Every finding on record at Altercare Newark South Inc.

Based on review of resident medical records, staff interviews and review of facility policy, the facility failed to ensure staff was knowledgeable about advanced directive procedures. This affected four of four residents (#1, #22, #24, and #46) reviewed for advanced directives. The facility census was 42 residents. Findings include: 1. Review of a resident medical record revealed that Resident #22 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease and dysphagia. Review of Resident #22's face sheet revealed that there were no advanced directives noted. Review of Resident #22's care plan dated 11/19/25 revealed that Resident #22 had elected the hospice benefit, and a goal listed was to have end of life care coordinated with hospice and the facility. The code status was not addressed in the care plan. Review of Resident #22's orders revealed that there were no orders for advanced directives noted. An interview on 06/28/26 at 1:46 P.M. with the Director of Nursing (DON) revealed that the hard charts will contain a copy of the advanced directives if there are any code statuses other than full code for a resident. The DON revealed that if a resident is a full code status, there will not be a form in their physical chart. An interview on 06/28/26 at 1:45 P.M. with Registered Nurse (RN) #135 revealed that she was unaware that there were physical hard charts available for residents. An interview on 06/29/2026 at 8:12 A.M. with Licensed Practical Nurse (LPN) # 350 revealed she would look in the electronic charting system for current physician order and on the resident's face sheet for current code status. An interview with Regional Clinical Nurse #221 on 06/29/26 at 10:15 A.M. verified Resident # 22's physician orders and face sheet did not contain advanced directive information. 2. Review of a resident medical record revealed that Resident #46 was admitted to the facility on [DATE] and had diagnoses that included Type II Diabetes mellitus and malignant neoplasm of endometrium. Review of Resident #46's face sheet revealed that there were no advanced directives or code status. Review of Resident #46's care plan revealed that there were no advanced directives noted in the care plan. Review of Resident #46's orders revealed that there were no advanced directive orders or code statuses ordered. An interview on 06/28/26 at 1:46 P.M. with the Director of Nursing (DON) revealed that the hard charts will contain a copy of the advanced directives if there are any code statuses other than full code for a resident. The DON revealed that if a resident is a full code status, there will not be a form in their physical chart. An interview on 06/28/26 at 1:45 P.M. with Registered Nurse (RN) #135 revealed that she was unaware that there were physical hard charts available for residents. An interview on 06/29/2026 at 8:12 A.M. with Licensed Practical Nurse (LPN) # 350 revealed she would look in the electronic charting system for current physician order and on the resident's face sheet for current code status. An interview with Regional Clinical Nurse #221 on 06/29/26 at 10:15 A.M. verified Resident #46's physician orders and face sheet did not contain advanced directive information. 3. Review of Resident # 01's medical record revealed an admission date of 02/27/26 with diagnoses that included but were not limited to chronic diastolic heart failure, cardiac arrest, acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. Further review of Resident # 01's record revealed a Do Not Resuscitate (DNR) form with DNR Comfort Care marked. Review of Resident # 01's current face sheet revealed no directive was selected for advanced directives. Review of Resident # 01's admission minimum data set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required assistance from staff with bathing, dressing and mobility. Review of Resident # 01's physician's orders dated May 2026 to June 2026 revealed no active orders for advanced directives. Review of Resident # 01's care plans last revised on 05/22/26 revealed no care plan for advanced directives. 4. Review of Resident #24's medical record revealed an admission date of 05/17/24 with diagnoses that included but were not limited to cerebral vascular accident with left hemiparesis, paralysis of vocal cords, dementia, depression, anxiety and malignant neoplasm of the prostate. Review of Resident # 24's quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and required assistance from staff with hygiene and dressing. Review of Resident # 24's active physicians orders revealed no active order for advanced directives. Review of Resident # 24's current face sheet revealed no directive was selected for advanced directives. Review of Resident # 24's care plans revised on 06/26/26 revealed no care plan for advanced directives. Interview on 06/29/2026 with LPN # 350 revealed she would look in the electronic charting system for current physician order and on the resident's face sheet for current code status. Review of the medical record during the interview LPN #350 confirmed Resident #01 and Resident # 24 did not have active orders for advanced directives or advanced directives selected on their face sheets this. When asked if she would look anywhere else Nurse # 350 stated she did not know of anywhere else to look.

Based on record review, and staff interview the facility failed to timely implement physician recommendations per the Medication Regimen Review (MRR) for three residents, (#1, #4, and #24) of five reviewed for unnecessary medications. The facility also failed to ensure the MRR were reviewed by the physician in a timely manner for three residents, (#4, #24, and #46) of five reviewed for unnecessary medications. The facility census was 42. Findings include: 1.Review of the medical record for Resident #01 revealed an admission date of 02/27/26 with diagnoses of, but not limited to, chronic diastolic heart failure, chronic kidney disease, and chronic pain. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 05/12/26 revealed the resident was cognitively intact. Review of the Medication Regimen Review (MRR) for May of 2026, signed 05/29/26, revealed a physician agreed with the recommendation to discontinue Tramadol (opioid), decrease Gabapentin (anticonvulsant) from 800 milligrams (mg) to 600mg three times a day for one week then 600mg twice a day. Review of the physician orders for Resident #01 revealed the Tramadol was not discontinued until 06/25/26 and the resident continued to have an active order, for Gabapentin 800mg three times per day with at start date of 02/27/26. Interview with Regional Nurse #221 on 06/30/26 at 2:25 P.M. confirmed the recommendations provided by the physician on the MRR were not followed. 2. Review of the medical record for Resident #04 revealed a readmission date of 02/15/25 with diagnoses of acute kidney failure, hyperlipidemia, and osteoarthritis. Review of the quarterly MDS 3.0 dated 06/22/26 revealed the resident was cognitively intact. Review of Resident #04 MRR for July of 2025 revealed a printed date of 07/21/25. The physician did not sign the MRR until 08/29/25. Review of the MRR for August of 2025 revealed an approved recommendation for laboratory (labs) tests for vitamin D, iron panel, and thyroid stimulating hormone (TSH) to be completed yearly and stated to draw the labs on the next convenient day. Review of the labs for Resident #04 revealed the labs were not drawn until May of 2026. Review of the MRR's revealed Resident #04 had no documented MRR for November of 2025 and February of 2026. Review of the MRR for March of 2026, printed 03/20/26 revealed no signature by the physician until 05/13/26. In addition, the MRR revealed an approved recommendation to discontinue bio freeze, Bisacodyl suppository (laxative), Docusate (stool softener), Fluticasone (antihistamine) nasal spray, Loperamide (antidiarrheal), and Ipratropium (anticholinergic), Albuterol (bronchodilator). Review of the physician orders for Resident #04 revealed the medications were not discontinued as recommended until 05/19/26. Interview with Regional Nurse #221 on 06/30/26 at 2:25 P.M. confirmed the recommendations provided by the physician on the MRR were not timely followed. Regional Nurse #221 also confirmed the missing MRR's for November of 2025 and February of 2026. 3. Review of the medical record for Resident #24 revealed a readmission date of 07/18/25 with diagnoses of, but no limited to, dementia, muscle weakness, and Type Two Diabetes. Review of the annual MDS 3.0 dated 04/22/26 revealed the resident was cognitively intact. Review of the MRR for September of 2025 revealed a physician supported recommendation for Carvedilol (antihypertensive)to be administered with food. Review of the physician orders for Resident #24 revealed the facility did not implement the change to the order until 10/24/25. Review of the MRR for March of 2026 revealed it was not signed by the physician until 05/13/26. Additional review of the MRR's revealed Resident #24 did not have a MRR for June of 2026. Interview with Regional Nurse #221 on 06/30/26 at 2:25 P.M. confirmed the recommendations provided by the physician on the MRR were not timely implemented. 4. Review of the resident medical record for Resident #46 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included Type II Diabetes Mellitus and bullous pemphigoid. Review of Resident #46's MDS 3.0 assessment dated [DATE] revealed that Resident #46 was assessed as receiving insulin. Review of Resident #46's Medication Regimen Review dated 03/20/26 revealed it was recommended by the pharmacist that Lispro insulin (a fast-acting insulin) be discontinued, Ozempic, a GLP-2 receptor antagonist used to treat diabetes, be reduced to 0.5 milligrams (mg) weekly, and Dapagliflozin, a sodium-glucose co-transporter II inhibitor used to treat Type II Diabetes Mellitus, 5 mg daily be added. Review of the document revealed the physician responded on 04/24/26 to the pharmacist's recommendations. An interview with Regional Nurse #221 on 06/30/26 at 2:25 P.M. confirmed the response to the pharmacist's recommendations was not made by the physician in a timely manner. Review of the facility policy titled, Consulting Pharmacist Monthly Drug Review, dated 05/01/25, revealed that the consulting pharmacist will conduct a monthly medication regimen review for each resident in the facility. The resident's attending physician must document in the medical record that the identified irregularity has been reviewed, and what, if any action has been taken to address it. If there is no change in the medication, the attending physician must document his or her rationale in the resident's medical record at the physician's next visit.

Based on record review, interviews, and facility policy review, the facility failed to implement interventions to prevent pressure ulcers. This affected one resident, (#24), of three residents reviewed for pressure ulcers. The facility census was 42. Findings include:Review of the medical record for Resident #24 revealed a readmission date of 07/18/25 with diagnoses of, but no limited to, dementia, muscle weakness, and Type Two Diabetes.Review of the annual Minimum Data Set (MDS) 3.0 dated 04/22/26 revealed the resident was cognitively intact. The MDS further revealed the resident was at risk for pressure ulcers.Review of the residents wound management detail report revealed on 06/11/26 the resident was identified as having an abrasion to his left ankle. On 06/18/26 the report identified the wound as being stable and scabbed, and on 06/26/26 the report documented the wound was no longer an abrasion and identified the wound as being a stage three pressure ulcer.Review of the care plan for Resident #24, reviewed on 04/27/26, revealed the resident was care planned to be encouraged and have assistance to float his heels as tolerated. Additionally, the care plan stated to observe and report any noncompliance or rejection of care for would management.Review of the medical record revealed in March 2026 the resident had a task for staff to off-load heels as tolerated by the resident. Review of the months April 2026 to June of 2026 revealed the off-loading heels prompt not to be present and there was no documentation in the record it completed.Review of the residents' physician orders revealed Resident #24 had orders for wound care treatment, however there were no ordered preventative skin mesaures. Interview on 06/29/26 at 11:30 A.M. with the Assistant Director of Nursing (ADON) #123 revealed the resident had a history of laying his foot ankle side down and refusing intervention to promote wound healing. ADON #123 was unable to identify where the residents' noncompliance/refusals were documented in the resident record.Interview on 06/29/26 at 1:00 P.M. with Regional Nurse #221 confirmed the Resident #24 had a task of off-loading heels in March 2026 but not for April 2026, May 2026, or June of 2026.Additional interview on 06/30/26 at 12:00 P.M. with ADON #123 confirmed if a resident had a wound and interventions are supposed to be in place it is an expectation for staff to be documenting when the intervention is in place or documenting the resident refusal. ADON #123 confirmed the facility was not doing this for Resident #24 and confirmed there was no documentation to show Resident #24 had preventative skin interventions in place to prevent his abrasion from becoming a stage three pressure ulcer.Review of the facility policy titled 'Pressure Injuries: Assessment, Prevention, and Treatment', updated 05/01/25, revealed it is the facility's policy to identify residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injures, and provide care for existing pressure injuries.

Based on review of resident medical records, staff interviews, and review of facility policy, the facility failed to monitor the nutrition status quarterly for one resident (#22). The facility failed to complete nutrition assessments timely for two residents, (#7 and #22). The facility failed to identify a significant weight loss for one resident, (#7). The facility also failed to notify the physician of significant weight losses for two residents, (#03 and #7). This affected three of four residents reviewed for nutrition. The facility census was 42 residents. Findings include: 1. Review of resident medical record revealed that Resident #7 was admitted to the facility on [DATE] and had diagnoses that included osteomyelitis, dysphagia and major depressive disorder. Review of Resident #7's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognitive status. Resident #7 was assessed as being dependent for eating, and being on a therapeutic diet. Review of Resident #7's assessment titled, Nutrition Observation dated 09/17/25 revealed that Resident #7's nutrition assessment was completed forty days after Resident #7's admission to the facility. Review of Resident #7's care plan dated 08/21/25 revealed that Resident #7 was at risk for altered nutrition status related to having a pressure ulcer, paraplegia and depression. A goal listed for Resident #7 was to receive adequate nutrition to meet his estimated nutritional needs, as evidenced by no significant weight changes. An approach listed to help Resident #7 meet this goal was to monitor Resident #7's weights. The dietitian and physician will be informed of a significant weight change over 5% of body weight. Review of Resident #7's weight history revealed that on 08/25/25, Resident #7's weight was 189.4 pounds (lbs). On 02/12/26, Resident #7's weight was 170.2 lbs, which was a weight loss of 19.2 lbs (10.1%) in 6 months. Review of Resident #7's progress notes authored by Dietitian #225 dated 02/11/26 revealed that Resident #7 had lost weight. A recommendation to increase a protein supplement to three times daily was recommended and implemented at that time. The progress notes were silent for physician notification of significant weight change. Review of Resident #7's weight history revealed that on 10/27/25, Resident #7 weighed 183.6 lbs., on 03/11/26, Resident #7 weighed 174.6 lbs., and on 04/27/26, Resident #7 weighed 163.8 lbs. Based on Resident #7's weight on 04/27/26, Resident #7 at that time had lost 6.2% weight in 1 month, and 10.8% weight in 6 months, which was a significant amount of weight loss. Review of Resident #7's progress notes dated 04/27/26 through 06/28/26 did not address the significant weight loss, and the progress notes were silent for physician notification of significant weight loss. Review of Resident #7's weight history revealed that from 04/27/26 to 06/01/26, Resident #7's weight stayed stable between 164 and 166.6 lbs. Review of Resident #7's MDS 3.0 assessment history revealed that Resident #7's comprehensive admission assessment was submitted on 08/22/25, and his quarterly assessments were submitted on 10/31/25, 01/23/26, and 04/24/26. An interview with Regional Nurse #221 on 06/29/26 at 5:36 P.M. confirmed the medical record was silent for the dietitian acknowledgment of the significant weight loss that occurred on 04/27/26 and silent for physician notification of the significant weight loss. An interview with Regional Dietitian #223 on 06/30/26 at 10:59 A.M. confirmed Resident #7 did have significant weight loss that was not addressed in the medical record, Resident #7's nutrition assessment was completed late and not within fourteen days of admission, that there was no evidence that the physician had been notified of the significant weight loss, and that the root cause of the weight loss was not investigated in a timely manner. 2. Review of resident medical record revealed that Resident #22 was admitted to the facility on [DATE] and had diagnoses that included Parkinson's disease and dysphagia. Review of Resident #22's MDS 3.0 assessment dated [DATE] revealed that Resident #22 had a BIMS score of 15, indicative of intact cognitive status. She was assessed as having no significant weight changes and having a mechanically altered diet. Review of Resident #22's MDS 3.0 history revealed that Resident #22 had a comprehensive assessment accepted on 03/13/25 and 12/05/25. Resident #22 had quarterly assessments accepted on 07/05/25, 08/22/25, 02/13/25, and 05/22/25. Review of Resident #22's assessment titled, Nutrition Observation, dated 03/25/25 revealed that Resident #22 had one nutritional assessment since admission. Resident #22 did not have a nutrition assessment that correlated with the comprehensive MDS assessment accepted on 12/05/25. Review of Resident #22's care plan dated 03/25/25 revealed that Resident #22 was at risk for altered nutrition status related to her diagnoses and was under hospice care as of November 2025. A goal listed for Resident #22 was to not have a significant change in her weight status. Review of Resident #22's weight history revealed that on 11/03/25, Resident #22 weighed 150.6 lbs, on 01/05/26, Resident #22 weighed 143.8 lbs, and on 04/07/26, Resident #22 weighed 138.2 lbs. Review of Resident #22's nutrition progress notes dated 02/11/26 authored by Dietitian #223 revealed that Resident #22 weighed 143.8 lbs, but did not acknowledge that Resident #22 had a weight loss trend of 6.8 lbs in 2 months. The medical record was silent for nutrition progress notes since 02/11/26, and did not have a nutrition progress note that correlated with the MDS quarterly assessment that was accepted on 05/22/26. The medical record did not acknowledge that Resident #22 had a 12.4 lb weight loss trend since 11/03/25. A dietitian did not document the root cause for the weight loss trend. An interview with Regional Dietitian #225 on 06/30/26 at 10:59 A.M. confirmed that residents should have nutrition assessments that correlate with the comprehensive MDS assessment schedule. Residents should be documented on by the dietitian every three months, in correlation to the MDS assessment schedule. Weight loss trends should be investigated and the root cause of the weight loss should be documented. If the weight loss was insidious, an intervention should be implemented to attempt to arrest the weight loss trend. Regional Dietitian #225 confirmed a resident being admitted to hospice does not negate the need to investigate a weight loss trend or document on a resident according to the MDS assessment schedule. 3. Review of the medical record for Resident #03 revealed a readmission date of 05/08/26 with diagnoses of, but not limited to, heart failure, atherosclerotic heart disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 05/11/26 revealed the resident was cognitively intact. Review of the MDS also revealed the resident was not on a physician-prescribed weight loss regimen. Review of the weights for Resident #03 revealed on 04/28/26 the resident had a weight of 246.8 pounds (lbs), 04/29/26 a weight of 234.2lbs, and 05/01/26 a weight of 228.8lbs totaling a weight loss of 18lbs/-8.04% in three days. Review of the Care Plan for Resident #03, reviewed 05/19/26, revealed a problem area of nutritional status with an intervention dated 07/14/25 to notify the Registered Dietician/Physician if the resident had a significant weight change over 5%. The care plan further revealed an additional intervention to observe and report any weight loss or decrease in appetite. Review of the progress notes for the resident revealed no notification to the physician nor the registered dietician regarding the resident's significant weight loss. Additional review of the progress notes revealed the resident was not seen by the registered dietician until 05/20/26. Interview on 06/30/26 at 4:36 P.M. with Regional Nurse #221 revealed the resident was not seen by the registered dietician following their weight loss due to being hospitalized for a planned procedure, beginning 05/04/26. Regional Nurse #221 confirmed Resident #03 had no documented notification to the physician or the dietician following the significant weight loss. Interview on 06/30/26 at 10:59 A.M. with Regional Dietician #223 confirmed if a resident experiences a significant weight loss the staff are expected to notify the dietician and/or the physician. Review of the facility policy titled 'Weight/Reweigh Policy', not dated, revealed the family, resident, and physician shall be notified of any significant weight variance by the nursing staff. The policy also revealed the notification should be documented in the electronic medical record.

Based on record review, staff interview and review of McGreer Criteria, the facility failed to ensure one resident, (#35) was not prescribed antibiotics unnecessarily. This affected one of five residents reviewed for infection control. The facility census was 42.Review of Resident # 35's medical record revealed an admission date of 02/21/25 with diagnoses that included but were not limited to encephalopathy, altered mental status, dementia with anxiety and obstructive uropathy.Review of Resident # 35's current care plans revealed the resident was cognitively impaired and required assistance from staff with toileting and dressing.Review of Resident # 35's Urine Culture and Sensitivity (UA C/S) dated 02/18/26 revealed the culture was positive for 60,000 colony-forming units per milliliter (col/ml) of Proteus mirabilis and 50,000 col/ml of staphylococcus aureus. Further review revealed susceptibility to proteus mirabilis.Review of Resident #35's McGeer's Criteria for Urinary Tract Infection (UTI) dated 02/19/26 at 6:02 P.M. revealed Resident # 35 did not meet criteria for a urinary tract infection.Review of Resident # 35's physicians orders revealed a new order for Ceftriaxone (antibiotic) 2 grams to be given via injection daily with a start date of 02/20/26 and an end date of 02/24/26, dated 2/19/26, and a new order for Nitrofurantoin (antibiotic) 100mg by mouth twice daily with a start date of 02/20/26 and an end date of 02/24/26, dated 02/19/26. Interview on 06/30/26 at 4:15 P.M. with the Director of Nursing (DON) revealed Resident # 35 was started on Ceftriaxone and Nitrofurantoin for the 02/18/26 UA C/S results. DON also verified the resident did not meet criteria for a UTI and starting antibiotics was not following antibiotic stewardship.

Based on record review, observation, and interviews, the facility failed to ensure expired medications were not available for use, failed to ensure medications were labeled accurately, and failed to store medications securely. This affected three residents (#5, #10, and #34) and had the potential to affect all residents who may be ordered facility stock medication. The facility census was 43.Findings include:1.Review of the medical record for Resident #5 revealed a current admission date of 08/14/25 with diagnoses to include but not limited to acute respiratory failure with hypercapnia, muscle weakness, dysphagia, Type II Diabetes Mellitus, hypertension, and atherosclerotic heart disease.Review of Resident #5's care plan revealed Resident #5 required assistance with medication administration.Review of Resident #5's medication administration record (MAR) revealed a physician's order dated 08/14/25 for Insulin Aspart U-100 insulin pen; 100 unit/milliliters (three ML); amount to administer: six units; subcutaneous.Observation on 11/20/25 at 9:04 A.M. of the medication cart revealed an open and used Insulin Lispro pen for Resident #5 which was undated. Assistant Director of Nursing (ADON) #230 confirmed Resident #5's insulin pen was undated, opened, and used at the time of the observation.2.Review of the medical record for Resident #10 revealed an admission date of 07/01/22 with diagnoses to include but not limited to hypertension, congestive heart failure, Type II Diabetes Mellitus, and chronic kidney disease stage three.Review of Resident #10's MAR revealed an order dated 11/10/25 for Lantus Solostar U-100 insulin (Insulin Glargine) Insulin pen; 100 unit/milliliter (three ML); amount to administer: 16 units; subcutaneous. Additionally, Resident #10 had an order dated 11/06/25 for Insulin Lispro Insulin pen, half-unit; 100 unit/milliliter (mL); amount to administer: per sliding scale; if blood sugar is less than 60, call MD (physician). If blood sugar is 150 to 200, give one unit. If blood sugar is 201 to 250, give two units. If blood sugar is 251 to 300, give three units. If blood sugar is 301 to 350, give four units. If blood sugar is 351 to 400, give five units. If blood sugar is greater than 400, give six units. If blood sugar is greater than 400, call MD.Observation on 11/20/25 at 9:04 A.M. of the medication cart revealed an open, used, and undated Insulin Lispro pen and an open, used, and undated Lantus pen. ADON #230 verified Resident #10's Insulin pens were open, used, and undated at the time of the observation.3. Review of the medical record for Resident #34 revealed an admission date of 11/14/24 and diagnosis to include but not limited to chronic obstructive pulmonary disease, asthma, irritable bowel syndrome, rheumatoid arthritis, altered mental status, abnormalities of gait, unsteadiness on feet, repeated falls, muscle weakness, hypertension, hypotension, congestive heart failure, Type II Diabetes, osteoarthritis, anxiety disorder, major depressive disorder, and need for personal assistance with personal care.Review of Resident #34's MAR and treatment administration record (TAR) revealed no current orders for Refresh eyedrops (eye lubricant), Tums (antiacid), Ammonium Lactate twelve percent moistening lotion, Diclofenac sodium (non steroidal anti inflammatory) topical gel cream, Bio freeze (menthol topical), and Cytoderm spray. Observation on 11/20/25 at 4:29 P.M. in Resident #34's room revealed Refresh eyedrops, Tums, Ammonium Lactate twelve percent moistening lotion, Diclofenac sodium topical gel cream, Bio freeze, and Cytoderm spray on a dresser in Resident #34's room. The Director of Nursing verified the medications were at the bedside with no orders and removed them from Resident #34's room.4. Observation on 11/20/25 at 9:38 A.M. to 10:14 A.M. of the medication storage room revealed two bottles of unopened four ounce (oz) mL children's Acetaminophen (analgesic antipyretic) bottles of 160 milligrams (mg) per five mL which had expired 10/2025, Aspirin (non steroidal anti inflammatory) 81mg unopened bottle which expired 10/2025, two bottles of tab-a vite Multivitamins with iron (vitamin supplement) which expired 10/2025, four bottles of Vitamin E 180 mg soft gels which expired 08/2025, 39 Nicotine transdermal step two patches which expired 08/2025, one tuberculin five Tuberculin units per 0.1mL vial opened and undated in the refrigerator, and multiple lancets in a plastic drawer which had no expiration date. The Director of Nursing verified the expired medications and lancets at the time of the observation.Review of the facility policy Medication Storage in the Facility dated 05/2020 under expiration dating (beyond-use dating) stated when the original seal of the manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. (note: the best stickers to affix contain both a date opened and expiration date notation line.) All expired medications will be removed from the active supply, regardless of the amount remaining. The medication may be destroyed at the facility or returned to the provider pharmacy in the usual manner.This violation represents non-compliance investigated under Complaint Number OH002647331.

Based on record review, and interviews, the facility failed to ensure timely assistance was provided to complete activities of daily living. This affected one resident (Resident #34) of seven residents reviewed for activities of daily living. The facility census was 43.Findings Include:Review of the medical record for Resident #34 revealed an admission date of 11/14/24 with diagnoses that included chronic obstructive pulmonary disease, asthma, irritable bowel syndrome, rheumatoid arthritis, altered mental status, abnormalities of gait, unsteadiness on feet, repeated falls, muscle weakness, hypertension, hypotension, congestive heart failure, Type II Diabetes, osteoarthritis, anxiety disorder, major depressive disorder, and need for personal assistance with personal care.Review of Resident #34's care plan revealed the resident required supervision or touching assistance with a shower, dressing upper and lower body, putting on and off footwear, and personal hygiene.Review of the shower sheet dated 11/12/25 revealed Resident #34 wanted a shower Friday morning before her appointment. Resident #34 was scheduled for an appointment Friday 11/14/25 for a colonoscopy. There was no shower sheet noted for Resident #34 dated 11/14/25 or a progress note which indicated Resident #34 received a shower on 11/14/25.Interview on 11/20/25 at 2:31 P.M. with Resident #34 revealed she asked for a shower before her appointment on 11/14/25 and the staff refused to give her a shower.Interview on 11/24/25 at 10:30 A.M. with Certified Nursing Assistant (CNA) #370 revealed facility residents received scheduled showers twice a week unless they had an appointment or requested an extra shower. CNA #370 stated the expectation was to give the resident a shower before an appointment or if the resident requested an extra shower.The Director of Nursing (DON) in an interview on 11/24/25 at 1:37 P.M. stated I'm not going to lie. There is no documentation that Resident #34 received a shower on 11/14/25 before her procedure.Review of the facility policy Shower-Tub Bath updated 05/01/25 stated it is the facility's policy to promote resident hygiene by offering and assisting residents with bathing per their plan of care.This violation represents non-compliance investigated under Complaint Number OH002673953.

Based on record review, observation, and staff interview, the facility failed to provide the physician ordered medication for one, (Resident # 5) of three reviewed for medications. The facility census was 43. Findings Include: Review of the medical record for Resident #5 revealed a current admission date of 08/14/25 with diagnoses to include of acute respiratory failure with hypercapnia, muscle weakness, dysphagia, Type II Diabetes Mellitus, hypertension, and atherosclerotic heart disease.Review of Resident #5's care plan revealed Resident #5 required assistance with medication administration.Review of facility provided physician orders for Resident #5 revealed an order for Insulin Aspart U-100 (fast acting insulin with onset in five to 10 minutes) Insulin pen 100 units/milliliter (ml) (3ml); 6 units subcutaneous, hold if blood sugar is less than 150 administer before meals at 8:00 A.M., 12:00 P.M. and 5:00 P.M. dated 08/14/25. Further review of Resident #5's physician orders revealed no order for Insulin Lispro.Review of Resident #5's medication administration record (MAR) for November 2025 revealed the facility staff were signing off they were administering Insulin Aspart U-100 Insulin pen; 100 unit/milliliters (three ML); amount to administer: six units; subcutaneous before meals unless the blood sugar was below 150. Observation on 11/20/25 at 9:04 A.M. of the medication cart revealed an open and used Insulin Lispro (fast acting Insulin with onset in 15 minutes of administration) pen for Resident #5, not an Insulin Aspart pen which was ordered for Resident #5 by the physician. Concurrent interview at the time of the observation with the Assistant Director of Nursing #230 confirmed the Insulin Lispro pen belonged to Resident's #5's and it was opened and had been used to provide insulin to the resident.

Based on observation, record review, and interviews, the facility failed to develop and implement a comprehensive, effective and individualized resident centered pressure ulcer prevention and treatment program for Resident #15 to prevent the development of pressure ulcers, to ensure treatments were completed as ordered and to promote timely and optimal healing of pressure ulcers. Actual Harm occurred on 03/17/25 when Resident #15, who was dependent on staff , was assessed to have an unstageable pressure ulcer (the left heel without evidence of interventions being implemented as ordered. The pressure ulcer required manual debridement resulting in the wound classification change to a Stage IV without evidence the physician ordered treatment was implemented for 10 days. This affected one resident (Resident #15) of three residents reviewed for pressure ulcers. Findings include: Review of the medical record revealed Resident #15 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included chronic kidney disease, type 2 diabetes, and displaced fracture of the left lower leg. The clinical admission documentation form dated 01/09/25 revealed Resident #15 was at risk for the development of pressure ulcers. An order dated 01/09/25 revealed skin prep (protective film) to be applied to Resident #15's bilateral heels twice a day. Review of the treatment administration record (TAR) revealed skin prep was applied to Resident #15's heels from 01/09/25 until 05/13/25. A plan of care dated 01/21/25 revealed Resident #15 was at risk for skin breakdown related to impaired mobility, diabetes, edema, friction, shearing, and appliance use. Interventions included pressure re-distribution cushion to wheelchair, assist as needed for turning and positioning in bed and chair, encourage to float heels as tolerated, provide nutritional assessment as ordered, observe wound for any redness, warmth, drainage, odor, and report to the physician as ordered, perform current treatment as ordered, and offloading boots while in bed. The boots were to be examined for rough areas or (signs of) wearing (on the boots) and Resident #15's skin was to be examined before and after use of the boots. On 04/02/25 an intervention was added to encourage Resident #15 to wear a pressure-reducing boot to the left foot. Review of the admission Minimum Data Set (MDS) 01/24/25 revealed Resident #15 was cognitively intact and dependent on staff for putting on and taking off footwear and personal hygiene. The assessment revealed the resident had no pressure ulcers but was identified at risk for pressure ulcer development. Review of shower/bathing documentation dated 03/13/25 revealed Resident #15 received a bed bath. No skin impairments were identified. It was documented that Resident #15's skin was checked for dry heels and any red or open areas. On 03/17/25 Resident #15 received a shower. No skin impairments were identified. It was documented that Resident #15's heels were checked for dry heels and any red or open areas. Review of the Treatment Administration Record (TAR) and orders revealed on 03/17/25 Resident #15 had a treatment put in place to cleanse the left heel with normal saline, pat dry, and cover with a foam dressing. There was no skin grid or progress note regarding the area or why the treatment was implemented at that time. An order dated 03/18/25 revealed Resident #15's left heel was to be cleansed with wound cleanser, patted dry, then apply calcium alginate (for moderate to heavily exudating wounds) and apply a border foam dressing daily. Review of the TAR revealed on 03/18/25 and 03/19/25 Resident #15's left heel was cleansed with wound cleanser, patted dry, with calcium alginate and a foam dressing applied. An initial wound evaluation and management note from Wound Physician #900 dated 03/18/25 revealed Resident #15 had a pressure wound identified on 03/17/25 to the left heel. The area was noted to be an unstageable pressure ulcer measured 3.5 centimeters (cm) long, 1.3 cm wide, and 0.2 cm deep with moderate serous (clear, thin, watery fluid) exudate. There was 80 percent thick, adherent, devitalized, necrotic tissue and 20 percent normal skin. An order was given for Mesalt (helps manage heavily discharging wounds) to be applied daily and covered with a gauze island border dressing for 30 days. Recommendations included to off-load wound, reposition per facility protocol, and pressure off-loading boot. The wound was debrided to remove the necrotic tissue and establish the margins of viable tissue. Review of the physician orders revealed no evidence the wound physician's order was written for the Mesalt. The previous treatment continued. The TAR revealed from 03/19/25 to 03/25/25 Resident #15's left heel was cleansed with wound cleanser, patted dry, and calcium alginate and border dressing were applied. A physician order dated 03/19/25 revealed Resident #15 was to wear heel pressure off-loading boots at all times while in bed or in a chair. The order indicated to ensure the boots have an open spot where the heel goes three times a day. A wound physician note dated 03/25/25 by Wound Physician #900 revealed Resident #15 had an unstageable pressure wound to the left heel that measured 1.2 cm long and 1.1 cm wide. The depth was not measurable due to the presence of nonviable tissue and necrosis. No exudate was present. There was 100 percent thick, adherent, devitalized, necrotic tissue. An order was given to apply betadine (topical antiseptic and germicide that can treat or prevent skin infections) to Resident #15's left heel once a day for 30 days. A wound physician note dated 04/01/25 by Wound Physician #900 revealed Resident #15 had an unstageable pressure wound to the left heel that measured 1.5 cm long and 0.8 cm wide. The depth was not measurable due to the presence of nonviable tissue and necrosis. No exudate was present. An order was to continue betadine daily for 23 days. A wound physician note dated 04/08/25 by Wound Physician #900 revealed Resident #15 had a Stage IV (full-thickness skin and tissue loss with exposed muscle, bone, or tendon) pressure wound to the left heel that measured one cm long, 1.3 cm wide, and 0.5 cm deep. There was a moderate amount of serous exudate. There was 100 percent thick, adherent, devitalized, necrotic tissue. The wound was debrided to remove the necrotic tissue and establish the margins of viable tissue. An order was given for Mesalt and bordered dressing to be applied daily for 30 days. A wound management detail report dated 04/15/25 by Assistant Director of Nursing (ADON) #539 who is the facility wound nurse revealed Resident #15 had a Stage IV pressure wound to the left heel that measured one cm long, 1.2 cm wide, and 0.2 cm deep. There was moderate serous exudate with 100 percent granulation. The wound physician would be in to assess the wound on 04/18/25. Review of the TAR revealed skin prep and betadine were the only treatments completed to Resident #15's left heel from 03/26/25 through 04/17/25. A wound physician note dated 04/18/25 by Wound Physician #900 revealed Resident #15 had a Stage IV pressure wound to the left heel that measured 1.1 cm long, 1.5 cm wide, and 0.3 cm deep. There was a moderate amount of serous exudate. There was 100 percent thick, adherent, devitalized, necrotic tissue. The wound was improving due to the decreased depth of the wound. An order was given for Mesalt and bordered dressing to be applied daily for 20 days. The TAR revealed from 04/18/25 to 04/24/25 Resident #15's left heel was cleansed with wound cleanser, patted dry, and Mesalt and border dressing were applied daily. A wound physician note dated 04/22/25 by Wound Physician #900 revealed Resident #15 was not seen due to Resident #15 was playing bingo. A wound management detail report dated 04/22/25 by ADON #539 revealed Resident #15 had a Stage IV pressure wound to the left heel that measured one cm long and 1.4 cm wide. There was light serosanguineous exudate with 100 percent necrotic tissue. The wound was calloused/firm with well-defined wound edges. A wound physician note dated 04/29/25 by Wound Physician #900 revealed Resident #15 had a Stage IV pressure wound to the left heel that measured 1.1 cm long, 1.5 cm wide, and 0.3 cm deep. There was a moderate amount of serous exudate. Mesalt and bordered dressing was to be applied daily for nine days. The wound was debrided to remove the necrotic tissue and establish the margins of viable tissue. A wound physician note dated 05/06/25 by Wound Physician #900 revealed Resident #15 had a Stage IV pressure wound to the left heel that measured one cm long, 1.8 cm wide, and 0.3 cm deep. There was a moderate amount of serous (clear) exudate. There was 100 percent thick, adherent, devitalized, necrotic tissue. The wound progress was exacerbated due to the patient being non-compliant with wound care (there was no evidence documented in the medical record the resident was non-compliant with wound care). An order was given for Santyl (enzymatic debriding agent), calcium alginate, and bordered dressing daily for 30 days. A wound management detail report dated 05/06/25 by ADON #539 revealed Resident #15's wound progress was exacerbated due to non-compliance with wound care. However, there was no evidence documented in the medical record to support the resident was non-compliant with wound care. Resident #15 did not like the wound touched. Resident #15 was informed that the care had to be done for the wound. A new order was received for pain medication during bandage changes. A wound physician note dated 05/12/25 by Wound Physician #900 revealed Resident #15 had a Stage IV pressure wound to the left heel that measured 0.8 cm long, 1.8 cm wide, and 0.3 cm deep. There was a moderate amount of serous exudate. There was 30 percent thick, adherent, devitalized, necrotic tissue, 40 percent slough, and 30 percent granulation (a type of new, temporary tissue that forms in the process of wound healing). The treatment of Santyl, calcium alginate, and bordered dressing daily was to continue for 24 days. The wound was debrided to remove the necrotic tissue and establish the margins of viable tissue. An interview on 05/10/25 at 1:35 P.M. with Licensed Practical Nurse (LPN) #520 revealed Resident #15 stated Santyl stung but she mainly jerked her foot because she was ticklish. LPN #520 verified treatments were completed by what populated in the TAR to be completed on her shift. LPN #520 stated Resident #15 was compliant with care and never refused treatments when she worked. An observation on 05/13/25 at 7:41 A.M. revealed Resident #15 was lying in bed with heel boots in place. An observation of the treatment to Resident #15's left heel by ADON #539 revealed the wound was pink and the wound had no signs of infection noted. Resident #15 pulled her left foot back some during the treatment. Resident #15 denied any pain and stated she was ticklish. The treatment included the wound cleansed with wound cleanser, patted dry, Santyl and Mesalt applied to the wound and then covered with foam dressing. The resident denied non-compliance with treatments. On 05/14/25 Resident #15's profile was updated for the Certified Nursing Assistants (CNA) to follow when providing care. The CNAs were to encourage/assist Resident #15 to always wear bilateral offloading boots. Skin checks were to be done prior to application and upon removal of the boots. The CNAs were to ensure Resident #15's boots had an open spot where the heel goes. Prior to 05/14/25, there was no intervention on the resident's profile to direct the CNA to use offloading heel boots. An interview on 05/14/25 at 7:06 A.M. Corporate Registered Nurse (RN) #606 verified the only treatments in place for the Stage IV pressure wound to Resident #15's left heel from 04/08/15 to 04/18/25 was skin prep and betadine. Corporate RN #606 verified Wound Physician #900 had put an order in place on 04/08/25 for Mesalt and bordered dressing to be applied daily for 30 days. An additional interview on 05/14/25 at 8:18 A.M. with Corporate RN #606 verified there was no documentation of Resident #15 being noncompliant with dressing changes and was unsure why Wound Physician #900 documented the wound healing progress was exacerbated due to Resident #15 being non-compliant with wound care. Lastly, she verified there was no information regarding the offloading boot to the resident's heels or left heel. An interview on 05/19/25 at 9:49 A.M. with Wound Physician #900 revealed an order would have been changed from betadine to Mesalt based on the amount of exudate. Wound Physician #900 stated he did not believe the wound would have gotten worse not using the Mesalt and bordered dressing but verified the wound could have become more macerated (the occurrence of skin softening and breaking down due to prolonged exposure to moisture). Wound Physician #900 stated he documented the exacerbation of the wound was due to Resident #15 non-compliance with wearing offloading boots (which the resident was dependent on staff for application of). Email correspondence on 05/19/25 at 8:42 A.M. with Corporate RN #606 verified there was an order for the heel protectors for Resident #15 on 03/19/25 which was updated on 05/14/25. Corporate RN #606 verified there was no documentation of heel protectors being used or refused from the time the heel protectors were care planned on 01/21/25 and initially ordered on 03/19/25. An interview on 05/19/25 at 12:55 P.M. ADON #539 revealed she did rounds with Wound Physician #900. ADON #539 verified she usually put the new orders from Wound Physician #900 in the computer but the orders from 04/08/25 were not put in the computer and she doesn't know what happened. ADON #539 verified the only orders from 04/08/25 to 04/18/25 to Resident #15's left heel was skin prep and betadine.

Based on observation, interview, and record review, the facility failed to ensure safe oxygen administration practices were implemented. This affected one resident (Resident #13) of eleven receiving oxygen in the facility. The facility census was 44. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE]. Diagnoses included asthma, dysphagia, dyspnea, dependence on supplemental oxygen, and obstructive sleep apnea. Review of physician orders dated 11/19/24 revealed the resident was to receive continuous oxygen at two liters per minute via nasal cannula due to oxygen dependence. Review of minimum data set (MDS) 3.0 assessment dated [DATE] showed Resident #13 scored 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The resident's respiratory treatments included oxygen therapy and a non-invasive mechanical ventilator. Review of a care plan dated 03/14/24 revealed Resident #13 exhibited hoarding behaviors. The care goal was for the resident to avoid harming self or others during daily care and activities. Interventions included encouraging communication between the resident and family regarding care and behavioral strategies, and notifying the physician of any new or escalating behaviors or safety concerns. Observation on 05/12/25 at 11:10 A.M. revealed various clothing items and plastic cups surrounding all sides of the oxygen concentrator. The machine was not powered on at the time, but the intake air vent was partially obstructed by clothing packed underneath the bed and around the concentrator. Observation on 05/13/25 at 7:42 A.M. revealed Resident #13 was seated in her recliner, approximately one foot from the oxygen concentrator (brand: Respironics). Surrounding all sides of the device were cardboard boxes containing clothing, trash, and plastic cups. The concentrator was in use, with items partially blocking the intake vent, at this time the concentrator was not alarming. Observation and interview on 05/13/25 at 10:34 A.M. with Licensed Practical Nurse (LPN) #519 confirmed the presence of numerous items surrounding the active oxygen concentrator which included partial occlusion. LPN #519 acknowledged the resident's hoarding behaviors and noted concerns about maintaining a safe room environment. She confirmed the resident consistently used the concentrator while in her room or recliner, doing so in an unsafe manner. Interview on 05/14/25 at 4:50 P.M. with corporate nurse #606 confirmed the oxygen concentrator air intake should be unobstructed during usage, if the machine was not functioning properly, it would alarm. Review of Respironics Everflo user manual revealed a warning indicating potential harm to the patient or operator if the device is not used properly. It emphasizes that the concentrator requires unobstructed ventilation, with intake ports located at the rear base and side. The manual advises keeping the device six to twelve inches away from walls, furniture, or curtains to ensure adequate airflow.

Based on record review, policy review and staff interview, the facility failed to ensure advanced directives were clearly reflected in the medical record. This affected one resident (#23) of 16 residents reviewed for advanced directives. The facility census was 44. Findings include: Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses included: Alzheimer's Disease, unspecified atrial fibrillation, essential hypertension, hyperlipidemia, anxiety disorder, and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had a Brief Interview of Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Review of electronic medical record for Resident #23 revealed no advance directive documentation in the advance directive section of the medical record. There was no mention of code status, do not resuscitate (DNR) or advance directive in the orders section of Resident #23's electronic medical record or in the care plan for Resident #23. The care plan indicated Resident #23 was a hospice resident as of 01/08/25. Further review of Resident #23's electronic medical record revealed that there was a portable document format (PDF) of Resident #23's Do Not Resuscitate (DNR) order dated 11/27/24 and uploaded five different times between 11/29/2024 and 01/09/25 to three different Resident Document sections: 7000, Pre-Admission Screening and Record Review (PASRR), Further Reviews, Level of Care (LOC), Discharge Summary, and Hospital Records/Admissions. Review of the physical medical record binder for Resident #23 revealed no DNR documentation in the front of the chart or behind the Advance Directive tab. There was a printed face sheet which stated there are no advanced directives selected for this resident. Interview on 05/13/25 at 9:00 A.M. with Registered Nurse (RN) #606 verified the facility kept advance directives/code status in the front of the resident binders and if there was no DNR document in the front of the physical chart, the resident was a full code (receive all life saving measures in the event of a cardiac or respiratory arrest). When asked if that applied even if the resident was on hospice, RN #23 reiterated that the physical chart is where they keep code status and if the DNR was not there, then that meant that Resident #23 was full code. Interview on 05/14/25 at 3:32 P.M. with the daughter/emergency contact for Resident #23 confirmed her mother's code status of Do Not Resuscitate Comfort Care Arrest (DNR-CC) (in the event of a cardiac or respiratory arrest, the resident is kept comfortable and no life saving measures/cardiopulmonary resuscitation is provided) Review of facility policy titled, Advance Directives updated on 05/01/25 revealed the Director of Nursing (DON) or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care.

Based on observation, interview and record review the facility failed to provide a clean and sanitary environment. This affected one resident (Resident #194) of three residents reviewed for environment. The facility census was 44. Findings include: Review of Resident #194's medical record revealed an admitted [DATE] and diagnoses including malignant neoplasm of the prostate, secondary malignant neoplasm of the bladder, secondary neoplasm of the bone, and Alzheimer's disease. Further review revealed Resident #194 was receiving hospice services. An observation on 05/12/25 at 12:01 P.M. revealed Resident #194 was lying in bed, on his right side, with his eyes closed. The bed was positioned with the left side and the foot of the bed against the walls. Further observation revealed a bag containing a soiled incontinence brief was noted on the floor, at the foot of the resident's bed. In an interview on 05/12/25 at 12:01 P.M. Regional Registered Nurse (RN) #606 confirmed a bag containing a soiled incontinence brief was on the floor and should have been thrown away.

Based on record review, interview, and policy review, the facility failed to ensure medication parameters were followed for Resident #15 and failed to ensure Resident #20 receive d an appropriate antibiotic for a urinary tract infection. This affected two residents (Resident #15 and #20) of six residents reviewed for unnecessary medications. Facility census was 44. Findings include: 1. Review of the medical record revealed Resident #15 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included urinary tract infection, chronic kidney disease, extended-spectrum beta-lactamases (ESBL), and type 2 diabetes. On 02/24/25, Resident #15 was ordered midodrine (to treat low blood pressure) 10 milligram (mg) every six hours and to hold for a systolic blood pressure (top number of the blood pressure reading) greater than 130 millimeters of mercury (mmHg). Review of the medication administration record (MAR) revealed midodrine was held due to low blood pressure/outside of parameters on: 04/01/25 at 4:00 A.M. A blood pressure was not recorded. 04/04/25 at 4:00 A.M. for a blood pressure of 112/64 mmHg 04/07/25 at 10:00 P.M. for a blood pressure of 112/60 mmHg 04/08/25 at 4:00 A.M. for a blood pressure of 108/62 mmHg 04/12/25 at 10:00 P.M. for a blood pressure of 116/58 mmHg 04/13/25 at 4:00 A.M. for a blood pressure of 108/56 mmHg 04/14/25 at 4:00 A.M. for a blood pressure of 112/73 mmHg 04/18/25 at 4:00 A.M. for a blood pressure of 118/62 mmHg 04/19/25 at 4:00 A.M. for a blood pressure of 120/64 mmHg 04/26/25 at 10:00 P.M. for a blood pressure of 110/66 mmHg 04/27/25 at 4:00 A.M. for a blood pressure of 108/50 mmHg 04/28/25 at 10:00 P.M. for a blood pressure of 88/54 mmHg 05/01/25 at 10:00 P.M. for a blood pressure of 112/66 mmHg 05/02/25 at 4:00 A.M. for a blood pressure of 108/56 mmHg 05/05/25 at 10:00 P.M. for a blood pressure of 112/62 mmHg 05/08/25 at 10:00 P.M. for a blood pressure of 113/78 mmHg 05/09/25 at 4:00 A.M. for a blood pressure of 112/68 mmHg 05/11/25 at 4:00 A.M. for a blood pressure of 116/58 mmHg 05/11/25 at 4:00 P.M. for a blood pressure of 118/72 mmHg An interview on 05/14/25 at 3:28 P.M. Regional Registered Nurse (RN) #606 verified Resident #15's midodrine was held when the systolic blood pressure was less than 130 mmHg. Regional RN #606 verified midodrine was administered to treat low blood pressure and should be held when systolic blood pressure was greater than 130 mmHg. 2. Review of the medical record revealed Resident #20 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included sepsis, cerebral infarction, chronic respiratory failure, hemiplegia and hemiparesis, tracheostomy, aphasia, acute kidney, obstructive reflux, Alzheimer's disease, anxiety disorder, altered mental status, and dysphagia. The quarterly MDS dated [DATE] revealed Resident #20 had cognitive impairment. A progress note dated 03/02/25 at 9:15 A.M. revealed Resident #20 returned from the hospital with new orders for Keflex (antibiotic) 500 mg four times a day seven days for a urinary tract infection. On 03/02/25, Resident #20 was ordered Keflex. Review of the medication administration record revealed Resident #20 received Keflex from 03/02/25 at 12:00 P.M. through 03/08/25 at 6:00 P.M. Further review of the medical record revealed Resident #20 was not ordered another antibiotic. Review of hospital urinalysis with culture and sensitivity dated 03/05/25 revealed Resident #20's urine had greater than 100,000 colony-forming units per milliliter (cfu/ml) pseudomonas aeruginosa and enterococcus faecalis and was not susceptible to Keflex. An interview on 05/14/25 at 3:28 P.M. with Regional RN #606 verified Resident #20's urinalysis with culture and sensitivity was not received until Resident #20 had been started on Keflex. Regional RN #606 also verified Keflex was continued despite the urine culture indicating the bacteria was not susceptible to Keflex. The Antibiotic Stewardship Program policy updated 11/2019 revealed when prescribing antimicrobials the physician/prescriber should select a antimicrobial with organism susceptibility. When a culture and sensitivity is ordered, it should be performed before the initiation of an antimicrobial. The culture and sensitivity results should be communicated to the physician/prescribed as soon as available to determine if current antimicrobial therapy is continued, modified, or discontinued.

Based on closed medical record review, hospital record review, drug information review, review of the American Heart Association Journal at ahajournals.org, review of the facility policy Anticoagulant Therapy and interview, the facility failed to ensure anti-coagulant medication was monitored to ensure it was administered at a therapeutic dose and timely held in the presence of adverse consequences. This resulted in Immediate Jeopardy and actual harm beginning on [DATE] when Resident #44, who had a history of atrial fibrillation and an artificial heart valve managed with the anticoagulant medication, Coumadin (warfarin) and had been diagnosed and treated for a subdural hematoma prior to her admission to the facility, was ordered to resume her Coumadin at a higher dose than previously administered and without an ordered neurology consultation before resuming the anticoagulant medication. The facility failed to obtain physician ordered weekly International Normalized Ratio (INR) (a blood test that tells how long it takes for your blood to clot when on Coumadin (warfarin)) laboratory testing the weeks of [DATE], [DATE] and [DATE], to ensure the resident was receiving a therapeutic dose of Coumadin. On [DATE], Resident #44 developed a large bruise on her left buttock and sacrum. However, the facility did not identify this as a potential side effect of the anticoagulant medication. On [DATE], an INR was obtained, and the results were critical (high) at 17.2 seconds (normal anticoagulant range is two to three seconds). Physician #300 discontinued the dose of Coumadin and ordered the reversal agent, Vitamin K to be given and an INR every other day until the INR was less than three seconds. On [DATE], the resident's INR remained critical at 9.7 and the Vitamin K daily and INR every other day orders continued. There were no additional INR results available for review until [DATE] when the INR was subtherapeutic at 1.0 seconds. The physician ordered to resume Coumadin at two mg daily beginning [DATE]; however, the resident had experienced a significant decline in condition and was unable to take medications. The resident expired on [DATE]. This affected one Resident (#44) of seven residents sampled for injuries of unknown origin. The facility census was 43. On [DATE] at 3:20 P.M. the Administrator, Director of Nursing (DON) and Regional Nurse Consultant #201 were notified Immediate Jeopardy began on [DATE] when Resident #44 was started on Coumadin 5 milligrams (mg) without evidence the medication was safe to administer and that the dose was a therapeutic dose. Weekly INR testing was not completed between [DATE] and [DATE] as ordered. On [DATE] the resident was assessed to have significant bruising to her lower back/hip area (a likely side effect of Coumadin medication) without staff identifying the possibility of the supratherapeutic level. On [DATE], the resident's INR was critically high at 17.2 (therapeutic level 2XXX,d+[DATE].0 seconds when receiving Coumadin), requiring the administration of the Coumadin antidote, Vitamin K, to lower the resident's risk of hemorrhage. The facility failed to obtain additional testing on [DATE] or [DATE] as ordered. On [DATE] the resident's INR level was subtherapeutic at 1.0 seconds. At that time an order was obtained to resume the medication, Coumadin; however, the resident had a significant decline in her condition and was unable to swallow the Coumadin. The physician was not notified. The resident expired on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 4:15 A.M. Resident #44 expired in the facility. On [DATE] at 12:05 P.M. to 12:15 P.M., Regional Nurse Consultant # 201 reviewed the records (including Coumadin orders, PT/INR, physician notification) for Resident #24, the only resident on Coumadin at the facility. As of [DATE] a plan was noted for Resident #24 to have laboratory testing (PT/INR) completed as ordered, PT/INR results reported within eight hours to the physician, signs and symptoms of elevated INRs (e.g. blood or black tarry stools, blood in sputum, emesis or urine, nose bleeds, bleeding gums and easy bruising or bleeding from wounds) identified and reported to the physician by a licensed nurse. On [DATE], in-service education for licensed nurses by the Director of Nursing (DON) via lecture began on the following topics: anticoagulation policy, signs and symptoms of bleeding related to Coumadin usage, lab policy, and change in resident condition or status which included abnormal labs. On [DATE] by 2:30 P.M. seven nurses (Licensed Practical Nurse (LPN) #133, LPN #104, LPN #125, LPN #130, LPN #108, Minimum Data Set (MDS) Nurse #106 and Assistant Director of Nursing (ADON) #123 were educated. The remaining four nurses (LPN #129, LPN #888, LPN #889 and Registered Nurse (RN) #109) would be educated before working their next scheduled shift. As of [DATE] the facility implemented a plan for all newly hired nurses to receive the education prior to working the floor. On [DATE] 3:00 P.M. the facility Lab Testing and Results policy was reviewed by the Executive Director and Director of Nursing. On [DATE] from 3:15 P.M. to 3:55 P.M., all 18 Certified Nursing Assistants (CNA) were educated by the DON via lecture on the signs and symptoms of bleeding that must be reported to the charge nurse. As of [DATE] the facility implemented a plan for all newly hired CNAs to receive the education prior to working the floor. On [DATE] at 4:00 P.M., MDS Nurse #106 completed a care plan review to ensure signs and symptoms of bleeding were addressed for residents receiving anti-coagulants. The facility identified and reviewed the care plan for 10 residents receiving anticoagulant medications (Resident #26, # 9, #24, #11, #32, #22, #29, #19, #28, and #4). Beginning [DATE], the Director of Nursing (DON) or designee would complete audits on all residents receiving Coumadin daily for two weeks, then three times a week for two weeks, then weekly for two weeks and then as needed to ensure PT/INR labs were obtained per order, notification to physician of PT/INR results were within eight hours and to ensure any signs and symptoms of bleeding were noted and reported to the physician as soon as practicable. Clinical findings and notifications will be documented in the clinical record. If the primary care physician is unable to be reached, the medical director will be notified. Beginning [DATE], the DON or designee would complete audits of five residents on anti-coagulant therapy three times a week for four weeks to ensure signs and symptoms of bleeding were addressed in the resident's care plan for residents receiving anti-coagulant medications. Any concerns identified with the audits will be forwarded to the Quality Assurance (QA) committee weekly for four weeks and as needed for immediate follow-up. The administrator will be responsible for ongoing compliance. Interviews on [DATE] from 1:12 P.M. to 1:21 P.M. with ADON #123, CNA #1000, CNA #124, and LPN #125 revealed knowledge of the corrective actions. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #44's closed medical record revealed an admitted [DATE] with diagnoses including traumatic subdural hemorrhage without loss of consciousness (present on admission), dysphagia, cerebral infarction, seizures, hypertension, atrial fibrillation and congestive heart failure. The resident passed away in the facility on [DATE]. Review of Resident #44's hospital discharge paperwork, dated [DATE], revealed Resident #44 was in the hospital from [DATE] until discharge to the facility on [DATE] due to a headache that was diagnosed as a spontaneous subdural hematoma due to a supratherapeutic INR level with her Coumadin on hold upon admission to the facility. The resident was noted to be taking Coumadin two mg daily five days a week and Coumadin one mg daily, two days per week prior to her hospitalization . The hospital records revealed Resident #44 was to follow with a cat scan (CT) (of her brain) and neurology after hospital discharge to resume her Coumadin. The neurology appointment was scheduled by the facility for [DATE]. Review of a CT scan of the brain without contrast obtained [DATE] revealed extra-axial mixed attenuation fluid collection at the left cerebellum that was worrisome for chronic/subacute subdural hematoma. The medical record contained no evidence that the physician was notified of the CT results. Review of the progress note, dated [DATE] at 4:20 A.M. and authored by Licensed Practical Nurse #543, revealed the resident's pulse was in the 150's (meaning the pulse was between 150 to 159 beats per minute with the normal range being ,d+[DATE] beats per minute) and an order was given to send the resident out to the hospital. Review of Resident #44's hospital discharge documentation, dated [DATE], revealed the resident was admitted to the hospital with atrial fibrillation (abnormal heart rhythm pertaining to the atrium (top part) of the heart) with a rapid ventricular rate and congestive heart failure (CHF). She was discharged on [DATE], back to the facility and there were no instructions for the resident's Coumadin to be resumed at this time. Further review of the medical record revealed no evidence that the resident attended the follow-up neurology appointment due to her hospitalization ([DATE] through [DATE]) and the appointment was not rescheduled upon her return to the facility. Review of a physician order dated [DATE] revealed an order for Resident #44 to receive Morphine concentrate 20 milligrams (mg)/ milliliter (ml) with a dose of 5 mg orally every hour as needed for pain. Review of a physician progress note, dated [DATE] and authored by Physician #300, revealed the resident would resume Coumadin at a later time with close monitoring due to (the resident) being high risk for a cerebral vascular accident secondary to a mechanical heart value. Further review of the progress note revealed the physician planned to resume the Coumadin 90 days after the resident's subdural hematoma/bleed. A review of a physician's order dated [DATE] revealed an order to admit Resident #44 to hospice services with the diagnosis of heart failure. Review of a physician progress note, dated [DATE] and authored by Physician #300, revealed the resident was to resume Coumadin with weekly INRs. Review of the physician's orders revealed an order for warfarin (Coumadin) five milligrams (mg) by mouth daily beginning on [DATE] for atrial fibrillation and the presence of a mechanical heart valve. A physician order was also noted (dated [DATE]) for an INR (laboratory testing) to be drawn every Wednesday with the first test to be completed on [DATE]. Review of the Medication Administration Record for [DATE] revealed the administration of Coumadin 5 mg during the 6:30P.M. to 10:30 P.M. time frame daily from [DATE] through [DATE]. Review of a social services note, dated [DATE] at 3:56 P.M. and authored by Social Services #137, revealed Resident #44 spoke about wanting to return home for a few days to see if she was able to care for herself. Social Service staff spoke with Physician #300, and he agreed to discharge the resident home for two days; however, he wanted hospice to be involved. Social Service staff also spoke with the resident's friend, who was her support system, regarding possible (leave of absence/discharge) arrangements. Review of a hospice notes dated [DATE] revealed Resident #44 was alert and oriented and ambulating to the bathroom with a walker and using Morphine for chronic back pain. The resident's physician agreed with the discharge. The facility made arrangements for home health and oxygen services. Review of a social service note, dated [DATE] at 10:16 A.M. and authored by Social Services #137, revealed the resident decided to cancel hospice services due to wanting to discharge home. A hospice patient notice of enrollment changes with the selection of I am seeking curative treatment which is not focused on comfort and palliation of symptoms for my terminal illness, signed by Resident #44, Social Services #137 and a hospice representative. Record review revealed no evidence the facility developed or implemented a plan of care related to Resident #44's anti-coagulant/Coumadin use and no nursing progress notes indicating the monitoring of side effects related to the Coumadin medication. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had a Brief Interview for Mental Status score of 15 out of a possible 15 points, indicating the resident was cognitively intact. The assessment revealed the resident required supervision or touching assistance with transfers and ambulation and was continent of bladder and bowel. The resident required staff set up and/or was independent with other activities of daily living. The MDS included the resident received anti-coagulant medication. Review of a social service note, dated [DATE] at 7:39 P.M. and authored by Social Services #137, revealed Resident #44 has successfully been attending physical therapy. The resident decided to return to her home on [DATE]. Review of the Certified Nursing Assistant point of care history (located in the electronic medical record) for Resident #44 revealed from [DATE] to [DATE] the resident experienced a decline in her activities of daily living as she was independent with rare, limited assistance then she began to require extensive and total assistance from staff. The resident was rarely incontinent of bladder and declined to frequently incontinent during her stay in the facility. Review of a progress note, dated [DATE] at 2:12 P.M. and authored by the DON, revealed Resident #44 had a skin abnormality. Resident #44 was interviewed by the DON on [DATE] and stated that she did not fall but it was possible that she sat down too hard on the toilet riser (an elevated toilet seat to aid in not having to reach low to sit on the toilet). Resident #44's physician was notified, and an x-ray was obtained of the resident's sacrum and coccyx with the results of the x-ray showing no bony abnormalities. Review of a social service note, dated [DATE] at 4:55 P.M. authored by Social Services #137, revealed the resident was to be discharged today, but she had developed a headache and pain from a bruise. Resident #44 also complained of no energy or being able to get out of bed to ambulate. She was very anxious about returning home and discussed her options with a revisit tomorrow on going home. (There was no further documentation in the medical record regarding the resident wanting to discharge home). Review of an Alteration in Skin Integrity form, dated [DATE] and authored by the DON, revealed it was marked as other: bruise and that an x-ray was completed with no fractures found. The human body illustration with the form had areas circled on the left buttock extending toward the left hip and the coccyx sacral area to indicate the placement of the bruising. There were no measurements of the bruise listed on the form. Review of the Medication Administration Record (MAR) dated [DATE] at 10:59 A.M. for Resident #44 revealed sacral pain rated an eight on a 0 to 10 pain scale with the administration of Morphine 20mg/ml give 5 mg orally with the results not effective. Further review revealed at 12:41 P.M. the resident continued to have sacral pain of an eight on a 0 to 10 pain scale with the administration of Morphine 5 mg. Review of a progress note, dated [DATE] at 2:17 A.M. and authored by LPN #133, revealed the resident's INR results were reported to the facility by the laboratory at a critical high level of 17.2 seconds. The physician was notified, and orders were received to hold the resident's Coumadin until the INR was below three and to give Vitamin K 10 mg one time and to have the INR done every other day beginning on [DATE] until the INR was below three. The note further revealed the Vitamin K was given and tolerated by Resident #44 and no bleeding was observed. The laboratory testing for the INR was collected on [DATE] at 12:31 P.M. and resulted at 4:57 P.M. Further review of Resident #44's physician's orders revealed an order for Vitamin K (medication administered to reverse the effects of Coumadin) 10 mg on [DATE] and then on [DATE] 10 mg daily until Resident #44's INR returned to below three. Resident #44's INR was to be checked every other day until the INR returned to below three. Review of the MAR revealed on [DATE] at 4:42 P.M. the resident reported pain rated a seven out of 10 on a pain scale and Morphine 5 mg was administered. Review of the MAR dated [DATE] at 7:51 A.M. for Resident #44 revealed coccyx pain rated a seven on a 0 to 10 pain scale with Morphine 5 mg administered by the Assistant Director of Nursing. Review of the laboratory test result dated [DATE] revealed the INR result was 9.7 (a critically high level). Review of a progress note, dated [DATE] at 1:18 P.M. and authored by the DON, revealed the MD (physician) was notified of INR results and new orders were received. Review of Resident #44's physician orders dated [DATE] revealed an order for Vitamin K 10 mg daily at bedtime until INR below three. Review of the [DATE] MAR revealed the Vitamin K 10 mg was administered daily from [DATE] through [DATE] except on [DATE] due to medication delivery. Review of Resident #44's care plan dated [DATE] (the first care plan for the resident's increased potential for bleeding related to medication use) revealed the facility staff were to observe for and report any adverse effects such as easily bruising, unexplained bruising or bleeding, bloating/stomach pain or chest pain/tightness. Staff were also to observe for and report to the physician any signs of active bleeding such as nosebleed, bleeding gums, petechiae (are round, brown purple spots due to bleeding under the skin), purpura (a rash of purple spots due to small blood vessels leaking into the skin), ecchymosis (bruised) areas, hematoma, blood in urine, black/tarry stool, blood in sputum, elevated temp, pain in joints, abdominal pain, or coffee ground emesis. Further review revealed laboratory work was to be obtained as ordered and reported to the physician. Review of the MAR dated [DATE] at 4:23 A.M. for Resident #44 revealed back pain rated a six on a 0 to 10 pain scale with Morphine 5 mg oral administered with semi effectiveness. There was no documentation Physician #300 was notified of the resident's use of her as needed (prn) dose of Morphine currently being frequently used. Review of a physician's order dated [DATE] revealed a new order for Resident #44 for a hospice consult for overall decline in condition. There was no documentation in the medical record regarding the resident's decline other than she began to experience lower back pain and was placed on hospice services. Review of a hospice visit note, dated [DATE] and authored by Hospice Nurse #322, revealed Resident #44 was only alert to person, was bed/wheelchair bound and had bruising to back and coccyx area with scattered bruising, also noted bruising to her upper and lower extremities with pain rated a five on a 0 to 10 pain scale using the FLACC (Face, Legs, Activity, Cry and Consolability)(a pain scale used in children and non-verbal adults who cannot communicate their pain verbally) pain scale, undetermined location. Review of a progress note, dated [DATE] at 12:21 P.M. and authored by Registered Nurse (RN) #777, revealed Resident #44's physician was notified the laboratory testing for the INR was not completed the day before. The physician discontinued the order for the [DATE] INR and ordered for the INR schedule to be resumed the next day as previously ordered ([DATE]). Review of a progress notes dated [DATE] revealed no mention the laboratory testing was not completed on this date and there was no documentation regarding follow-up with the lab or the physician regarding the scheduled INR. Review of the MAR dated [DATE] at 10:30 P.M. for Resident #44 revealed the resident complained of back pain rated a six on a 0 to 10 pain scale with Morphine 5 mg administered. Review of a physician progress note dated [DATE] revealed Resident #44's INR to be pending and to resume Coumadin when INR was less than 3.5 at two mg every day. Review of the INR results dated [DATE] revealed the resident's INR was 1.0 seconds (low/subtherapeutic) on this date. An order was received on [DATE] at 9:38 A.M. for Coumadin two mg daily. However, review of the MAR for [DATE] revealed the resident was unable to take the Coumadin on [DATE] and [DATE]. Review of the medical record revealed the resident was pronounced deceased by Physician #300 at 4:15 A.M on [DATE]. Review of the fax sheet from the contracted Laboratory Services, sent to the facility for Resident #44, revealed the INR lab was cancelled on [DATE] due to the specimen quantity not sufficient for testing. This fax was sent to the facility on [DATE] at 1:06 P.M. (and the only record of lab communication regarding this INR and why the lab was not completed. There was no evidence of facility follow-up regarding the missing lab until [DATE]). On [DATE] at 2:00 P.M. an interview with the DON revealed the bruising on Resident #44's left buttock extending toward the left hip and coccyx/sacral area was not measured (facility policy is to not measure bruises) but was of significant size. The DON further stated Resident #44, when questioned, did say that she might have sat down on the toilet riser in such a way as to hit the area causing the bruising. A follow-up interview with the DON on [DATE] at 9:00 A.M. revealed the facility had not completed the laboratory testing for Resident #44's INR as ordered on [DATE]. The INR testing was completed on [DATE] as a result of an audit for missing laboratory work (unrelated to Resident #44) completed by the facility and not because of the bruising on Resident #44's left buttock extending toward the left hip and coccyx sacral area that had been identified on [DATE]. The DON verified the facility had not identified the missing INR labs at the time of the resident's bruising and verified this bruising was not considered a possible side effect of the resident's Coumadin. On [DATE] at 3:15 P.M. an interview with the DON revealed nurses who received orders to place residents on Coumadin medication were to place the order for laboratory monitoring in matrix care (the facility's electronic medical record system) and in the facility's electronic system for communicating with their laboratory provider (the laboratory order system). Nursing staff were expected to monitor residents on Coumadin for signs and symptoms of bleeding such as active bleeding, black tarry stools or abnormal bruising. If a resident on Coumadin had an unwitnessed fall or a fall where they hit their head the staff was to notify the DON and the physician, and the resident would be sent to the emergency room for evaluation. On [DATE] at 8:40 A.M. an interview with Physician #300 revealed the physician expected residents who were taking Coumadin to have weekly INR monitoring as ordered. Physician #300 stated he was aware of the bruising on Resident #44's left buttock extending toward the left hip and coccyx sacral area. Physician #300 further stated the bruising was most likely a result of the elevated INR. Physician #300 stated he did not know why the INR was so elevated but stated that he would like to think it would have been caught prior to reaching a critical high level if the INRs had been completed weekly as ordered. During the interview, Physician #300 stated at no time did the resident have any active bleeding. However, no additional information was provided as to how this determination was made. On [DATE] at 10:15 A.M. an interview with Certified Nursing Assistant (CNA) #138 revealed Resident #44 had a large bruise on her lower back below her waist. CNA #138 stated prior to the bruise being identified, Resident #44 would get up by herself with her walker and take herself to the bathroom. Resident #44's toilet was equipped with a toilet riser to elevate the toilet seat for the resident. CNA #138 stated Resident #44 would at times flop on to the toilet instead of using the safety bars to lower herself to the seat and she could have easily bumped the toilet riser if she flopped on to the toilet seat when by herself. On [DATE] at 1:28 P.M. an interview with RN #123 revealed the nurse who receives the order for Coumadin was responsible for entering the order into matrix care (the electronic medical record software) and enters the order for the laboratory testing/INR to be completed, usually weekly. The nurse working the night laboratory tests were to be drawn prints the log from the lab system and checks matrix care for laboratory test orders. It was the responsibility of the nurse who received the order to put the INR order in matrix care and the lab system. RN #123 stated nurses caring for a resident on Coumadin should watch for bruising, black tarry stools and any bleeding. On [DATE] at 12:00 P.M. an interview with the DON revealed the DON believed Physician #300 was aware of the resident's CT scan results on [DATE] and that the resident missed her neurology appointment on [DATE] due to her hospitalization but verified neither notification was documented in the resident's medical record. On [DATE] at 8:43 A.M. an interview with a nurse who wished to remain anonymous, revealed following admission to the facility, Resident #44 was always alert and oriented and self-ambulatory. The anonymous staff revealed the resident had experienced an obvious decline in condition in [DATE] after the nurse had been off work for a couple days. During this time period, the resident was no longer oriented as before, was bed bound and required staff assistance, which was not the resident's baseline. On [DATE] at 9:23 A.M. a follow-up interview with Physician #300 revealed he was not aware the resident was having extensive pain that required Morphine. The physician revealed when he ordered the hospice consultation on [DATE] it included a diagnosis of encephalopathy which he based on the resident's cognition level. Physician #300 revealed he was not aware of the resident's laboratory/INR testing not being completed until several weeks had passed and he did not think her condition warranted a hospital visit for an INR being over 17 as he did not believe the resident was actively bleeding. The physician indicated he treated the elevated INR level with Vitamin K. The physician also indicated he was aware the resident was still receiving Vitamin K daily as his order was to give until her INR was below three and he was never notified of her INR not being drawn for [DATE]. During the interview, Physician #300 revealed despite Resident #44 being new to his care upon her admission to the facility in [DATE], he believed administering Coumadin 5 mg daily with weekly INR testing was safe for the resident. However, the physician indicated his course of care would have changed if he had been notified of labs not being drawn appropriately or if the resident was having extensive pain. However, the physician stated he was not aware of this. No additional information was provided during interview regarding the CT scan results, the resident not attending the neurology appointment or if additional testing was considered or obtained when the INR was identified as supratherapeutic on [DATE]. On [DATE] at 1:01 P.M. information obtained via email from the Administrator revealed the resident's INR was not completed on [DATE] due to an inadequate amount of blood being obtained. The facility had been notified of this via telephone (the specimen could not be used); however, there was no documentation of the lab notification, so the facility had the lab fax the sheet over to show the reason the lab wasn't completed per order. Messages were left with the hospice provider for interview during the onsite survey; however, no return calls were received. Review of the undated facility Anticoagulant Therapy Policy revealed the facility was to make arrangements to have appropriate laboratory testing completed as ordered by the physician. Further review revealed the physician would be notified of any change in condition of the resident including bruising and bleeding. Review of undated Additional Drug Information for warfarin (Coumadin) available in the electronic medical record/the resident's electronic medication administration record (this is the information nurses have available related to the medications ordered and can use as a resource if needed) revealed side effects include but are not limited to intracerebral hemorrhage, hemorrhage and purpura (the collection of small blood pools under the skin). Label warning included immediately report bleeding or bruising to your doctor. Review of the American Heart Association Journals at ahajournals.org dated [DATE] revealed Coumadin (warfarin) is a prescription medication used to prevent harmful blood clots from forming or growing larger. Beneficial blood clots prevent or stop bleeding, but harmful blood clots can cause a stroke, heart attack, deep vein thrombosis, or pulmonary embolism. Because warfarin interferes with the formation of blood clots, it is called an anticoagulant. Many people refer to anticoagulants as blood thinners; however, warfarin does not thin the blood but instead causes the blood to take longer to form a clot. The formation of a clot in the body is a complex process that involves multiple substances called clotting factors. Warfarin decreases the body's ability to form blood clots by blocking the formation of vitamin K-dependent clotting factors. Vitamin K is needed to make clotting factors and prevent bleeding. Therefore, by giving a medication that blocks the clotting factors, your body can stop harmful clots from forming and prevent clots from getting larger. It is important to monitor the INR (at least once a month and sometimes as often as twice weekly) to make sure that the level of warfarin remains in the effective range. If the INR is too low, blood clots will not be prevented, but if the INR is too high, there is an increased risk of bleeding. This is why those who take warfarin must have their blood tested so frequently. Unlike most medications that are administered as a fixed dose, warfarin dosing is adjusted according to the INR blood test results; therefore, the dose usually changes over time. This deficiency represents non-compliance investigated under Complaint Number OH00161229.

Based on closed medical record review, hospital record review, facility policy review and interview, the facility failed to ensure Resident #44's physician was notified timely of missed consultation appointments and laboratory studies. This affected one resident (#44) of seven sampled residents. The facility census was 43. Findings include: Review of Resident #44's closed medical record revealed an admitted [DATE] with diagnoses including traumatic subdural hemorrhage without loss of consciousness, dysphagia, cerebral infarction, seizures, hypertension, atrial fibrillation and congestive heart failure. Resident #44 passed away in the facility on 01/11/25. Review of Resident #44's hospital discharge paperwork, dated 09/18/24, revealed Resident #44 was in the hospital from 09/12/24 until discharge to the facility on [DATE] due to a headache that was diagnosed as a spontaneous subdural hematoma due to a supratherapeutic International Normalized Ratio (INR) (a blood test that tells how long it takes for your blood to clot when on Coumadin (warfarin) level with her Coumadin on hold upon admission to the facility. The hospital records revealed Resident #44 was to follow with a cat scan (CT) (of her brain) and neurology after hospital discharge to resume her Coumadin. The neurology appointment was scheduled by the facility for 10/29/24. Review of a CT scan of the brain without contrast obtained 10/01/25 revealed extra-axial mixed attenuation fluid collection at the left cerebellum that was worrisome for chronic/subacute subdural hematoma. The medical record contained no evidence that the physician was notified of the CT results. Review of the progress note, dated 10/29/24 at 4:20 A.M. and authored by Licensed Practical Nurse #543, revealed the resident's pulse was in the 150's (meaning the pulse was between 150 to 159 beats per minute with the normal range being 60-90 beats per minute) and an order was given to send the resident out to the hospital. Review of Resident #44's hospital discharge documentation, dated 11/02/24, revealed the resident was admitted to the hospital with atrial fibrillation (abnormal heart rhythm pertaining to the atrium (top part) of the heart) with a rapid ventricular rate and congestive heart failure (CHF). She was discharged on [DATE], back to the facility. Further review of the medical record revealed no evidence that the resident attended the follow-up neurology appointment due to her hospitalization (10/29/24 through 11/02/24) and the appointment was not rescheduled upon her return to the facility. Review of the 12/23/24 Minimum Data Set (MDS) revealed Resident #44 had a Brief Interview for Mental Status score of 15 out of 15 indicating the resident was cognitively intact. The assessment revealed the resident required supervision or touching assistance with transfers and ambulation and independent with all other aspects of care. The assessment also noted the resident received anti-coagulant medication. Review of the plan of care dated 01/02/25 for Resident #44 revealed the resident was at risk for bruising/bleeding related to use of potential side effect of medication: anti-coagulant with an intervention including obtain/report lab work per doctor order. Review of the physician's orders dated 01/02/25 revealed an order for an international normalized ratio (INR) (a blood test that tells you how long it takes for your blood to clot when on blood thinners, therapeutic ranges of INR results for a resident on an anticoagulation medication are 2.0 to 3.0 and levels become critical at 5.0) laboratory test to be completed every other day until INR was below three and the order was to be STAT with the scheduled time of 3:00 A.M. to 6:30 A.M. for draw time. Review of the medical record revealed no INR results were found for 01/06/25. Review of the progress notes dated 01/06/25 revealed no documented evidence the physician was notified of the laboratory testing not being completed on this date. On 02/06/25 at 12:21 P.M. an interview with the Director of Nursing (DON) revealed if laboratory tests were ordered as STAT, the physician should be notified by the end of the day if the laboratory result was not obtained for any reason and/or of the test results. On 02/06/25 at 1:28 P.M. interview with the Regional Nurse verified the physician was not notified on 01/06/25 of lab testing not being completed for Resident #44 due to insufficient specimen quantity. On 02/07/25 at 12:00 P.M. an interview with the DON revealed the DON believed Physician #300 was aware of the resident's CT scan results on 10/01/24 and that the resident missed her neurology appointment on 10/29/24 due to her hospitalization but verified neither notification was documented in the resident's medical record. On 02/07/25 at 9:23 A.M. interview with Physician #300 verified he was not aware the resident's labs were not completed on 01/06/25 until several weeks had passed. Review of the facility undated policy titled Anticoagulant Therapy Policy revealed physician notification was required for all abnormal lab results. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observation, staff interview and review of facility policy, the facility failed to ensure staff followed infection control procedures including the proper use of personal protective equipment (PPE) to prevent transmission of COVID 19. This had the potential to affect all thirteen residents (Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, and Resident #26) residing in Resident #26's assigned care area. Findings include: Resident #26 was admitted on [DATE] with diagnoses that included Parkinson's disease without dyskinesia, dysphasia following cerebral infarction, chronic kidney disease, congestive heart failure, atrial fibrillation, cardiomyopathy, gastro-esophageal reflux disease without esophagitis, and depression. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was cognitively intact with minimal depression. Resident #26 had no impairment of range of motion in upper or lower extremities and uses a walker. Resident #26 was independent for eating and oral hygiene. Resident #26 required set-up/clean-up assistance for toileting, personal hygiene, and dressing and required partial/moderate assistance for showering. Resident #26 had a care plan that addressed transmission-based precautions for a positive COVID 19 test. The care plan also addressed Resident #26's preference for door to room to be open at all times due to the fear Resident #26 has when the door is closed. 09/03/24 10:30 A.M. interview with Licensed Practical Nurse (LPN) #460 confirmed Resident #26 was placed in airborne isolation on 08/31/24 after becoming symptomatic and then testing positive for COVID 19. 09/03/24 at 12:33 P.M. observation of Resident #26's door revealed it was wide open with the resident in bed watching TV. Observed State tested Nursing Assistant (STNA) #410 walk into Resident #26's room with only a surgical face mask on. STNA #410 then left the room and went into Resident #24 and #25's room asking if the residents were done with their trays. STNA #410 did not change her mask or perform any hand hygiene. Interview on 09/03/24 at 12:42 P.M. with STNA #400 confirmed Resident #26's door was open. STNA #400 stated Resident #26 doesn't like his door closed; he was afraid when it was closed, and he opens it back up. STNA #400 confirmed STNA #410 went into Resident #26's with just a surgical face mask and when there was no tray to remove, she left and went into Resident #24 and #25's room with the same mask and no hand hygiene to collect meal trays. Interview on 09/03/24 at 12:44 P.M. with STNA #410 confirmed she went into Resident #26's with just a surgical face mask. STNA #410 stated they were told they only had to wear the PPE for direct patient care, if they were just delivering or picking up trays, a mask was okay. Interview on 09/03/24 at 3:30 P.M. with Resident #26 confirmed Resident #26 preferred to have his door open, at least far enough to see what is going on in the hallway. Interview on 09/03/24 at 4:00 P.M. with the Administrator confirmed the goal was to keep the door shut with airborne isolation if the resident can tolerate the door shut if but it is okay to have the door open. Administrator was told when the STNA's were asked about wearing PPE, they stated they were told they only had to wear PPE if they were doing direct care, and the Administrator stated the STNA's were confusing enhanced barrier precautions with isolation precautions. Interview on 09/03/24 at 3:45 P.M. with the Administrator confirmed the STNAs were assigned a specific group of rooms at the beginning of each shift. Resident #26 was included in the room [ROOM NUMBER] through 318 assignment (Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, and Resident #26). Review of policy Infection Control Guidelines for All Nursing Procedures, undated, revealed an outline of education provided to all nursing staff, general guidelines for the difference between Standard Precautions and Transmission - Based Precautions. The policy addresses appropriate hand hygiene and use of personal protective equipment. These are considered general guidelines and refers readers to procedures for any specific infection control precautions. Review of Policy Coronavirus (COVID 19) Protocol, undated, specified staff would wear a N95 mask, eye protection, and gowns in quarantine/isolation rooms.

Based on medical record review, hospital record review, and staff interview, this facility failed to ensure glucose monitoring was completed for a resident who had a diagnosis of type two diabetes mellitus with hyperglycemia (elevated blood glucose levels) and was prescribed a medication that would cause hyperglycemia in patients with diabetes. This affected one (Resident #60) of the four residents reviewed for glucose monitoring. The facility census was 28. Findings include: Review of the medical record for Resident #60 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included type two diabetes mellitus with hyperglycemia, heart disease, and parainfluenza virus pneumonia. Review of Resident #60's hospital daily progress note dated 10/26/23 at 12:00 P.M. created by Physician #300 revealed under section titled Assessment/Plan 8. Diabetes mellitus: Hyperglycemia due to steroids Ac 7.2% Continue Levemir 8 units twice a day plus a sliding scale insulin. Goal glucose between 140-180, steroids being reduced. Continued review of hospital discharge orders revealed a order for Prednisone 10 milligrams (mg) tablets, dose pack. Start on 11/03/23. Take 6 tablets one time each day for one day, then 5 tablets one time a day for one day, then 4 tablets one time a day for one day, then 3 tablets one take a day for one day, then 2 tablets one time a day for one day and then the last dose will be one tablet one day a day for the final day. Review of Resident #60's discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's memory was intact and the resident was independent with daily decision making abilities. Review of Resident #60's orders for November 2023 revealed blood glucose monitoring was not ordered until 11/08/23 where her glucose levels were noted to be 386 milligrams per deciliter (mg/dL) Interview on 12/11/2023 at 2:30 P.M. with Regional Nurse #45 confirmed Resident #60 had a diagnosis of type two diabetes mellitus and while in the hospital had experienced high blood glucose readings (hyperglycemia) resulting in glucose monitoring and insulin which was noted to be caused by the resident receiving Prednisone or steroids. Regional Nurse #45 also confirmed Resident #60 continued this Prednisone medication while at the facility but there was not order for the nursing staff to monitor the resident glucose levels. Regional Nurse #45 confirmed one of the nursing staff should have realized this resident had a history of hyperglycemia while taking this medication and recommended frequent glucose monitoring to the physician. This deficiency represents non-compliance investigated under Complaint Number OH00148334.

Based on observation, interview, and record review the facility failed to implement a care plan related to hospice needs and oxygen status for Resident #19 and did not implement a care plan for anticoagulant use for Resident #16. This affected two residents (#16 and #19) of 19 residents whose care plans were reviewed. The facility census was 35. Findings include: 1. Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses including cachexia, dysphagia, malignant neoplasm of colon, hypertension, depression, chronic systolic heart failure, anxiety disorder, and actinic keratosis. Review of the Comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had intact cognition. Review of the physician order dated 08/09/23 revealed Resident #19 was admitted to hospice care. Observation on 09/05/23 at 10:02 A.M. revealed Resident #19 had oxygen in place. Review of the plan of care revealed it was absent for hospice or oxygen use. Interview on 09/05/23 at 5:09 P.M. with the Director of Nursing (DON) verified Resident #19 was on oxygen and had not had a care plan for this prior to 09/05/23. Interview on 09/07/23 at 2:45 P.M. with MDS nurse #101 and Regional MDS #133 verified they had initiated the care plans for hospice and oxygen on 09/05/23. 2. Review of the medical record for Resident #16 revealed an admitted [DATE]. The resident was admitted with diagnoses including hypothyroid, atrial fibrillation, hypertension, dysphagia, and anorexia. Review of the quarterly MDS dated [DATE] revealed Resident #16 had severe cognitive loss. The resident required supervision with Activities of Daily Living (ADLs). Further review revealed Resident #16 had needed physical help for bathing of one person. Additionally, the resident was documented as having anticoagulant. Review of the physician orders dated 08/09/23 revealed Resident #16 had order for warfarin tablet 2.5 milligram (mg) oral at bedtime on Tuesday and warfarin 5 mg tablet at bedtime on Sunday, Monday, Wednesday, Thursday, Friday, and Saturday. Review of Resident #16's most recent care plan revealed no goals or interventions in place for anticoagulant. Interview 09/07/23 with Regional Director #131, verified that no plan of care was implemented for the usage of an anticoagulant. Review of the policy Care plan- Use of undated, revealed changes in a residents condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan could be made.

Based on record review, observation, interview, and facility policy review the facility failed to revise Resident #14's care plan with changes to meet the need of resident care interventions as determined by the resident's need or as requested by the resident. This effected one resident (# 14) of 19 resident's for plans of care reviewed. The census was 35. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses including , dysphagia, unspecified injury of the head, acute respiratory failure, cerebral aneurysm, chronic ischemic heart disease, epileptic seizures, displaced fracture of the first cervical vertebra, candida sepsis, Unspecified hearing loss, bilateral, Cervical disc disorder with myelopathy, mid-cervical region, unspecified level and closed displaced fracture of acromial end of left clavicle. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed 07/28/23 revealed Resident #14 had moderate cognitive loss. Further evaluation of Resident #14's functional status required supervision for bed mobility, walk in corridor, locomotion off unit, dressing and personal hygiene. Resident #14 was independent for transfers, walk in room, locomotion on unit, eating, toilet use and was continent of bowel and bladder. Record review of Resident #14 medical records revealed that on 08/15/23 at 7:30 A.M., Resident #14 was found by staff in room on floor with 1 inch laceration on left side of head in hairline and unable to move arm without pain and was transported to hospital where a closed displaced fracture of acromial end of left clavicle was diagnosed . Further review of Resident #14's medical record revealed on 08/24/23 at 12:33 A.M. that Resident #14 slid off the footrest of her chair on to her buttocks and on 08/27/23 at 6:35 A.M. she was found sitting on floor beside her bed. Plan of care dated 12/30/22 for Resident #14 was silent for usage of sling/immobilizer device for left arm. Further review of plan of care for incidents on 08/24/23 and 08/27/23 and was found to be silent for new or reevaluated of previous interventions for both incidents. Interview and subsequent observation with Resident #14 on 09/05/23 at 10:34 am, stated she had fallen a few weeks ago while walking in her room causing an arm fracture and had to wear a sling on her arm since the fall and that she had fallen a few times after her fracture. Observation of Resident # 14, sitting in chair and left arm in sling/immobilizer device. Interview 09/07/23 with Regional Director #131, verified that no plan of care was implemented at the time of the device application nor was new or updated fall interventions placed on plan of care for the 08/24/23 and 08/27/23 incidents. Review of facility non-dated policy, Care Plan-Use Of, states the care plan shall be used in developing the residents daily care routines. Review of facility non-dated policy, Falls and Fall Risk, Managing, states, if falling recurs despite initial interventions, staff will implement additional or different interventions or indicated why the current approach remains relevant.

Based on interview and record review the facility failed to ensure a significant change assessment was completed when Resident #19 was admitted to hospice. This affected one resident (#19) of one resident reviewed for change in condition. The facility census was 35. Findings include: Review of the medical record for Resident #19 revealed an admitted [DATE] with diagnoses including cachexia, dysphagia, malignant neoplasm of colon, hypertension, depression, chronic systolic heart failure, anxiety disorder, and actinic keratosis. Review of the Comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had intact cognition. Review of Resident #19's MDS assessments on 09/05/23 revealed a significant change assessment had not been initiated. Review of the physician order dated 08/09/23 revealed Resident #19 was admitted to hospice care. Interview on 09/07/23 at 2:45 P.M. with MDS nurse #101 and Regional MDS #133 verified a comprehensive assessment was not initiated when Resident #19 was admitted to hospice as it should have been. Review of the policy Care plan- Use of undated, revealed changes in a residents condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan could be made.

Based on medical record review, hospital admission and discharge record record review, staff, physician and surgeon interview, and policy and procedure review, the facility failed to implement the necessary care and treatment at the time of admission to prevent Resident #23's surgical wounds from becoming necrotic, infected and dehisced in 12 days. Actual harm occurred on 05/03/23 when Resident #23 was readmitted to the local hospital for incision, drainage, surgical debridement, wound vacuum placement and intravenous antibiotics for infection following a femoral arterial graft (bypass). This affected one of three residents reviewed for non pressure wound care. The facility identified two other residents with non pressure wounds. The facility census was 35. Findings include: Review of the medical record for Resident #23 revealed an admitted [DATE] with a discharge return anticipated on 05/03/23. Diagnoses included encounter for displacement of femoral arterial graft (bypass), other disorder of circulatory system, metabolic encephalopathy, and altered mental status. Review of the hospital discharge instructions for Resident #23 dated 04/21/23 revealed to apply a clean dressing to the wounds. Review of the admission nursing assessment dated [DATE] at 6:15 A.M. identified Resident #23 was admitted with a wound. The note referred the reader to the skin grid document. Review of the initial wound assessment dated [DATE] revealed Resident #23 had a surgical wound to the right calf and right groin. The right calf surgical wound measured seven inches in length with 15 staples, and the right groin measured two and half inches with 12 staples. There was no tunneling or undermining noted and the wounds surface was red with staples in place. The nurse noted the hospital paperwork noted at the top of the right calf an area was open that measure 3.5 centimeters (cm) by 1.5 cm where two staples were removed to allow drainage of a hematoma. A scant amount of sanguineous drainage with no odor was noted to the small open area that was also beefy red in color. The staples were intact and edges well approximated. The initial wound assessment also indicated Current wound treatment: none listed. The physician and family were notified. Review of the base line plan of care dated 04/22/23 revealed Resident #23 had a surgical wound. The goal was show evidence of healing through 30 days. Approaches included check the resident's skin weekly with daily care and bathing, report skin concerns to the physician and or Nurse Practitioner (NP), inform physician and or NP of any changes in skin conditions, and monitor for pain. Review of physician's orders for April 2023 and May 2023 revealed no orders for care of the surgical wounds. Review of the Treatment Administration Record (TAR) for April 2023 and May 2023 revealed no documentation Resident #23 received care and treatment to the surgical wounds to right groin and right calf. Review of the skilled nursing note dated 04/22/23 revealed Resident #23's skin was warm, dry with dressing in place. A skilled nursing note dated 04/23/23 revealed Resident #23's skin was warm, dry with dressing place. A skilled nursing note dated 04/29/23 revealed Resident #23's skin was warm, dry with no dressing in place. A skilled nursing note dated 05/01/23 revealed Resident #23's skin was warm, dry, with dressing in place. A skilled nursing note dated 05/02/23 revealed Resident #23's skin was warm, dry with dressing in place. A skilled nursing note dated 05/03/23 revealed Resident #23's skin was warm, dry with dressing in place. Review of the weekly wound monitoring sheets dated 04/25/23 revealed Resident #23 had a surgical wound to right calf and right groin area. No exudate or odor noted. The staples were in place and the top of the right calf wound remained open. The wound treatment was to leave open to air. A weekly wound monitoring sheet dated 05/03/23 revealed Resident #23 had a surgical wound to right calf and right groin area. The open area at top of right calf had moderate amount of serosanguinous drainage with no odor. The skin was separating from the staples per the in house wound physician due to arteries not healing after surgery. Resident #23 had a follow up appointment with surgeon this date (05/03/23). Review of the comprehensive Minimum Data Set assessment, dated 04/28/23 revealed Resident #23 had intact cognition. Resident #23 required limited assistance of one person for bed mobility and transfers. Ambulation did not occur during the look back period. The assessment indicated Resident #23 had a surgical wound with no treatment. Review of hospital documentation dated 05/03/23 by attending Surgeon #4 revealed Resident #23 returned to his office today for surgical follow up. Resident #23's entire right calf incision had dehisced (a partial or total separation of previously approximated wound edges, due to failure of proper wound healing) and had skin necrosis (death) in that area. Resident #23 also had an open area to the proximal incision that measured less than one cm. The physician probed the area with a wooden swab and return of 0.5 cubic centimeter of purulent drainage was extruded from the site. The wounds were cleaned, and dressed. Resident #23 stated the wound dressings had not been changed in four days. Resident #23 was a direct admit to the hospital for intravenous antibiotics, wound care including debridement and wound vacuum placement. The wound team assessment on 05/04/23 revealed the dressings were removed, the wounds cleaned and cultures were obtained from both wounds. The wounds were redressed as Resident #23 was having surgical debridement the following day. Resident #23 had surgical wound debridement on 05/04/23 with a wound vacuum placed on groin area and dressing applied to right calf. On 05/08/23 a wound vacuum was placed on the right calf as well. An interview on 05/11/23 at 1:14 P.M. with the Director of Nursing (DON) confirmed by review of Resident #23's physician's orders there was not an order addressing Resident #23's surgical wounds, including care, monitoring or treatment. The DON stated Resident #23 had two surgical wounds with staples and typically those wounds would be monitored and left open to air. The DON confirmed all wound care and treatment for wounds would be on the resident's TAR and wound monitoring sheets would be completed weekly. The DON stated she did not recall if Resident #23 had wound dressings in place. On 05/03/23 the DON asked the in house wound physician to assess Resident #23's wounds as they did not look good. A phone interview on 05/11/23 at 3:35 P.M. with the in house wound physician, Physician #5, revealed the nurses at the facility had asked him to look at Resident #23's right leg. Physician #5 stated the wound concerns could be from a complication from the surgery and the necrosis tissue on the edge of the incision was typical with little blood supply. Physician #5 would expect the facility nursing staff to provide care and treatment for wounds and follow the physician orders. Physician #5 also stated surgical wounds with staples would not necessarily have wound care. Usually, the first 48-72 hours the surgeon would not want the dressing removed although Physician #5 was not sure if this was the case for Resident #23. Physician #5 did not know if Resident #23 had a dressing to her wounds. There was not a dressing in place when Physician #5 assessed the wounds on 05/03/23. An interview on 05/17/23 at 9:45 A.M. with the Medical Director, Physician #3, revealed Physician #3 completed his admission assessment for Resident #23 on the Wednesday after her admission on 04/26/23 and stated the wounds had no issues or problems. Physician #3 did not recall if Resident #23 had dressings in place to the wounds. Physician #3 assessed Resident #23 again around 05/03/23 and stated there was a small area dehiscing at the opening at the top of the groin incision. There was no drainage and no cellulitis (bacterial infection involving the inner layers of the skin). The physician did not give any orders for care or treatment as Resident #23 was scheduled to see the surgeon. Physician #3 stated his expectations for a wound with staples would be to clean daily, monitor and dressing change per surgeon's orders. Physician #3 also stated he would expect the nursing staff to ask for orders for wound care if not on discharge instructions. An interview on 05/17/23 at 10:20 A.M. with Licensed Practical Nurse (LPN) #14 revealed Resident #23 arrived at the facility later in the evening. LPN #14 did not recall any orders for care of the surgical wounds. LPN #14 stated wounds should have orders to monitor and clean, but in this case there were no orders. LPN #14 said when there was a wound and no orders, she would ask the day shift nurse to contact the surgeon for orders. LPN #14 was an agency nurse and worked again on 05/02/23. Resident #23's son asked LPN #14 to look at his mother's wounds. LPN #14 stated the wounds looked pretty nasty and she covered them with a dry dressing. LPN #14 stated she did not notify the physician. An interview on 05/17/23 at 10:30 A.M. with Registered Nurse (RN) #46 revealed on admission all residents received a skin assessment and if the resident had a wound, the nurse would assess the wounds and notify the physician of admission and request orders if needed. The admitting nurse would put orders in the chart and complete all assessments. A subsequent interview on 05/17/23 at 10:50 A.M. with the DON revealed there was not a dressing on Resident #23's surgical wounds that she witnessed. There was not an order for wound care, and with no orders the wound would be left open to air. The DON again stated that was how the facility handled surgical wounds with staples. The facility did not provide a policy or procedure guide stating that information. Review of facility policy titled Wound Care with no date, revealed the facility failed to verify that there was a physician order for wound care as indicated in the policy. Review of the facility policy titled Admissions to the Facility with no date, revealed the facility failed to notify the attending physician for information needed for the immediate care of the resident including orders for care of surgical wounds as indicated in the policy. This deficiency represents non-compliance investigated under Complaint Number OH00142638.