezer. 2. On 7/21/24 at 9:45 A.M., the high temperature dish washer was observed to reach a temperature of 168 degrees during the rinse cycle. On 7/21/24 at 9:56 A.M., Daily Data Sheets were provided for 7/14/24 through 7/20/24 which lacked documentation of food temperatures, dish machine temperatures, refrigerator and freezer temperatures and manual ware washing concentration for the evening shift on 7/14/24, 7/15/24, and 7/20/24. One sheet lacked a date, evening meal temperatures, dish machine temperatures for all meals, A.M. and P.M. refrigerator and freezer temperatures, and manual ware washing concentration for all meals. The dishwasher rinse temperature on 7/20/24 was logged as 170 for breakfast and 172 for noon meal. During an interview on 7/21/24 at 9:53 A.M., [NAME] 17 indicated if the dishwasher rinse cycle did not reach 180 degrees, he would notify the Dietary Manager or if he saw the maintenance man he would tell him. Neither one was here yesterday when he recorded the rinse temperature at 170 degrees at breakfast and 172 degrees at lunch so he didn't notify anyone. He had not notified anyone that morning about the rinse temperature being below 180. He indicated he didn't know when the company had been there last for maintenance. The Dietary Manager or Maintenance Director would call the company to work on the dishwasher. During an interview on 7/21/24 at 11:25 A.M., the Administrator indicated that she had just been notified that the dishwasher had not been reaching 180 degrees rinse temperature, and the facility was going to start using a three compartment sink to wash all dishes. During an interview on 7/21/24 at 11:37 A.M., the Administrator indicated all dishes washed this morning will be rewashed in three compartment sink and plastic would be used for lunch if the dishes couldn't be rewashed in time. Since there have been inconsistencies in the rinse temperatures, a service man has been called to service the dishwasher. During an interview on 7/21/24 at 11:42 A.M., the Administrator indicated the kitchen staff was going to run the dishes back through the dishwasher since it was back up to 180 degrees. The staff felt they have time to rewash them before lunch. During an interview on 7/21/24 at 12:03 P.M., two cognitively intact random residents indicated there have been no Styrofoam dishes used for meals recently. On 7/22/24 at 9:34 A.M. The rinse cycle temperature was observed to be 174 degrees on the dish washer. Dishes were used to serve meals from 7/21/24 through 7/26/24. No disposable dishes were used. During an interview on 7/24/24 at 10:02 A.M., the Dietary Manager indicated all temperatures should be logged 3 (three) times a day with each meal for the kitchen. During an interview on 7/24/24 at 11:32 A.M., the Dietary Manager indicated food in freezers should be in plastic containers with lids with the food left in plastic bags with labels or kept in plastic bags rolled down with box closed and labeled. On 7/21/24 at 11:25 A.M., the Administrator provided a Dish Machine Standard Operating Policy, dated 5/31/2016, which indicated .Check that temperatures are appropriate: High Temp- .Rinse temp (temperature) should be 180-185 degrees F (Fahrenheit) . On 7/21/24 at 11:25 A.M., the Administrator provided a Dishmachine Temp (Temperature)/Sanitizer Policy, dated 5/31/2016, which indicated .2. Dishmachine temperatures and sanitizer concentration will be recorded at each meal .3. If the wash or rinse cycle temperatures or sanitizer concentration do not meet the minimum requirements, the Dining Services manager will be notified . On 7/22/24 at 9:49 A.M., the Administrator provided a Hot and Cold Temperature Holding Guideline Policy, dated 5/31/2016, which indicated The temperatures of all foods on the serving line will be measured prior to resident service and recorded at every meal . On 7/22/24 at 2:55 P.M., the Administrator provided a Storage Procedures Policy, dated 5/31/2016, which indicated .3. All food in the freezer are wrapped in moisture proof wrapping or placed in suitable containers, to prevent freezer burn. Items are labeled and dated . 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure care plan conferences were completed. Quarterly care plan conferences were not completed for 4 of 5 residents reviewed for unnecessary medications. (Resident 28, Resident 8, Resident 19, Resident 29) Findings include: 1. On 7/23/24 at 1:59 P.M., Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors and hypertension. Resident 28's clinical record lacked a care conference between 1/2/24 and 6/3/24. 2. On 7/23/24 at 8:12 A.M., Resident 8's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder and depression. Resident 8's clinical record lacked a care conference between 12/12/23 and 5/8/24. 3. On 7/24/24 at 9:21 A.M., Resident 19's clinical record was reviewed. Diagnoses included, but was not limited to, hypertension and anxiety disorder. Resident 19 lacked a care conference between 8/27/23 and 1/3/24 and 5/30/24. 4. On 7/23/24 at 10:39 A.M., Resident 29's clinical record was reviewed. Diagnoses included, but were not limited to, fibromyalgia and depression. Resident 29 lacked a care conference between 8/27/23 and 12/12/23 and 6/11/24. During an interview on 7/24/24 at 9:23 A.M., the Social Service Director (SSD) indicated Resident 28, Resident 8, Resident 19, and Resident 29 should have had a care plan conference every 3 months. On 7/25/23 at 1:03 P.M., Regional Support 2 provided a current Resident's First Meeting Guidelines policy, reviewed 12/31/23 that indicated, .communication and participation regarding the resident's plan of care, medical condition and care needs between the resident, family, resident and care givers .2. Subsequent meeting for .residents should be conducted at a minimum of quarterly . 3.1-35(d)(2)(B)

Based on observation and interview, the facility failed to ensure a sanitary and homelike environment was provided for 3 of 3 resident halls observed and 1 of 1 shower room. Resident toilets were visibly soiled, fracture pans and urine hats were uncovered and placed between the handrail and wall, vitals machine and lift equipment were visibly soiled. The carpet was stained on the 200 Hall. The shower room grout was soiled, tiles were chipped, and there was a broken tile by the bathroom wall. (100 Hall, 200 Hall, 300 Hall, Shower Room) Findings Include: 1. On 7/22/24 at 11:02 A.M., the bathroom of room [ROOM NUMBER] was observed. There was a brown substance on the back of the toilet and an uncovered fractured (flattened) bedpan on the handrail. There were black scuffs on the walls. On 7/26/24 8:21 A.M., the same was observed. 2. On 7/22/24 at 9:14 A.M., the bathroom of room [ROOM NUMBER] was shared by 2 residents and was observed to have an uncovered fractured bedpan on the handrail. On 7/26/24 at 8:22 A.M., the same was observed. 3. On 7/21/24 at 8:56 A.M., a sit to stand lift was observed in room [ROOM NUMBER] with food and other debris on the area where the residents place their feet. On 7/26/24 at 8:47 A.M., the same was observed. 4. On 7/22/24 at 10:08 A.M., room [ROOM NUMBER] was observed. In the bathroom, the vent fan and handrail behind the toilet were dusty. In room [ROOM NUMBER], there was a package of open wipes on the bedside table, the bar under the bottom of the bed closest to the door was dusty, the walls under the clock and facing the bathroom door were plastered without paint, a brown substance was on the door frame and wall, and black scuff marks were along the walls by the bathroom door. There was a wheelchair sitting next to the bed closest to the window with flaking leather on both armrests. On 7/26/24 at 9:12 A.M., the same was observed except for the open wipes on the bedside table. 5. On 7/22/24 at 10:18 A.M., room [ROOM NUMBER] was observed. In the bathroom, there was an uncovered gray fractured bedpan on the handrail and the vent fan was dusty. In room [ROOM NUMBER], there was large sized area of the wall to the left of the head of bed where the wallpaper had been taken off and not covered, a fan by the bedside in use that was dusty, and linens for the bed stored on a stand by the air conditioner unit. Out in the hallway, there was a black smear and scuffs that went down the hall from the entrance door of room [ROOM NUMBER] to the exit doors at the back of the hall. On 7/26/24 at 9:25 A.M., the same was observed except there were no linens stored in the room. 6. On 7/22/24 at 10:24 A.M., room [ROOM NUMBER] was observed. In the bathroom, there was paint rubbed away by the handrail, the call light cord was brown, there was a black substance smeared in front of the toilet, the inside of the toilet bowl was soiled, a used glove behind the trash can on the floor, brown smears on the wall behind the trash can, a package of open wipes on the back of the toilet, an uncovered urine hat on the handrail, and above the cabinet there was peeling paint and plaster hanging from the ceiling. In room [ROOM NUMBER], there was an uncovered cracker and pieces of chips on a paper towel on the cabinet by the closet, the closet door was propped open, and food debris was scattered on the floor around the recliner. On 7/26/24 at 9:08 A.M., the same was observed in the bathroom except for the used glove behind the trash can. The food in the room was now in bags on the cabinet by the closet and there was less food debris on the floor. 7. On 7/22/24 at 10:32 A.M., room [ROOM NUMBER] was observed. In the bathroom, there were 2 uncovered pink dish pans and 1 gray uncovered bed pan laying under the sink on the floor, the floor was sticky and the bathroom had a strong urine smell. On 7/26/24 at 9:06 A.M., the same was observed except the gray bed pan was covered. 8. On 7/22/24 10:48 A.M., the Shower Room was observed. There was an upholstered chair with stains on the seat, a brown substance and dust were behind the door in the corner, the door frame had a brown substance on it, the grout in the tiles throughout the room were soiled, there was a broken tile by the bathroom door, and tiles throughout the floor were chipped. There was a black substance smeared throughout the shower room on the floor. The cloth covering where the towels are kept had 3 brown smudges on the top, the inside of the toilet bowl was soiled and there was a blackish brown substance on the toilet seat, used paper towels were on the floor, and a spider web was in the corner behind toilet. The toilet paper holder was missing on one side, the vent fan was dusty, and the sink facet had brown along the caulking. Over by the spa, there was hair, dust, food debris, and trash scattered on the floor. The carpet outside the shower room was blackened. Wallpaper just past the Shower Room door was peeling off. On 7/26/24 at 8:48 A.M., the same was observed. 9. On 7/22/24 at 10:37 A.M., the following was observed in the 200 Hall. The vitals machine by room [ROOM NUMBER] was dusty, there was black smears and brown spots. On 7/26/24 at 8:47 A.M., the same was observed. 10. The ABHR (Anti Bacterial Hand Rub) dispensers by Rooms 210, 207, 206, 204, and 203 were dusty on top and had black dust on the bottom catch plate. On 7/26/24 at 8:47 A.M., the same was observed. 11. A sit to stand lift in the hall by room [ROOM NUMBER] was rusty, dusty, and had food and other debris on the foot plate and black scuffs on the legs. On 7/26/24 at 8:47 A.M., the same was observed. 12. The carpet in the 200 hall had blackish/brown spots by the medication cart and black and brown marks in hall between room [ROOM NUMBER] and 206. There was random food and trash debris throughout. On 7/26/24 at 8:47 A.M., the same was observed. 13. On 7/22/24 at 2:18 P.M., where the 300 Hall starts, there was a piece of the wood floor missing and the carpet was observed coming loose. On 7/26/24 at 9:21 A.M., the same was observed. On 7/26/24 at 10:00 A.M., the resident grievances for the past 6 months were reviewed and indicated the following: 3/6/24 Dirty carpet - carpet in TV room has had spots of food on it for a while 4/30/24 Recliner and carpet needs cleaned 5/5/24 TV room dusty - Son stated TV room was dusty and did not want grandchildren in room with the dust. Got washrag from staff and dusted room himself 6/25/24 Room had a odor of urine - resident had a complaint of room smelling like urine . 7/14/24 smell in room (urine) - asking to change to a different room d/t [due to] urine smell in current room, stated has smelled like this since arrival On 7/26/24 at 10:15 A.M., a Daily Cleaning Schedule was provided by the Environmental Services Director and she indicated the the following should be done in each room daily, staff should sign and date that it was completed, and list any comments about the room: Restroom: clean toilet and toilet bottom clean sink and sink pipes mirrors/lights/vents check toilet paper/soap/towels clean handrail shower if needed sweep and mop Resident Room: wash mattress dust all furniture dust flat surfaces dust overbed light clean bedside table and bottom check bed for dust clean window vacuum room During an interview on 7/26/24 at 10:51 A.M., the Environmental Service Director indicated the housekeeping staff have a schedule for deep cleans performed monthly but they should do the daily cleaning list on every room every day. She indicated the carpets were cleaned monthly with the big machines and done weekly with a smaller one usually on Wednesdays. They are not in charge of cleaning the resident equipment such as the vitals machines or sit to stand lifts. The shower room should be cleaned daily in the afternoon and the last housekeeper here and evening shift laundry should do it before they leave, but there wasn't a checklist for that. She would expect them to dust, sweep, mop, and sanitize. The grout has not been cleaned in awhile but they do clean it. She was unsure if the upholstered chair in the shower room was kept in there or how they clean or sanitize it. She indicated the hand sanitizer dispensers on the walls should be cleaned daily and the fractured bed pans and urine hats should be stored in plastic bags in the resident nightstands. During an interview on 7/26/24 at 11:01 A.M., the Maintenance Director indicated staff should notify him via TELS (electronic maintenance software) program that he has on his phone and computer and he addresses things from there. Staff was aware of what to look for and should notify him of rooms needing attention. During an interview on 7/26/24 at 11:10 A.M., the Administrator indicated CNAs (Certified Nurse Aides) were in charge of cleaning the resident equipment. During an interview on 7/26/24 at 11:11 A.M., CNA 23 indicated she was not sure who was supposed to clean the resident equipment. She did know she was to notify nurse/housekeeping/maintenance if there was a concern in a room, but she was not shown how to enter a work order into the system so she tells them verbally. At that time, she indicated linens, clean or dirty, were not to be kept in resident rooms. During an interview on 7/26/24 at 11:30 A.M., Regional Support 2 indicated there was not a policy for the cleanliness of equipment but it should be done when found soiled or dirty and anyone could do it. It is not said in the policy, but the urine hats were to be single use so those hats should not be stored and the fractured bedpans/dishpans should be covered. During an interview on 7/26/24 at 11:46 A.M., Regional Support 4 indicated there was not a policy for environment but it would be their policy to strive to provide a homelike environment. 3.1-19(f)

Based on observation and interview, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents observed for incontinence care. Gloves were not changed and hands were not sanitized between dirty and clean tasks. A resident's incontinence pad was laid on the bathroom floor before it was placed on the resident. (Resident 39, Resident 7) Findings include: 1. On 7/25/24 at 10:40 A.M., CNA (Certified Nurse Aide) 48 and CNA 56 were observed providing incontinence care on Resident 39. CNA 48 put on shoes on the resident, transferred resident from her bed to her wheelchair, and pushed Resident 39 into the bathroom. She washed her hands with a 5 second lather and put gloves on. CNA 56 washed her hands with a 10 second lather and put on gloves. CNA 48 then went out of the bathroom and back into the bathroom using a gloved hand to open the door and close it. CNA 48 and CNA 56 assisted the resident to stand from the wheelchair and transfer to the toilet. While resident was sitting, CNA 48 laid the clean incontinence pad on the bathroom floor, took off the residents pants and dirty incontinence pad, picked up the incontinence pad from the bathroom floor, put it and her pants back on. She assisted resident to stand and grabbed a wipe. She wiped the resident from front to back, folded the wipe, and wiped the resident from front to back again. After discarding the wipe, she pulled up the incontinence pad and pants, pulled her shirt down, pushed the wheelchair to the sink for the resident to wash her hands. She pushed for the soap to dispense, and grabbed paper towels for the resident to wipe her hands with. CNA 48 pushed the resident out of the bathroom into the hallway. CNA 56 washed her hands with a 4 second lather and exited the room. As CNA 48 was walking away, CNA 48 was questioned her about about performing hand hygiene. At that time, she indicated she did not perform hand hygiene and proceeded to enter Resident 39's bathroom and washed her hands with a 6 second lather. 45933 2. On 7/25/24 at 10:32 A.M., Certified Nurse Aide (CNA) 23 and CNA in training 21 provided incontinence care on Resident 7. CNA 23 used her gloved hands to move the bedside table, grabbed a trash bag from the trash can, opened the trash bag and placed it on the bed. Next, CNA 23 used the same gloved hands to raise Resident 7's head of the bed with the remote, moved an oxygen tank, removed the blankets, and removed 2 pillows that were under the resident. CNA in training 21 wiped Resident 7 while CNA 23 used the same gloved hands to hold Resident 7's [NAME] (excess skin and fat that hangs down from the abdomen). At that time, CNA 23 rolled Resident 7 by touching her leg and arm with her gloved hands and CNA in training 21 used 5 wipes to clean Resident 7's bottom. CNA in training 21 failed to change gloves and perform hand hygiene before she placed the clean brief under the resident. CNA in training 21 used both gloved hands to assist Resident 7 to roll. CNA 23 and CNA in training 21 both fastened the clean brief and pulled down Resident 7's gown. At that time, CNA 23 and CNA in training 21 removed gloves, and CNA 23 failed to perform hand hygiene before she pulled up Resident 7's blankets. CNA 23 donned a new pair of gloves and placed a pillow under the resident's feet, handed Resident 7 her phone, and then lowered the head of the bed with the remote. CNA 23 removed gloves, but failed to perform hand hygiene and placed the bedside table next to resident 7 and then opened the door to leave the room. During an interview on 7/25/24 at 1:41 P.M., the DON (Director of Nursing) indicated staff should lather their hands with soap for 20-30 seconds during hand hygiene. She would expect staff to wash hands, put gloves on, and perform incontinence care without touching other items. If they would touch other items such as doorknobs, bed controller, or bedside table, she would expect gloves to be changed and hand hygiene performed between. At that time, the DON indicated staff should not lay the incontinence pad on the bathroom floor. On 7/25/24 at 1:00 P.M., Regional Support 2 provided a current Guideline for Handwashing/Hand Hygiene policy, reviewed 12/31/23 that indicated, Handwashing is the single most important factor in preventing transmission of infections. Hand hygiene is a general term that applies to either handwashing or the use of antiseptic hand rub .1. All health care workers shall utilize hand hygiene frequently and appropriately .After removing gloves, worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen,etc . 3.1-18(b) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure posted nurse staffing sheets were posted and contained the correct information daily for 1 of 6 days reviewed during the survey. (July 21) Findings include: On 7/21/24 at 10:09 A.M., the Posted Nurse Staffing form was observed sitting on the 100, 200, 300 Hall nurse's station dated 7/19/24. During an interview on 7/25/24 at 1:41 P.M., the ADON (Assistant Director of Nursing) indicated the Scheduler posted the Posted Nurse Staffing form daily in the morning at the beginning of the shift. On the weekend, the 300 Hall nurse posted it in the morning at change of shift. On 7/25/24 at 1:02 P.M., Regional Support 2 provided a Guidelines for Staff Posting policy, revised 5/11/16, which indicated At the beginning of the day the number and amount of hours of licensed nurses (RN [Registered Nurse] and LPN [Licensed Practical Nurse]) and the number and hours of unlicensed nursing personnel, per shift, who provide direct care to residents will be posted .

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was in place to prevent a resident with a history of exit-seeking behavior from exiting the facility for 1 of 3 residents reviewed for elopement. A resident unknowingly exited the facility and was found in the facility's parking lot approximately 45 minutes later. (Resident C) Finding includes: During a review of facility reported incidents on 3/18/24 at 10:15 A.M., an incident dated 3/13/24 at 7:07 P.M. included that a staff member noted resident C to be sitting in his wheelchair near the heath center sign located outside the health center entrance. During record review on 3/18/24 at 10:45 A.M., Resident C's diagnoses included, but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side, dysphagia, aphasia, depression, unsteadiness on feet, lack of coordination, and history of falling. Resident C's most recent quarterly MDS (Minimum Data Set) assessment, dated 1/12/24, included that the resident's cognition was severely impaired, used a manual wheelchair for locomotion, and could wheel himself 50 feet with partial/moderate assistance. Resident C's physician orders included but were not limited to check function of wandering alert bracelet/device daily (started 8/28/23). Resident C's care plan included, but was not limited to Resident exhibits exit-seeking behaviors. A target goal included, resident will not elope from the facility (started 8/28/23). Resident C's nurse's notes included the following: 8/27/23 6:16 P.M. - Resident has been wandering today. He was sitting by front door but not trying to exit. Another resident's family exited out the door to sit on entrance. Resident C followed them out there. Staff went looking for him and found him sitting outside with other resident's family. Staff asked the family if they were going to leave, to come find staff so staff could assist Resident C back inside. Family came back in the building and left Resident C outside alone. Resident was found laying in the parking lot. When the other resident's family was leaving the facility they found Resident C near their car laying on the ground. 03/13/2024 at 8:00 P.M. - Resident was found outside by a staff member leaving for the day. Noted resident was outside the front entrance and was brought back in. Resident had wander guard on his wheelchair, but the alarm system was not functioning. Resident was brought to a secure location to monitor his safety and well being. 15 minute checks started on this resident. During an observation on 3/18/24 at 2:40 P.M., Resident C was laying in bed with his wheelchair next to the bed. A wander guard bracelet was around the resident's wheelchair. During an interview on 3/20/24 at 9:00 A.M., LPN 4 indicated that Resident C can transfer himself to his wheelchair and can wheel himself around the facility. LPN 4 indicated the resident often wanders and likes to look out the facility doors. LPN 4 indicated the main entrance door was not functioning properly when Resident C was able to exit on 3/13/24. Staff check the residents' wander guard bracelet to ensure proper functioning daily and chart in the record. Maintenance checks the doors Monday - Friday and assigned staff check the doors on the weekends. During an interview on 3/18/24 at 1:22 P.M., Activities 6 indicated that she saw Resident C sitting outside in the parking lot just past the health center sign on 3/13/24. Activities 6 indicated that she was leaving the facility for the day when she saw Resident C and that he was happy to be outside and found it funny that he was able to get out. During an interview on 3/18/24 at 12:52 P.M., Maintenance 8 indicated that the device he uses to check the doors indicates that door is functioning properly but the alert system did not detect the resident's wander guard bracelet and the door did not lock as it should have. During an interview on 3/18/24 at 1:15 P.M., LPN 10 indicated that the doors should automatically lock and signal an alarm when a resident with a wander guard is in close proximity to an exit. During an interview on 3/18/24 at 10:45 A.M., the facility administrator indicated that Resident C was observed on camera exiting the health center main exit door at 7:07 P.M. on 3/13/24 and was brought back inside at 7:53 P.M. The facility administrator indicated that the wandering alert system had been checked on the doors and that the main health center door is currently not being used. A new wander alert system had been ordered and would be installed as soon as possible. On 3/18/24 at 2:15 P.M., the facility administrator supplied a facility policy titled, Elopement Risk Assessment and Prevention, dated 12/31/23. The policy included, .These policies assist to define the mechanisms and procedures for monitoring and managing residents at risk for elopement, help to minimize the risk of a resident leaving a safe area without authorization and/or appropriate supervision . Procedure . 8. A check will be completed of alarmed doors and individual resident alarms to ensure proper functioning . The deficient practice was corrected on 3/14/24 after the facility implemented a systemic plan that included the following actions: Ad HOC QAPI on 3/14/24 an action plan included inservice review of policy for elopement with all staff, wander guard sensor and testing, elopement risk assessments of all residents, and the on going monitoring of the residents for elopement risk, staff training with elopement drills, and the monitoring of the wander guard system. This tag relates to complaint IN00430645. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide assistance with bathing for 4 of 5 residents reviewed for activities of daily living (ADLs). Residents did not receive assistance with ADL's (bathing) according to the plan of care and bathing schedule. (Resident B, Resident C, Resident D, Resident F) Findings include: 1. During a review of facility grievances on 1/25/24 at 10:15 A.M., Resident B's family member had submitted a grievance, dated 12/27/23, that included, it had been two weeks since resident had a shower . During record review on 1/25/24 at 12:30 P.M., Resident B's diagnoses included, but were not limited to hemiplegia and hemiparesis following cerebral infarction, heart disease, dementia, weakness, and depression. Resident B's most recent admission MDS (Minimum Data Set) assessment, dated 12/4/23, included that the resident was cognitively intact, had upper and lower one-side extremity impairments, and was dependent for bathing activities. Resident B's care plan included but was not limited to; resident requires staff assistance to complete ADL tasks completely and safely with a goal of; Resident will have functional needs met safely by staff, and an approach including provide facial shaving and nail care on shower days (initiated 11/2/23). Resident B's scheduled shower days were Tuesdays and Fridays during day shift. During review of Resident B's documented bathing from 12/1/23 thru 1/25/23, the following showers/complete bed baths were provided: 12/5/23 - Shower 12/8/23 - Complete Bed Bath 12/12/23 - Shower (Resident missed two consecutive bathing days on 12/15/23 and 12/19/23.) 12/22/23 - Shower (Resident missed three consecutive bathing days on 12/26/23, 12/29/23, and 1/2/24.) 1/5/24 - Complete Bed Bath 1/6/23 - Shower 1/9/24 - Shower 1/12/24 - Shower (Resident missed two consecutive bathing days on 1/16/24 and 1/19/24.) 1/23/23 - Shower During an observation and interview on 1/26/24 at 10:45 A.M., Resident B was sitting up in her wheelchair, in her room, dressed, and groomed. Resident B indicated she received assistance with bathing about once a week. 2. During record review on 1/25/24 at 1:10 P.M., Resident C's diagnoses included, but were not limited to Alzheimer's disease, dementia, type 2 diabetes, and muscle weakness Resident C's most recent significant change MDS (Minimum Data Set) assessment, dated 10/3/23, included that the resident was unable to complete a cognitive function assessment, had a one-sided lower extremity impairment, and was dependent for bathing activities. Resident C's care plan included but was not limited to; resident requires staff assistance to complete ADL tasks completely and safely with a goal of; Resident will have functional needs met safely by staff, and an approach including provide facial shaving and nail care on shower days (initiated 6/2/23). A progress note, dated 7/3/23, included Resident C's family member was visiting and requested that Resident C's nails be trimmed, and expressed, displeasure of resident care. During review of Resident C's documented bathing from 7/1/23 thru 9/20/23, the following showers/complete bed baths were provided: (7 days without documented offered bathing) 7/8/23 - Complete Bed Bath (13 days without documented offered bathing) 7/22/23 - Resident Refused (13 days without documented offered bathing) 8/5/23 - Resident Refused (12 days without documented offered bathing) 8/18/23 - Complete Bed Bath (10 days without documented offered bathing) 8/29/23 - Shower (No documented complete bed baths or showers in September, 2023.) 3. During record review on 1/26/24 at 9:15 A.M., Resident D's diagnoses included, but were not limited to type 2 diabetes, visual loss, dizziness and giddiness, and muscle weakness. Resident D's most recent annual MDS (Minimum Data Set) assessment, dated 12/20/23, included that the resident was cognitively intact, had upper and lower one-side extremity impairments, and required substantial to maximum assistance for bathing activities. Resident D's care plan included but was not limited to; resident requires staff assistance with ADL's (initiated 3/29/23). Resident D's scheduled shower days were Tuesdays and Fridays during day shift. During review of Resident D's documented bathing from 12/1/23 thru 1/25/24, the following showers/complete bed baths were provided: (Resident missed two consecutive shower days on 12/1/23 and 12/5/23.) 12/8/23 - Shower 12/12/23 - Shower (Resident missed two consecutive shower days on 12/15/23 and 12/19/23.) 12/22/23 - Complete Bed Bath (Resident missed three consecutive shower days on 12/26/23, 12/29/23, and 1/2/24.) 1/6/24 - Shower 1/9/24 - Shower 1/12/24 - Shower (Resident missed two consecutive shower days on 1/16/24 and 1/19/24.) 1/23/24 - Shower 4. During record review on 1/26/24 at 10:00 A.M., Resident F's diagnoses included, but were not limited to. Resident F's most recent quarterly MDS (Minimum Data Set) assessment, dated 11/22/23, included that the resident was cognitively intact and required partial to moderate assistance with bathing activities. Resident F's care plan included but was not limited to; resident requires staff assistance with ADL's (initiated 7/11/17). Resident F's scheduled shower days were Wednesdays and Saturdays during evening shift. During review of Resident F's documented bathing from 12/20/23 thru 1/25/24, the following showers/complete bed baths were provided: 12/20/23 - Shower (Resident missed a shower day on 12/23/23.) 12/27/23 - Resident refused (Resident missed eight consecutive shower days on 12/30/23, 1/3/24, 1/6/24, 1/10/24, 1/13/24, 1/17/24, 1/20/24, and 1/24/24.) During an interview on 1/26/24 at 10:15 A.M., CNA 4 indicated all residents should receive a complete bed bath or a shower, per their preference, at least twice weekly. Staff should offer bathing on the residents' scheduled shower days and document in the residents' record the type of bathing that occurred. Should the resident refuse their bathing, staff should document the refusal. On 1/26/24 at 1:00 P.M., the Facility Administrator supplied a facility policy titled, Nursing ADL Documentation Guidelines, dated 12/31/23. The policy included, .2. ADL services will be conducted and documented by the CNA each shift at the 'point of care' or as reasonably possible after care . This citation is related to complaints IN00418698 and IN00424901. 3.1-38(b)(2)

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer on a resident's heels, and discovered one of the pressure ulcers when it had already developed eschar (dark patches of dead skin on a wound surface), and failed to ensure a dressing to a pressure ulcer was changed daily as ordered, for 2 of 3 residents reviewed with pressure ulcers, in a sample of 8. Residents A and C Findings include: 1. On 11/14/16 at 9:20 A.M., during the initial tour, the Director of Nursing (DON) indicated Resident A had a left heel wound, which was being treated by therapy 5 days a week. The clinical record of Resident A was reviewed on 11/14/16 at 11:15 A.M. [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 6/20/16, indicated the resident scored 11 out of 15 for cognition, with 15 indicating no memory impairment. Resident A required total dependence of two+ staff for transfer, and extensive assistance of two+ staff for bed mobility, dressing, and personal hygiene. The resident had no pressure ulcers. Documentation indicated the resident returned to the facility on [DATE], following hospitalization for a fractured left leg. A physician's orders [REDACTED]. Resident Progress Notes included the following notations: 8/19/16 at 6:17 P.M.: Resident returned from acute care stay .left leg is now in a 1/2 cast only to posterior portion of leg, the leg is covered with cotton wrap and secured with ace bandage. This area will need to be removed and assessed twice daily to monitor for skin breakdown. 8/19/16 at 6:20 P.M.: Admission assessment complete .Resident is to keep left leg in immobilizer and the wrap is to be removed twice daily and area beneath it assessed, resident foot and toes are warm to touch she has some [MEDICAL CONDITION] (swelling) noted A Care Plan, dated 8/19/16, indicated: Problem: I have a fractured L (left) tib/fib (leg) related to [MEDICAL CONDITION] bone disease .Approach: Splint as ordered/position as needed. Progress Notes continued: 8/20/16 at 2:48 P.M.: LT (left) leg splint removed .to inspect pts (sic) skin integrity .no pressure areas noted lt heel, Achilles region or post aspect of leg. A Physical Therapy Plan of Care, dated 8/23/16, indicated, Reason for Referral: .new splint in place. Nursing made a referral to PT (Physical Therapy) to address positioning, appropriate fit of splint and also to address skin integrity issues .Underlying impairments: Pt has history of MS ([MEDICAL CONDITION]), osteopenia and [MEDICAL CONDITION] and demonstrates decreased ROM (range of motion), strength and sensation. Pt is dependent with transfers, using total mechanical lift for transfers. Due to new splint, patient is at risk for skin breakdown due to decreased ROM, strength and coordination and patient is unable to reposition self appropriately. Also, due to MS, patient has impaired sensation which limits her ability to self moniter (sic) her skin and pain levels. Staff repositioning and skin assessments necessary to maintain skin integrity A physician's orders [REDACTED]. Progress Notes continued: 8/29/16 at 2:50 A.M.: Cont to have 2 staff for position changes and lt leg supported well along with staff working to keep good alignment of legs .Continues with protective/preventative skin care 9/3/16 at 3:29 P.M.: Noted (with) splint removal from lt leg dried eschar area measuring 1.0 x 4.0 (with) loose edges area skin prepped and [MEDICATION NAME] drsg (dressing) to lt heel area splint reapplied and heel floated on specialty air mattress ( This was the first documented assessment of the wound sine admission 8/19/16.) A Care Plan, dated 9/3/16, indicated: Problem: I have a pressure ulcer as evidenced by skin breakdown on my L heel .Approach: Assist me with repositioning. Continue to educate me about my pressure ulcer causes, the risk factors of developing a pressure ulcer .Please assess my skin for changes Progress Notes continued: 9/9/16 at 3:34 P.M.: Dressing removed from left leg cradle splint, area unstageable pressure area on ball of heel noted .discussed interventions to relieve pressure caused by the cradle to this area .see new order regarding use of foam to cradle the heel off of the cradle splint 9/12/16 at 11:26 P.M.: Unstageable area to Lt heel continues Q (every) 4 hour skin checks 9/16/16 at 12:11 P.M.: Unstageable area to left heel measures 3.4 cm x 2.4 cm black eschar intact .Therapy has applied extra padding to splint to left leg for added pressure reduction 9/18/16 at 11:05 P.M.: Noted friction blister at resident right inner heel. Cause by friction from splint. Skin is intact, fluid filled blister .Applied skin prep to area and placed pillow in between legs/heel. A PT Progress Note, dated 10/17/16, indicated, Pt presents with unstageable pressure ulcer to left heel which occurred during use of original splint following fracture .Caregivers educated regarding recommended use of splint for transfers only and to remove once pt. safely positioned in bed/chair with heels floated . The most recent skin measurements, dated 11/10/16 at 1:43 P.M., indicated, Right heel, Stage 2 wound measures 0.6 x 0.1 x <0.1 .Left heel unstageable measures 1.1 x 1.2 x U (unstageable) On 11/15/16 at 9:05 A.M., Resident A was observed sitting in therapy. Physical Therapist (PT) # 1 was observed doing the resident's treatment. An open ulcer was observed on her left heel. The wound had hard, yellow tissue. PT # 1 indicated the ulcer had been unstageable, but that she could probably stage it as a 3. PT # 1 indicated the resident acquired the pressure ulcer from her left leg splint. She indicated the resident had fractured her left leg, and a splint was applied. PT # 1 indicated she thought the staff was inspecting the area, but that after a week or so, it broke down. Resident A complained that her left heel was sore. The resident's heel had a dressing on her right inner heel. PT # 1 removed the dressing, and a hardened, light tannish scab was observed on that. PT # 1 indicated, Nursing takes care of that one. 2. On 11/14/16 at 9:20 A.M., during the initial tour, the DON indicated Resident C had a pressure ulcer on her heel. The DON indicated therapy was treating the area. The clinical record of Resident C was reviewed on 11/14/16 at 3:00 P.M. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 9/12/16, indicated Resident C scored a 7 out of 15 for cognition, required total assistance of two+ staff for transfer, and extensive assistance of two+ staff for bed mobility and personal hygiene. A Care Plan, dated 10/17/16, indicated, Problem: I have a pressure injury as evidence (sic) by my skin breakdown - deep tissue injury L medial heel. The Approaches included: Treat my wounds as ordered and evaluate the effectiveness of the treatment. A physician's orders [REDACTED]. A Nurses Note, dated 11/10/16 at 1:53 P.M., indicated, Nursing to complete resident treatments and noted a skin impairment on lateral left heel DTI (deep tissue injury). Area is 1.0 x .9 x .9 undetermined depth. Left heel stage 3 pressure injury measures 0.5 x 0.3 x U (undetermined) On 11/15/16 at 9:05 A.M., PT # 1 indicated that Nursing takes care of (Resident C's) wound. On 11/15/16 at 9:10 A.M., LPN # 2 indicated she was caring for Resident C that day. She indicated she did not do wound care for Resident C, but therapy does. On 11/15/16 at 9:15 A.M., a wound assessment was requested. The DON indicated that she usually changed the dressings daily, but on weekends, the nurse working would change them. She indicated she and therapy worked together, and that she would notify therapy as a back up if the resident required debridement. Resident C was sitting in her wheelchair. A pillow was under both of her heels, not relieving pressure off of the heels. A dressing, dated 11/13/16, was observed on the resident's left heel. When the DON removed the dressing, a small amount of old, blackish drainage was observed. An open area was observed on the resident's left heel, with yellow tissue observed. On 11/15/16 at 2:00 P.M., the DON indicated she counseled LPN # 2 regarding not completing the resident's treatment on 11/14/16, but signing off on the Treatment Record that she had completed it. On 11/15/16 at 3:10 P.M., the Administrator provided the current facility policy, Guidelines for Pressure Prevention, dated 8/2/16. The policy included: Purpose To maintain good skin integrity and avoid development of pressure ulcers. Care plan interventions shall be implemented based on risk factors identified in the nursing assessment. Interventions may include but not limited to: .Inspect the skin daily during care for signs of breakdown or changes to the skin .Utilize padding for casts and splints. Monitor skin closely when these devices are present STAGES OF PRESSURE ULCERS, AMDA - 2008, included: Stage 1: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence . Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the ulcer bed. Often includes undermining and tunneling. Note: The depth of a Stage 3 or 4 varies by anatomical location . Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the ulcer bed. Note: Until enough slough or eschar is removed to expose the base of the ulcer, the true depth and therefore stage, cannot be determined. This Federal tag relates to Complaint IN 356. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure care was provided to a resident admitted with pressure ulcers, did not develop additional pressure ulcers for 1 of 3 residents who met the criteria for review of pressure. This deficient practice resulted in the resident experiencing Stage 2 pressure ulcers to the left hip, right buttock, and coccyx, blisters to the right axilla and right thigh, an Unstageable pressure ulcer to the left heel, a Stage 4 pressure ulcer to the right ankle, and a Stage 3 pressure ulcer to the left ischium. (Resident #10) Findings include: During an interview on 1/14/16 at 11:00 A.M., the MDS Coordinator indicated Resident #10 experienced a facility acquired Stage 3 pressure ulcer to the left ischium, a facility acquired Unstageable pressure ulcer to the right outer ankle related to the use of a pressure relieving boot for the right heel and was on complete bedrest. During an interview on 1/15/16 at 9:35 A.M., CNA #17 indicated Resident #10 had been repositioned at approximately 9:00 A.M. During an observation of care on 1/15/16 at 9:38 A.M. Resident #10 was observed lying in bed positioned towards the left side. During an interview, at that time, CNA #16 and CNA #17 indicated they were going to reposition Resident #10 for pressure ulcer care to be provided to the left ischium/buttock. CNA #16 and CNA #17 were observed to reposition Resident #10 to the right side by grasping a draw sheet underneath Resident #10 and pulling Resident #10 across the surface of the mattress. During the repositioning, the right ankle was observed to be covered with a dressing. CNA #16 and CNA #17 then indicated repositioning was complete and the right ankle was observed, at that time, to be in direct contact with the surface of the mattress. No further positioning of Resident #10 was observed by CNA #16 and CNA #17. On 1/15/16 at 9:40 A.M., PTA (Physical Therapy Assistant) #1 was observed to enter the room of Resident #10 with the DON (Director of Nursing). During an interview, at that time, PTA #1 indicated she usually provided the weekday treatments to the left ischium/buttock wound, but was not going to provide care or assess the wound on the left ischium/buttock of Resident #10 at that time, because she had already performed the treatment for [REDACTED]. The DON then indicated the left ischial/buttock wound could not be visualized, at that time, but the unstageable wound on the right ankle could be assessed. The DON and PTA #1 were then observed to exit the room. On 1/15/16 at 9:46 A.M., the DON was observed to return to the room of Resident #10 and indicated she was going to perform pressure ulcer care to the right ankle of Resident #10. During an interview, at that time, the DON indicated the wound was initially observed on 1/6/16 as an Unstageable wound with 100% eschar. CNA #16 and CNA #17 were then observed to reposition Resident #10 to the left side and prop the right ankle with a pillow. The DON was observed to remove the dressing, and cleanse the right ankle wound. The wound was observed to be 2.2 cm (centimeters) in length and 1.3 cm in width. The wound was observed to contain 90% white/yellow slough and have a red peri-wound. The DON then indicated the threads of a screw were visible in the base of the wound and the wound would be re-classified as a Stage 4 pressure wound. The clinical record of Resident #10 was reviewed on 1/15/16 at 11:00 A.M. The record indicated Resident #10 was admitted to the facility on [DATE], was transferred to a local hospital on [DATE], and was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #10 did not have a terminal diagnosis, experienced severe cognitive impairment, bilateral range of motion impairment to the upper and lower extremities, was at risk for development of pressure ulcers, was admitted with 8 unhealed Stage 2 pressure ulcers and 1 unhealed Unstageable pressure ulcer, received Physical Therapy services, and required the extensive assist of two staff for bed mobility, personal hygiene, and toileting. The most recent Quarterly MDS assessment dated [DATE] indicated Resident #10 did not have a terminal diagnosis, experienced severe cognitive impairment, bilateral range of motion impairment to the upper and lower extremities, a facility acquired Stage 3 pressure ulcer and a facility acquired Unstageable pressure ulcer with eschar. The assessment further indicated Resident #10 was at risk for the development of pressure ulcers and had experienced healing of previous pressure ulcers. The Admission Physician order [REDACTED].Pressure reducing cushion to w/c (wheel chair) . The admission orders [REDACTED]. A Nursing Admission assessment dated [DATE] indicated Resident #10 was admitted with a Stage 1 pressure ulcer to the right ankle, a Stage 2 pressure ulcer to the left heel, a Stage 1 pressure ulcer to the left great toe, a Stage 2 pressure ulcer to the left buttock, and a Stage 2 pressure ulcer to the mid coccyx. The most recent physician's orders [REDACTED].weekly skin inspection .turn et reposition every 2 hours .float heels on bed, pressure reducing cushion to w/c at all times; check placement q (every) shift, pressure reducing mattress to bed at all times, apply pressure reduction boots, off load heels, keep all pressure off wounds when positioning in bed and w/c .(brand name of protective sleeve) sleeves to all extremities when transfering (sic) with (brand name of mechanical lift) lift . The January 2016 Treatment Administration Record indicated the following: .apply pressure reduction boot .off load heels-6/1/15 .keep all pressure off wounds when positioning in bed and w/c-6/13/15 .float heels while in bed-6/18/15 . A Care Plan for Skin dated 6/18/15 indicated interventions of, turn and reposition for comfort and with care, Prevent skin from touching skin, elevate heels off surface, use lift sheet to reposition in bed, provide pressure relieving device .to bed .ensure resident is clean and dry observe labs . provide vitamins and supplement per physician order [REDACTED]. A Resident Conference note dated 6/23/15 indicated a new intervention of, .chair cushion . was implemented. A Resident Conference note dated 7/22/15 indicated a new intervention of, .specialty mattress . was implemented. A Pressure Ulcer assessment dated [DATE] indicated the Stage 1 pressure ulcer on the right ankle was healed. The assessment further indicated the meaning of Stage 1 was, .intact skin with non-blanchable redness . A Pressure Ulcer assessment dated [DATE] indicated the Stage 2 pressure ulcer to the mid coccyx was healed. The assessment further indicated the meaning of Stage 2 was, .Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister . A Pressure Ulcer assessment dated [DATE] indicated the Stage 2 pressure ulcer on the left heel was healed. A Pressure Ulcer assessment dated [DATE] indicated the Stage 1 pressure ulcer on the left great toe was healed. A Pressure Ulcer assessment dated [DATE] indicated the Stage 2 pressure ulcer to the left buttock was healed. A Clinically At-Risk weekly follow up form dated 8/5/15 indicated, Wounds healed at this time .current interventions of pressure red. (reduction) cushion to w/c, staff assist with T/R (turn and reposition) Q (every) 2 hours and PRN (as needed), pressure reducing boots to offload pressure to heels . A Care Plan for Skin dated 9/10/15 indicated a new intervention of, .use a draw sheet for turning and repositioning me to decrease the probability of my getting shear or friction injuries . A Skin Impairment Circumstance, Assessment, and Intervention form dated 9/12/15 indicated Resident #10 experienced a facility acquired Stage 2 pressure ulcer to the left ischium/buttock and lacked any documentation to indicate a new intervention for pressure relief was implemented. A Pressure Ulcer assessment dated [DATE] indicated Resident #10 experienced a facility acquired Stage 2 pressure ulcer to the left hip on 9/18/15 which had healed. A Weekly Clinically At Risk Follow Up form dated 10/8/15 indicated, .Continue current interventions A Pressure Ulcer assessment dated [DATE] indicated Resident #10 experienced a facility acquired Stage 2 pressure ulcer to the right buttock on 10/7/15 which had healed. A Weekly Clinically At Risk Follow Up form dated 10/15/15 indicated, .Continue current interventions .Has new wound on Lt (left) heel . A Care Plan for Skin dated 10/20/15 lacked any documentation to indicate new pressure relief interventions had been implemented related to the left heel. A Pressure Ulcer assessment dated [DATE] indicated Resident #10 experienced a facility acquired Unstageable wound with eschar to the left heel on 10/13/15 which had healed. The assessment further indicated the meaning of Unstageable was, .non-removable dressing, slough/eschar; suspected deep tissue injury in evolution . A Weekly Clinically At Risk Follow Up form dated 11/5/15 indicated, .continue current interventions .new area on coccyx . A Resident Conference note dated 11/9/15 lacked any documentation to indicate new pressure relief interventions had been implemented related to the new area on the coccyx. An untimed Physician's Telephone Order dated 11/12/15 indicated an order was received for, Patient to utilize pressure reducing air cushion . A Weekly Clinically At Risk Follow Up form dated 11/19/15 indicated, .continue current interventions .open area continues with slough . The form lacked any documentation to indicate which wound contained slough. A Care Plan for Skin dated 11/18/15 indicated a new intervention of, .air bed . was implemented. A Physician's Telephone Order dated 11/19/15 at 1:00 P.M. indicated an order was received for, .PT (Physical Therapy) eval (evaluation) r/t (related to) Stage 3 area The order lacked any documentation to indicate the location of the Stage 3 area. A Pressure Ulcer assessment dated [DATE] indicated Resident #10 experienced a facility acquired Stage 2 pressure ulcer to the coccyx on 11/5/15 which had healed. A Skin Impairment Circumstance Assessment and Intervention form dated 12/5/15 indicated Resident #10 experienced a facility acquired Stage 2 pressure blister to the right axilla and lacked any documentation to indicate a new intervention for pressure relief was implemented. A Weekly Clinically At Risk Follow Up form dated 12/3/15 indicated, .continue current interventions . A Monthly Nursing assessment dated [DATE] indicated no new interventions for pressure relief were implemented. A Skin Impairment Circumstance, Assessment, and Intervention form dated 12/23/15 indicated Resident #10 experienced a facility acquired Stage 2 blister to the right thigh and lacked any documentation to indicate a new intervention for pressure relief was implemented. A Weekly Clinically At Risk Follow Up form dated 12/31/15 indicated, .continue current interventions . An untimed Nursing note dated 1/6/16 indicated, .new area noted on Rt. (right) ankle with Eschar . The note lacked any documentation to indicate new interventions for pressure relief to the left ischium/buttock or right ankle were implemented. A Skin Impairment assessment dated [DATE] indicated Resident #10 experienced a facility acquired Stage 2 blister to the right axilla on 12/5/15 which had healed. A Skin Impairment assessment dated [DATE] indicated Resident #10 experienced a facility acquired Stage 2 blister to the right thigh on 12/23/15 which had healed. A Care Plan for Skin dated 1/7/16 lacked any documentation to indicate new pressure relieving interventions were implemented after 9/10/15. A Weekly Clinically At Risk Follow Up form dated 1/7/16 indicated, .Wound is not exhibiting s/s (signs/symptoms) of healing or appears to be worsening. See below for updated interventions .new unstageable area noted on Rt outer ankle, awaiting [MEDICATION NAME] level, letter of unavoidability. The form lacked any documentation to indicate new pressure relief interventions were implemented. The most recent Complete Metabolic Profile laboratory report dated 1/7/16 indicated the total protein level was 6.9 g (gram)/dl (deciliter) with the therapeutic level identified as 6.0-8.2 g/dl. The report further indicated the [MEDICATION NAME] level was 3.5 g/dl with the therapeutic level identified as 3.4-4.8 g/dl. and BUN (Blood Urea Nitrogen) 31 mg (milligrams)/dl with the therapeutic level 8-23 mg/dl. and Creatinine 0.8 mg/dl with a therapeutic level identified as 0.4-1.1 mg/dl. A Physician Pressure Ulcer Letter of Unavoidability dated 1/7/15 at 12:15 P.M. indicated, .Despite routine preventative care such as turning and proper positioning, application of pressure reduction or relief devices, good skin care, and maintaining adequate nutrition and hydration this resident is at high risk for skin breakdown .Clinical conditions this resident exhibits that make the likelihood of this pressure ulcer unavoidable include, but are not limited to, resident immobility and .diagnosis (sic) Diabetes .Chronic bowel incontinence .head of bed elevated the majority of the time due to medical necessity tube feeding 6p (6:00 P.M.)-6a (6:00 A.M.) pale skin .muscle wasting . A Pressure Ulcer assessment dated [DATE] indicated Resident #10 experienced a facility acquired Stage 2 pressure ulcer on the left buttock/ischium that measured, .2.3 cm (centimeters) in length .2.5 cm width .0.1 cm depth . with a red wound bed on 9/12/15. The assessment further indicated, the wound contained 50% slough on 9/29/15 and Stage 3 .70% slough . on 10/7/15. The assessment indicated the meaning of Stage 3 was, .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 . The Assessment lacked any documentation to indicate new interventions were implemented to provide pressure relief to the left buttock/ischium were initiated until 10/7/15, .bedrest until wounds improved (sic) . The Pressure Ulcer Assessments dated 10/13/15 through 1/11/16 were reviewed and lacked any documentation to indicate new pressure relief interventions were implemented. A Pressure Ulcer assessment dated [DATE] indicated Resident #10 experienced a facility acquired Unstageable pressure ulcer with 100% black/brown eschar with an intact peri-wound on the Rt (right) outer ankle on 1/6/16. The assessment indicated the right ankle wound exhibited a red peri-wound on 1/13/16 and lacked any documentation to indicate a new intervention to provide pressure relief to the right ankle was implemented until 1/13/16. The assessment further indicated the meaning of Stage 4 was, .Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or schar (sic) may be present on some parts of the wound bed. Often includes undermining and tunneling . A Nursing note dated 1/14/16 at 10:35 A.M. indicated, Charge Nurse .came to discuss unstageable area on Rt ankll (sic) . Residents (sic) daughter .at bedside, she shared that resident had fractured the ankle and had a stent placed as well has repair pinned. POA wants the pressure reducing boot removed from Rt foot. She will allow the foot to be elevated .POA also shared that residents (sic) perfusion in that extremity was compromised and that she had a stent placed .discussed residents (sic) co-morbidities that compromise the ability to heal .discussed the letter of unavoidability . A Care Plan for Alteration in .skin integrity dated 1/14/16 lacked a comprehensive list of current wounds or interventions and lacked any documentation new interventions for pressure relief to left ischium or the right ankle were implemented. An untimed Physician's Telephone Order dated 1/14/16 indicated an order was received for, .Keep Rt L (lower) leg on pillow . During an observation of care on 1/19/15 at 9:00 A.M., Resident #10 was observed lying in a supine position in bed with pillows behind the left back. PTA #1 indicated she was going to perform pressure ulcer care to the Stage 3 pressure ulcer on the left ischium of Resident #10. During an observation, at that time, PTA #1 and RN #5 were observed to reposition Resident #10 to the right side by grasping a draw sheet underneath Resident #10 and pulling Resident #10 across the surface of the bed. The left ischium wound was observed, at that time, to measure 2.1 cm X 1.8 cm X 0.9 cm with yellow slough, undermining, rolled edges, and areas of maceration on the peri-wound. The right ankle was observed to be covered with a dressing and in direct contact with inner surface of a u-shaped air-filled pillow on the surface of the bed. During an interview, at that time, RN #5 indicated the u-shaped pillow was utilized to provide pressure relief to the left heel. An untimed PT Daily Treatment Note dated 1/19/15 indicated, .Left ischial wound .wound measurement 2.1 X 1.8 X 0.9 .maceration of wound edges from 4 oclock (sic) to 7 oclock (sic) with remaining edges pink in color. Wound edges are rolled and noted undermining from 9oclock (sic) to 2 oclock (sic). Wound bed at 85% yellow necrosis prior to sharps (sic) debridement with 80% remaining after completion of sharps (sic) debridement . During an interview on 1/19/16 at 11:15 A.M., the MDS Coordinator indicated Resident #10 had not experienced a change in condition since admission. During an interview on 1/19/16 at 11:30 A.M., the DON indicated the Stage 4 pressure wound to the right ankle and the Stage 3 pressure wound to the left ischium were unavoidable. The DON further indicated no Skin Impairment Circumstance form could be provided related to the Unstageable pressure wound initially observed on 1/6/16, but it had been documented in a nursing note that same day. The DON then indicated, skin inspections were completed for each resident weekly. A Weekly Clinically At Risk Follow Up form dated 1/21/16 indicated, .wound is not exhibiting s/s of healing or appears to be worsening. See below for updated interventions . The form lacked any documentation to indicate new pressure relief interventions were implemented. During an interview on 1/25/16 at 9:00 A.M., the DON indicated no documentation could be provided to indicate the [MEDICATION NAME] level was monitored between 6/18/15 and 1/6/16, no documentation could be provided to indicate the attending physician had visualized the wound, and Resident #10 had not been referred to a wound specialist for follow-up because the resident was being treated by PT. A Policy and Procedure for Letter of Unavoidability Guidelines provided by the RNC (Regional Nurse Consultant) #1 on 1/25/16 at 11:00 A.M. indicated, .To provide physician certification of unavoidable wounds due to resident condition despite proper implementation of care interventions .2. Staff will make every effort to identify and implement care interventions to prevent skin breakdown . A Policy and Procedure for Wound Risk Assessment Guideline provided by the RNC #1 on 1/25/16 at 11:00 A.M. indicated, To provide guidelines for the identification of risk factors predisposing residents to skin breakdown .5. Recognized risk factors shall have care plan interventions/approaches identified and put in place to mitigate the risks to the extent possible. A Policy and Procedure for Monthly Nursing Assessment and Data Collection provided by the RNC #1 on 1/25/16 at 11:00 A.M. indicated, 6. The nurse completing the form shall identify the risk factors and follow the care plan intervention for minimizing and/or eliminating safety concerns. a. Care plan interventions should be reviewed and evaluated for effectiveness and modified as indicated. b. Interventions should be specific to the resident and target the impact of the risk to the individual . A Policy and Procedure for Guidelines for Circumstance and Reassessment Forms provided by the RNC #1 on 1/25/16 at 11:00 A.M. indicated, .4. New approaches or interventions should be evaluated and added as a care plan update .Approaches/interventions already in effect should not be listed again . During an interview on 1/25/15 at 11:30 A.M. the RNC #1 indicated the Wound Risk Assessment policy was the comprehensive policy followed by the facility, specific interventions could be located on the Admission/Monthly Nursing assessments or the Skin Impairment Circumstance, wound prevention was basic nursing knowledge, and no specific policy could be provided for Pressure Ulcer Prevention. 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure restorative nursing services were provided for 1 of 1 resident who met the criteria for review of range of motion. This deficient practice resulted in Resident #10 experiencing increased contractures of the left knee and new contracture of the right knee. (Resident #10) Findings include: During an interview on 1/14/15 at 11:00 A.M., the MDS (Minimum Data Set) Coordinator indicated Resident #10 experienced contractures to the bilateral upper and lower extremities. The MDS Coordinator further indicated, at that time, Resident #10 did not use splints and did not receive range of motion services. During an observation of care on 1/15/16 at 9:38 A.M., Resident #10 was observed lying in bed with a left hand contracture. Resident #10 was observed to have bilateral upper and lower extremity impairment and to not be utilizing splints. The clinical record of Resident #10 was reviewed on 1/15/16 at 11:00 A.M. The record indicated the [DIAGNOSES REDACTED]. The Admission MDS assessment dated [DATE] indicated Resident #10 experienced severe cognitive impairment, bilateral range of motion impairment to the upper and lower extremities, required the extensive assist of two staff for bed mobility, hygiene, and toileting, and received Physical Therapy services. The most recent MDS assessment dated [DATE] indicated Resident #10 experienced severe cognitive impairment, bilateral range of motion impairment to the upper and lower extremities, did not receive restorative nursing services and did not use splints or receive range of motion services. The most recent physician's orders [REDACTED]. A Restorative Care Program referral dated 6/11/15 indicated, .joint contracture .will tolerate resting hand splint on LUE (left upper extremity) and RUE (right upper extremity) daily .perform gentle stretching of LUE and RUE prior to donning resting hand splint . The Admission Nursing assessment dated [DATE] indicated Resident #10 experienced a left hand contracture and included, but was not limited to, an intervention of ROM (range of motion) per protocol. An OT (Occupational Therapy) Plan of Care dated 6/19/15 indicated, .Discharge plan .Pt (patient) will discharge from OT able to tolerate splints for positioning of BUE (bilateral upper extremities) and prevention of contractures .underlying impairments: Pt LUE rigid with contractures noted . A Resident Conference dated 6/23/15 indicated, .OT (Occupational Therapy) with positioning/splint mgt (management) .was using splint; gradually increasing .PT: working on ROM in legs .still has tightness in legs . A PT-Therapist Progress note dated 7/2/15 indicated, .Pt has demonstrated improved ROM of bilateral ankles and left knee since initiation of skilled PT services .has demonstrated improved joint mobility since initiation of skilled services .PT .Prognosis For Further Progress: Good due to increased ROM . An OT-Therapist Progress note dated 7/2/15 indicated, .prior level of function 6/19/15 .is at risk for new contractures and worsening of existing contractures . A PT-Therapist Progress note dated 7/14/15 indicated, .Pt. (patient) would benefit from implementation of nursing restorative program .to continue maintaining joint mobility at max (maximum) level Pt continues with BLE contractures .which warrants continued PT to establish a restorative program which will help to maintain joint mobility and alignment .Pt has been able to maintain joint mobility without further progression of flexion contractures .focus on implementing restorative program for ROM (range of motion) to BLE to maintain joint mobility and alignment .will implement nursing restorative program for continued maintenance of joint mobility . An OT-Therapist Progress note dated 7/15/15 indicated, .Caregivers have been inconsistent with proper donning/doffing of bilateral hand splints and management of wearing schedule . A Restorative Care Program referral dated 7/16/15 indicated, .Diagnosis: [REDACTED]. Patient is discharged from PT effective 7/17/15. Goals for Restorative Program: .Maintain ROM in BLEs (sic) (bilateral lower extremities) to prevent contractures and allow for optimal positioning .PROM (passive range of motion) and gentle stretching to BLE X (times) 10 reps (repetitions) . A PT-Therapist Progress and Discharge Summary dated 7/17/15 indicated, .The patient demonstrates PROM of LLE (left lower extremity) knee from 55 to 130 degrees .Pt has demonstrated improved ROM of bilateral ankles and left knee .would benefit from restorative nursing program for ROM to BLE's to maintain maximal joint mobility and prevent further contractures .Recommendations made for nursing restorative program for PROM to maintain joint mobility and prevent further contractures .at risk for joint contracture .d/c (discharge) from PT with recommendations made for nursing restorative program . The summary lacked any documentation related to the right lower extremity. An OT-Therapist Progress & Discharge Summary dated 7/17/15 indicated, .Patient discharged to SNF with recommendations including continue with splints (restorative program established) and positioning techniques . A Monthly Nursing assessment dated [DATE] indicated Resident #10 experienced contractures and lacked any documentation to indicate Resident #10 received range of motion services or used splints. The Plan of Care dated 1/14/16 lacked any documentation related to contractures or restorative nursing services. During an observation of care on 1/19/16 at 9:30 A.M., PTA (Physical Therapy Assistant) #1 was observed to not be able to move the bilateral knee joints of Resident #10 during repositioning. PTA #1 stated, at that time, the bilateral lower legs were, really contracted. CNA #5 was then observed to not be able to move the bilateral upper extremities shoulder or elbow joints during repositioning. RN #5 then indicated Resident #10 was admitted with contractures of the bilateral upper and lower extremities. During an interview on 1/19/16 at 11:00 A.M., OT #1 indicated Resident #10 was discharged from Physical Therapy Services on 7/17/5 and referred for restorative nursing services on 7/16/15. OT #1 further indicated, at that time, she was not aware who was responsible for the restorative nursing program or how the program worked, and provided a restorative nursing referral. During an interview on 1/19/16 at 11:15 A.M., the MDS Coordinator indicated she was responsible for the Restorative Nursing Program, she had not been made aware Resident #10 was referred for restorative nursing services, and Resident #10 did not receive restorative nursing services between 6/18/15 and 1/18/16 or use splints on the bilateral upper extremities after Occupational Therapy ended in July of 2015. An untimed PT Daily Treatment Note dated 1/25/16 indicated, .L (left) knee 135-80 degrees (-80 degrees from full knee extension) .R (right) knee 135-25 degrees (-25 degrees from full knee extension) . The PT daily treatment notes indicated Resident #10 experienced a 25 degree loss of extension in the left and right knee between 7/16/15 and 1/25/16. During an interview on 1/25/16 at 2:00 P.M., OT #1 indicated the documentation reflected Resident #10 experienced decreased range of motion in the bilateral lower extremities since being discharged from therapy service. A Policy and Procedure for Nursing Restorative and Functional Maintenance Program provided by the DON (Director of Nursing) on 1/25/16 at 8:05 A.M. indicated, .To promote Restorative and Functional Maintenance Nursing Programs to enable residents to attain or maintain the highest level of functioning regarding physical .well-being . 7. Restorative programs will be delivered according to the established program plan . 3.1-42(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 developed a pressure ulcer and the ulcer deteriorated to a stage 3 for 1 of 1 resident who met the criteria for review of pressure ulcers. This deficient practice resulted in Resident #13 experiencing a stage 3 pressure ulcer. (Resident #13) Findings include: During an observation on 12/03/14 at 1:19 P.M., Resident #13 was in the dining room sitting in her Geri Chair (Geriatric Reclining Chair) with her new positioning device in place. The clinical record of Resident #13 was reviewed on 12/05/14 at 9:55 A.M. The record indicated Resident #13 was admitted on [DATE]. The [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. An "Individual Care Plan Report" dated 10/6/14 read as follows' "...Provide me with pressure distribution products for my bed and chair." The Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #13 experienced severe cognitive impairment and required the extensive assistance of two plus staff for bed mobility, positioning, and transferring. A "PRESSURE/STASIS/ARTERIAL/DIABETIC ULCER ASSESSMENTS" form dated 12/2/14 documented the wound was located on the left buttock of Resident #13 and was a Stage 3 pressure ulcer acquired on 3/25/14. The measurement on 12/2/14 of the pressure area was 1.7cm (centimeters) length, 1.2 cm width and 0.1 cm in depth. The color of the tissue was document as 80% red and 20% yellow. The wound margins were rolled and surrounding tissue was red. "Current preventive interventions: hospice provided new cushion for geri chair..." The "PRESSURE/STASIS/ARTERIAL/DIABETIC ULCER ASSESSMENTS" form indicated , "...Stage 3..., ...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..." During an interview on 12/5/14 at 2:45 P.M., " OT #1 indicated a lateral support was added to Resident #13's wheelchair to help with her positioning. An "OT (Occupational Therapy) DAILY TREATMENT NOTE" was provided at that time and read as follows, "...8/28/13...W/C (wheel chair) modification including installing lateral support..." An "INTERDISCIPLINARY HOSPICE COMMUNICATION" form dated 11/20/14 indicated the following: "...Lateral supports have a bar @ (at) the coccyx area where supports secure to W/C (wheel chair). Discussed removal of supports to see if wd (wound) will improve/heal with this intervention. Agree with this assessment et (and) they will have maintenance remove support. Will use 2 flow cushions for support..." During an observation with RN #11 on 12/5/14, Resident #13 had a wound area located on her left buttock slightly left of her coccyx. The wound was open with a red wound bed and yellow slough covering 30% of the wound bed. No drainage or odor was noted at the time of observation. During an interview on 12/5/14 at 09:58 A.M., the Assistant Director of Nursing (ADON) indicated Resident #13 had a padded positioning bar placed in her wheel chair in 2013. Over time, the padding on the positioning bar wore out, leaving a piece of metal exposed. The exposed metal was believed to be the cause of a stage 3 pressure area on Resident #13's coccyx. The ADON further indicated that, since the time the positioning bar was removed from the chair and a new positioning device was installed, Resident #13's pressure area had improved. 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident identified at risk for falls received adequate supervision and/or assistance to prevent further falls for 1 of 1 resident reviewed for falls. This deficient practice resulted in Resident #45 experiencing a hip fracture. (Resident#45) Findings include: On 12/3/14 at 12:22 P.M., Resident #45 was observed sitting in her wheelchair in the main dining room. An alarm box was noted on the back of her wheelchair. Resident #45's clinical record was reviewed on 12/2/14 at 10:41 A.M. Resident #45 had been admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated Resident #45 was always continent of urine. The assessment indicated supervision of 1 staff needed for bed mobility, transfers, and ambulation in her room and the corridor. The assessment indicated the limited assistance of 1 staff was needed for toileting. The 7/8/14 MDS indicated a cognitive score of 4 (severe cognitive impairment). A quarterly MDS dated [DATE], indicated Resident #45 was always continent of urine, needed limited assistance of 1 staff for bed mobility and transfers, and extensive assistance of 1 staff for toileting. Cognition score was 5 (severe cognitive impairment). A significant change MDS dated [DATE], indicated extensive assistance of 2 staff needed for transfers, bed mobility, and toilet use. A cognition score of 3 indicated severe cognitive impairment. A fall care plan initiated 06/05/12 and last updated on 10/11/14, indicated the resident was at risk for falls related to antianxiety and antidepressant medications and unsteadiness related to position change from sit to stand. Interventions included but were not limited to, low bed, half rails as enabler, use of wheelchair as an adaptive device, educate and remind resident to request assistance before ambulating, and "...orange duct tape to walker as visual aid to use." On 12/3/14 at 10:30 A.M., the Assistant Director of Nursing (ADON) was made aware the fall assessment of Resident #45's 10/31/14 fall was missing from her clinical record. The ADON at that time was unable to locate in the clinical record the 10/31/14 fall assessment and circumstance or the documentation of the 10/31/14 fall in the nursing progress notes. She indicated at that time she would continue to look for the missing fall documentation. On 12/3/14 at 12:30 P.M., during interview with the Director of Nursing (DON) she indicated she was aware of the fall assessment for the 10/31/14 fall was not in Resident #45's clinical record. She indicated the facility's RN Consultant would continue to look for the missing fall assessment. On 12/3/14 at 1:40 P.M., the following fall assessments and care plans were reviewed with the Director of Nursing (DON). A "Fall Circumstance, Assessment and Intervention" form dated 7/18/14 indicated, Resident #45 had fallen and was found on the bathroom floor at 6:00 P.M. The section of the assessment regarding activity at the time of the fall was left blank. New interventions initiated were, "Lock bed wheels, Therapy evaluation, Frequently used items within reach, low bed, and PT (Physical Therapy) OT (Occupational Therapy) eval. (evaluation)." The fall assessment also indicated cognitive impairment had affected the resident's judgment in regard to safety and that assistance was needed for transfer and ambulation. The DON indicated at that time (12/3/14 at 1:40 P.M.) documentation was lacking that assistance had been provided for transfer to toilet in regard to the 7/18/14 fall. The DON also indicated Occupational Therapy (OT) had picked up the resident for services after the 7/18/14 fall. The DON reviewed the OT notes (7/18/14) and indicated on OT discharge the resident had needed the assistance of 1 staff for ADLS (activities of daily living) and ambulation of short distances in her room. On 12/5/14 at 8:55 A. M., Occupational Therapist #1 was interviewed regarding the OT therapy provided after the 7/8/14 fall. She indicated OT therapy had started on 7/22/14 after the resident fell in her bathroom toileting herself on 7/18/14. OT Therapist #1 indicated at OT discharge on 8/20/14, Resident #45 had needed contact guard assistance for steadiness when dressing and toileting. She explained contact guard was "hand on" care/assistance that would be provided if needed. She explained on discharge 8/20/14, the resident needed contact guard assistance for transfers. OT Therapist #1 indicated at that time Resident #45 had needed contact guard and assistance to toilet and transfer before the fall of 9/25/14. Another fall assessment indicated a fall had occurred on 9/25/14. The documentation had indicated the fall had occurred in the resident's bathroom at 1:50 P.M. The report indicated the activity at the time of the fall was "... ambulating s (without) device from toilet lost balance & slid down the wall..." The DON was made aware at that time the 9/16/14 MDS had indicated the resident needed assistance to toilet. The DON agreed staff assistance was lacking in regard to the 9/25/14 fall. The assessment lacked documentation of immediate interventions being initiated to prevent further falls until interventions were documented the next day on 9/26/14 by the Interdisciplinary team. The Interdisciplinary team interventions included: "balance loss r/t (related to) 0 (zero) utilizing adaptive device, apply orange duct tape to walker to act as visual cue and enabling to (arrow up symbol)(increase) compliance of utilizing walker... " , and a medication review. On 12/5/14 at 8:55 A.M., during interview with Occupational Therapist #1, she indicated Resident #45 had needed contact guard assistance by staff to toilet and transfer before the fall of 9/25/14. She indicated Resident #45 was not picked up for therapy after the 9/25/14 fall. She indicated Resident #45 had fallen in her bathroom on 10/31/14 and broke her hip and at present was receiving therapy. A "Resident Transfer Form" dated 10/31/14, indicated Resident #45 had been transferred to a hospital. The documentation indicated resident was up "... transferring self & fell in Br (bathroom) - usually uses w/c for locomotion transfers self for toileting needs. Res (resident} c/o (complaint) LT (left) knee, hip & shoulder pain..." The transfer form documented assistance was needed for the bed activity of turning and sitting and assistance was needed for transfer to tub and toilet. The transfer sheet also indicated Resident #45's mental status was documented as forgetful. A Hospital History and Physical dated 11/1/14 regarding Resident #45 indicated, "...This is a [AGE] year old female from a skilled nursing facility, who fell injuring her left hip. She was brought to (hospital name here) where she was found to have left intertrochanteric hip fracture (fracture of the upper femur)..." On 12/3/14 at 1:40 P.M., the DON was made aware that documentation was lacking of a facility assessment (Fall Circumstance Assessment and Intervention) of Resident #45's 10/31/14 fall. Documentation of the 10/31/14 fall was also lacking in the nursing notes of Resident #45. The DON indicated at that time she was aware the clinical record lacked the fall circumstance assessment. She indicated the facility had contacted the hospital for documentation that had been sent with the resident when she had been transferred to the hospital. She indicated the hospital had faxed the facility papers that had been sent during transfer. She indicated the facility fall assessment of the 10/31/14 fall had not been included. She indicated a facility incident report (internal facility documentation not part of the clinical record) of the 10/31/14 fall had been completed. The facility did not provide the 10/31/14 incident report. The facility did not provide any documentation in regard to the fall assessment of the 10/31/14 fall. On 12/5/14 at 10:10 A.M., the DON was made aware there was a problem with lack of adequate supervision and assistance being provided during transferring and toileting to prevent falls. The DON at that time provided no further information. On 12/5/14 at 10:30 A.M., the facility fall policy entitled "FALLS MANAGEMENT PROGRAM GUIDELINES (revision date 3/08) was received and reviewed. The policy included but was not limited to, "...Procedure: 3. Should the resident experience a fall the attending nurse shall complete the 'Fall circumstance and Reassessment Form' The form includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT (Interdisciplinary team) to evaluate thoroughness of the investigation and appropriateness of the interventions..." 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure adequate supervision was provided to a resident with an alarm and recent history of falls for 1 of 4 residents reviewed for falls. Resident #47's fall resulted in a transfer to the emergency room with a small subdural hematoma. Resident #47 Findings include: Resident #47's closed record was reviewed on 9/30/13 at 4:00 P.M. On 5/17/13 at 4:50 P.M., Resident # 47 was admitted to the facility. His [DIAGNOSES REDACTED]. His admission Minimum Data Set Assessment ((MDS) dated [DATE], indicated a summary score of 14 (cognition intact). He needed extensive assistance of 2 or more staff for transfers. He needed limited assistance of 2 or more staff for ambulation in his room. His care plan with an initiation dated of 10/20/11(used from previous facility admissions) indicated a history of falls and potential for falls. Interventions included but were not limited to: bed in low position, walker, wheelchair, and occupational and physical therapy. A facility fall circumstance, assessment, and intervention form dated 6/7/13, indicated a fall had occurred on 6/7/13 at 12:35 P.M. Documentation indicated the fall had occurred in the resident's room and the resident had been found on the floor. The activity documented at the time of the fall was that the resident was transferring his self. New interventions after the fall were to move urinal within reach and to add a bed and chair alarm. A nursing progress note dated 6/10/13 at 11:55 P.M., indicated, "CNA walking in hallway observed resident fall backwards & strike head on floor. Was unable to reach him in time to intervene. Manual cervical traction applied. I could feel hematoma on back of head lt (left) side & visualized laceration et (and) back of head. Resident was non responsive approx (approximately) 2 minutes when began to respond, was slow @ first but quickly became alert, oriented & appropriate c (with) responses. PEARL (pupils equal and react to light) bil.(bilateral) Grasp= bil & strong. C (cervical) spine stabilization continued manually until EMS arrived. Dr. (physician's name) triage notified, order received..." A nursing progress note dated 6/10/13 at 12:15 A.M., indicated, "EMS departed facility to (name of hospital) hospital..." On 9/30/13 at 4:10 P.M., the Director of Nursing Services (DON) was interviewed. She indicated the resident was admitted on [DATE] from the hospital. She indicated according the nursing admission assessment (5/17/13) he was alert and oriented on admission. The DON indicated the resident on admission was to use a walker and wheelchair. She indicated the resident had received therapy on admission and used 1/2 side rails. The DON stated he had a history of [REDACTED]. The DON indicated regarding the 6/7/13 fall the resident had reached for the urinal and fell . She indicated new interventions after the 6/7/13 fall were to apply bed and chair pressure alarms and give the resident a urinal. The DON stated the resident did not have any injuries from the 6/7/13 fall. The DON stated his next fall occurred on 6/9/13 at 11:55 P.M. She indicated the resident had been restless and lost his balance and was sent out to the hospital. The DON indicated the alarm had been sounding at the time of the fall. The DON indicated the resident's alarm was sounding but staff was unable to get to the resident in time. She also indicated the resident should not have been up by himself without assistance. A hospital Discharge Summary dated 6/14/13, indicated final Diagnoses: [REDACTED]. 3.1-45(a)(2)