Every finding on record at Altercare of Canal Winchester Post-Acute RC

Based on record review and interviews the facility failed to complete a comprehensive pain assessment on admission for Resident # 71 and failed to provide timely pain management for Resident # 72. This affected two of three residents reviewed for pain management. The facility census was 62.Findings include: 1. Review of Resident # 71's record revealed an admission date of 07/01/26 with diagnoses that included but were not limited to post surgical removal of spinal cord tumor, spinal meningioma, right renal cancer, neuralgia and neuritis, lumbar stenosis and acute pain due to trauma. Review of Resident # 71's admission Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and required assistance from staff with toileting, transfers and bed mobility.Review of Resident # 71's clinical admission assessment dated [DATE] revealed the assessment was incomplete with multiple unanswered questions and incomplete sections including baseline care plans. Further review revealed the assessment was not signed off by a licensed nurse as complete. Further review revealed under pain symptoms Licensed Practical Nurse (LPN) # 508 marked the resident had verbally expresses pain however questions for intensity of pain/pain scale and frequency of pain were not completed. Review of Resident # 71's July 2026 physicians orders revealed an order dated 07/01/26 for Tylenol (analgesic) 975 milligrams (mg) every eight hours as needed; 07/03/26 for Tylenol 325mg every four hours as needed for moderate to severe pain; 07/03/26 for oxycodone (opioid) 5 mg every four hours as needed; 07/03/26 oxycodone 7.5/325 mg every six hours for pain; 07/01/26 pregabalin (anticonsulvant) 50 mg twice a day and 07/03/26 pregabalin 100 mg twice a day.Review of Resident # 71's July 2026 medication administration record (MAR) revealed on 07/01/26 pregabalin 50 mg and tylenol 975 mg signed as given for pain level of seven; on 07/02/26 pregabalin 50 mg signed as given.Interview on 08/05/26 at 4:35 P.M. with the Director of Nursing (DON) confirmed Resident # 71 did not have a completed pain assessment, and the admission assessment was incomplete.Interview on 08/05/26 at 4:57 P.M. with LPN # 508 confirmed she partially completed the pain assessment for Resident #71. LPN # 508 revealed Resident # 71 stated she was in pain and the nurse contacted the provider for an order for tTylenol but did not complete a comprehensive pain assessment. 2. Review of Resident # 72's record revealed an admission date of 07/02/26 with diagnoses that included but were not limited to lung cancer with bone metastasis, neoplasm related pain and polyneuropathy. Review of Resident # 72's 5-day Minimum Data Set (MDS) dated [DATE] revealed the resident had moderately impaired cognition and required assistance from staff with toileting, transfers and bed mobility. Review of Resident # 72's after visit summary dated 07/02/26 revealed orders for oxycodone 20mg every four hours as needed for pain with last dose given 07/02/26 at 4:14 P.M. Review of Resident # 72's July 2026 physicians orders revealed orders dated 07/02/26 for tylenol 625 mg every four hours as needed for pain, 07/02/26 for gabapentin (anticonvulsant) 800 mg every eight hours; 07/02/26 for methadone (opioid) 15 mg twice a day and 07/02/26 oxycodone 20 mg every four hours as needed for pain. Review of Resident # 72's July 2026 medication administration record (MAR) revealed he received oxycodone 20 mg at 11:44 P.M. Further review revealed no other pain medications given on 07/02/26. Review of Resident # 72's admission clinical assessment dated [DATE] revealed the resident reported pain of nine during the assessment. Review of Resident # 72's progress notes dated 07/02/26 revealed he was admitted at 6:15 P.M. and verbalized pain; however the resident reeived a dose of pain medication at 4:15 P.M. Further review revealed at 11:13 P.M. the resident complained of pain and the nurse obtained an authorization to pull oxycodone 20 mg to administer. Interview on 08/05/26 at 10:20 A.M. with Director of Nursing (DON) confirmed there was no documented follow up for pain or pain assessment completed after Resident # 72 reported a pain level of nine on admission at 6:15 P.M. and his first dose of pain medication given 07/02/26 at 11:44 P.M for a pain level of nine. Review of facility policy titled Pain Assessment and Management dated 05/01/25 revealed upon admission each resident will receive a comprehensive pain assessment completed and at minimum should include location, severity, type and onset and duration. This citation represents noncompliance investigated under Complaint Numbers 3133024, 3074084 and 30721799.

Based on record review, observation and interviews, the facility failed to provide treatment care per physician's orders for one resident, (#62) of three reviewed for skin impairment. Facility census was 62.Findings include: Review of Resident # 62's record revealed an admission date of 08/20/20 with diagnoses that included but were not limited to multiple sclerosis, left tibial fracture, diabetes mellitus type II with neuropathy and neurogenic bladder.Review of Resident # 62's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required total assistance from staff with toileting, transfers and bed mobility. Further review of the MDS revealed she was coded as having moisture associated skin damage (MASD).Review of Resident # 62's current physicians orders revealed the following orders:Cleanse with normal saline (NS), pat dry and apply Triad cream as needed; dated 12/13/25.Apply moisture barrier cream to buttocks after each incontinence; dated 04/23/26.Calmoseptine ointment; MASD: cleanse groin and buttocks with soap and water and apply ointment every shift and as needed (PRN); dated 05/08/26.Buttocks: cleanse with soap and water, pat dry, apply zinc oxide cream twice daily and PRN; Dated 07/29/26 Review of Resident # 62's July 2026 and August 2026 medication and treatment administration record revealed Calmoseptine ointment to buttocks signed off by licensed nurses daily every shift as completed; Buttocks: apply zinc oxide cream twice daily was signed off by licensed nurses as completed 07/29/26 to 08/03/26 daily every shift. There were no signed days of application of zinc oxide to the buttocks PRN. Observation on 08/03/26 at 3:18 P.M. of incontinence care revealed Certified Nursing Assistant (CNA) # 228 provided incontinence care and then applied Triad cream to Resident # 62's buttocks. CNA #228 confirmed he used Triad cream after each incontinence episode. He stated he was unaware of any additional creams the nurses provided.Interview on 08/03/26 at 3:53 P.M. with Licensed Practical Nurse (LPN) # 220 verified the current treatment order for Resident # 62's MASD to her buttocks was zinc oxide, and the nurses applied it twice a day and as needed. When asked if zinc oxide should be applied after incontinence episodes LPN #200 stated she would clarify orders with the provider. LPN # 200 also confirmed there were multiple active orders for creams- zinc oxide, triad and moisture barrier cream ordered for Resident # 62's buttocks.

Based on review of a resident medical record, staff interview and review of a facility policy, the facility failed to complete a baseline care plan for a resident. This affected one resident (#73) out of eleven residents reviewed. The facility census was 62 residents. Findings include: Review of a closed resident medical record revealed Resident #73 was admitted to the facility on [DATE] and had medical diagnoses that included chronic kidney disease and Type II diabetes mellitus. The resident discharged from the facility on 08/03/26. Review of Resident #73's medical record revealed that Resident #73 did not have a completed nursing assessment or baseline care plan. Review of Resident #73's medical record revealed Resident #73's functional abilities were not assessed. A Brief Interview for Mental Status score was not completed. An interview with the Director of Nursing (DON) on 08/04/26 at 3:53 P.M. confirmed the nursing assessment and baseline care plan were not completed for Resident #73 by the date of Resident #73's discharge from the facility on 08/03/26. Review of a facility policy updated on 05/01/25 titled, Care Planning- Comprehensive, revealed that a baseline care plan is completed upon admission (within 48 hours) based on data available at the time of admission.

Based on review of a resident medical record, staff interview, and review of a facility policy, the facility failed to provide bathing to a resident who could not perform bathing independently. This affected one resident (#9) out of three residents reviewed for bathing. The facility census was 62 residents. Findings include: Review of a resident medical record revealed that Resident #9 was admitted to the facility on [DATE] and had diagnoses that included hemiplegia and hemiparesis, schizoaffective disorder, and vascular dementia. Review of Resident #9's Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status score of eight, indicative of moderate cognitive impairment. Resident #9 was assessed as needing substantial to maximal assistance with showering/bathing. Review of Resident #9's comprehensive care plan dated 02/03/20 revealed that Resident #9 had impaired ability to perform activities of daily living (ADL) care related to vascular dementia, schizoaffective disorder and hemiplegia. A listed approach included providing assistance with all ADL care as able. Review of Resident #9's shower sheets dated 06/01/26 through 08/01/26 revealed that Resident #9 did not receive a shower or bath from 06/20/26 through 07/20/26. Review of Resident #9's bathing task documentation in the point of care revealed no evidence that Resident #9 was offered a shower or bath 06/20/26 through 07/20/26. An interview with the Director of Nursing (DON) on 08/05/26 at 10:05 A.M. confirmed there was not any documented evidence that Resident #9 was offered a shower from 06/20/26 through 07/20/26. Review of a facility policy updated 05/01/25 titled, Shower- Tub Bath, revealed that it is the facility's policy to promote resident hygiene by offering and assisting residents with bathing per their plan of care. This citation represents noncompliance investigated under Complaint Numbers 3133024 and 3074084.

Based on closed medical record review, hospital record review, facility policy review, and interviews, the facility failed to timely identify and seek necessary medical intervention following an acute change in condition for Resident #78. This resulted in Immediate Jeopardy, with actual serious life-threatening harm beginning on 03/12/26 at 12:34 P.M., when Resident #78 was noted to be lethargic (a reduced level of consciousness), with elevated blood glucose of 522 milligrams per deciliter (mg/dL, normal results 70-99 mg/dL). The resident's blood sugar was not re-checked for four hours and remained elevated at 353 mg/dL when it was rechecked. The resident continued with limited food and fluid intake and lethargy. The facility failed to monitor the resident, provide comprehensive assessments, and medical support for the resident. On 03/13/26 at 8:30 A.M. Resident #78 became unresponsive and could not be awakened by a sternal rub (painful physical stimuli). Certified Nurse Practitioner, (CNP) #561 was notified, and the resident was transferred and admitted to the intensive care unit of the hospital with diagnoses of severe sepsis with septic shock, acute encephalopathy, multifactorial in the setting of hypernatremia and sepsis, acute kidney injury, hyperglycemia, urinary tract infection, hypernatremia. The resident remained in the hospital receiving medical treatment until 03/25/26 and returned to the facility with hospice services. The resident passed away at the facility on 04/14/26. A concern that did not rise to the level of Immediate Jeopardy but did rise to the level of Actual Harm was identified on 08/21/25 when the facility failed to take action when Resident #88, who was cognitively impaired and required substantial to maximal assistance with toileting hygiene and was assessed as being incontinent, had not had a bowel movement documented in three days. There was no evidence Resident #88 had a bowel movement from 08/19/25 until 08/26/25. On 08/26/25, Resident #88 was discharged to the hospital due to a change in his condition. At the hospital on [DATE], Resident #88 received a computed tomography (CT) scan of his abdomen, which revealed a moderately stool-distended rectal vault with findings that he was developing stercoral colitis, a rare but serious inflammation of the colon caused by fecal impaction, which could lead to life-threatening complications if untreated. The resident received treatment and services of disimpaction while in the hospital for 11 days.In addition, concerns that did not rise to the level of Immediate Jeopardy or Actual Harm were identified related to the facility's failure to ensure treatments were provided in management of congestive heart failure (CHF), vascular wounds, change in condition related to urinary tract infections, and glaucoma. This affected nine residents (#23, #31, #55, #61, #78, #88, #90, #91 and #93) of 36 residents reviewed for quality of care and treatment. The facility census was 57 residents. On 04/09/26 at 4:35 P.M. the Administrator, (LNHA), Director of Nursing (DON), Regional Nurse Consultant #583 and Regional Nurse Consultant #594 were notified Immediate Jeopardy began on 03/12/26 when staff failed to monitor Resident #78 for an acute change in condition (including blood glucose monitoring and vital sign monitoring) and failed to notify the nurse practitioner of continuing hyperglycemia and diarrhea. The lack of comprehensive monitoring and assessment resulted in a delay in necessary medical intervention. Resident #78 was subsequently found unresponsive to painful stimuli, and was hospitalized with severe sepsis with septic shock, acute encephalopathy, multifactorial in the setting of hypernatremia and sepsis, acute kidney injury, hyperglycemia, urinary tract infection, hypernatremia. The resident was hospitalized until 03/25/26 and returned to the facility with hospice services. The resident passed away in the facility on 04/14/26 at the facility.The Immediate Jeopardy was removed on 04/10/26 when the facility implemented the following corrective actions: -On 04/09/26 Regional Nurse Consultant #594 reviewed 57 current resident records from 03/12/26 to 04/09/26 for changes in condition (including vital signs) and any concerns identified were reviewed with the medical provider. Five residents were identified with a concern and those concerns were reviewed with the medical provider. -On 04/09/26 the facility change in condition policy was reviewed by the Administrator and the DON. -As of 04/09/26 the facility indicated Resident #78 would have a change in condition timely identified, a thorough assessment completed including vital signs, and notification to the physician as soon as possible with clinical findings documented in the clinical record by ADON #1 or ADON #2. The DON/designee would ensure compliance by completing audits. -The facility implemented a plan that by 04/09/26 all current residents would have a change in condition timely identified, a thorough assessment completed including vital signs, and notification to the physician as soon as possible with clinical findings documented in the clinical record by a licensed nurse. The DON/designee would ensure compliance by completing audits.-On 04/09/26 at 5:30 P.M. in-service education for licensed nurses, by the DON, via lecture began on the following topics: change in condition policy, completing an assessment of a resident with a change in condition including vital signs, and notification to the physician. By 04/09/26 at 10:00 P.M. Twenty-two nurses (100%) were educated. As of 04/09/26 the facility implemented a plan for all newly hired nurses to receive the education prior to working the floor.-On 04/09/26 at 5:30 P.M. in-service education for CNAs by the DON via lecture on reporting changes in resident condition to the charge nurse. By 04/09/26 at 10:00 P.M. 58 CNAs (100%) were educated. As of 04/09/26 the facility implemented a plan for all newly hired CNAs to receive the education prior to working the floor.-On 04/09/26 at 8:00 P.M. Ad Hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with the medical director, Certified Nurse Practitioner (CNP) #561, the Administrator, DON, ADON #226, ADON #381, and Regional Nurse Consultant #564 on the action items listed in the facility corrective action plan along with a root cause analysis which determined lack of continued monitoring of a resident after identification of change in condition.- On 04/10/26 at 1:00 P.M. ADON #226 and ADON #381 completed assessments on all fifty-seven residents' current condition and obtained a full set of vital signs on all current residents. -On 04/10/26, the DON or a designee began daily audits for two weeks. After two weeks the audits would be completed three times a week for two weeks, then weekly for two weeks, and then as need to ensure residents with a change in condition was timely identified, a thorough assessment completed including vital signs and notification to the physician as soon as possible with clinical findings documented in the clinical record. This would be monitored through review of the resident nursing progress notes and vital signs. The DON/designee would conduct an observational audit on five residents three times a week for four weeks and then as needed to ensure residents were not experiencing a change in condition that was not previously identified. Any concerns identified with the audits would be forwarded to QAPI committee weekly for four weeks and as-needed for immediate follow-up. The administrator would be responsible for ongoing compliance.Although the Immediate Jeopardy was removed on 04/10/26, the facility remained out of compliance at 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: 1.Closed record review revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes mellitus type two, hypertension, multiple sclerosis, seizures and history of stroke. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 06. The assessment revealed the resident was assessed to require partial or moderate (staff) assistance for eating and was completely dependent on staff for hygiene and mobility. Review of the care plan dated 04/03/26 revealed Resident #78 was at risk for alteration in blood glucose metabolism related to diabetes mellitus. The care plan included facility staff should observe the resident for signs and symptoms of hyperglycemia and notify the physician. Review of the nursing progress notes revealed on 03/12/26 at 12:34 P.M. Registered Nurse (RN) #270 assessed Resident #78 to be very lethargic, and the resident's blood glucose was noted to be elevated at 522 milligrams per deciliter, (mg/dl). Pulse, oxygen saturation, temperature and blood pressure were not documented as being obtained/recorded at this time. RN #270 notified CNP #561, who requested the resident be given Lispro (a rapid-acting, man-made insulin used to treat type 1 and type 2 diabetes by controlling high blood sugar, particularly after meals. It works within 10–15 minutes, peaks in 30–90 minutes and lasts 2–5 hours) to resolve her high blood glucose, and facility staff were to continue to monitor the resident for the next 24 hours. Review of the vital sign documentation in the facility's medical record of Resident #78 revealed the next blood glucose reading, entered into the resident's medical record at 4:03 P.M. was elevated at 353 mg/dl. This was also the scheduled time of the insulin administration, which would have prompted the nurse for the resident's current blood glucose. Neither additional vital signs (pulse, oxygen saturation, respirations, temperature and blood pressure) nor physical assessment of the resident were completed at this time. Review of the vital sign documentation in Resident #78's medical record revealed on 03/12/26 at 8:05 P.M. the resident's blood glucose was elevated at 212 mg/dl. The resident's pulse was documented to be 85 beats per minute, (BPM) and blood pressure 123/69 millimeters of mercury (mm hg). Oxygen saturation, respirations, temperature and physical assessment were not documented as completed at this time. There were no additional vital sign monitoring, blood glucose readings, or physical assessments of the resident completed overnight on 03/12/26. The vital sign documentation in Resident #78's medical record reflected on 03/13/26 at 8:32 A.M. the resident's blood glucose was elevated at 391 mg/dl. This was also the scheduled time of Resident #78's insulin administration, which would have prompted the nurse for the resident's current blood glucose. Record review revealed no additional physical assessment or vital sign monitoring (pulse, oxygen saturation, respirations, temperature and blood pressure) were completed at this time. Review of the nursing progress note revealed on 03/13/26 at 9:54 A.M. LPN #256 found Resident #78 unresponsive and unarousable, even after attempting a sternal rub. CNP #561 was notified, who issued an order for Resident #78 to be transferred to the hospital. Review of the hospital records for Resident #78 revealed the resident was admitted to the critical care unit, with mechanical ventilation required. She was hospitalized from [DATE] until 03/25/26. During her hospital stay, she was found to be in septic shock related to pneumonia and a urinary tract infection. The resident's (hospital) course was further complicated by acute kidney injury on top of chronic kidney disease, significant electrolyte imbalances, and high blood sugar levels. The resident's treatment course included mechanical ventilation, intravenous fluids, and antibiotics. Palliative care was consulted during her stay, and the resident's family chose to continue hospice services following her discharge from the hospital. At the time of the resident's hospital stay, the hospitalist noted the resident was medically stable for discharge but remained minimally responsive and on supplemental oxygen.Review of the acute care hospital Discharge summary dated [DATE] revealed on 03/13/26, Resident #78 presented to the emergency room with altered mental status. Vital signs included a temperature of 107 degrees Fahrenheit, (normal reading 98.6 degrees Fahrenheit) and blood pressure 70/50 mm/Hg, (normal 120/80 mm/Hg). Resident #78's laboratory values included an elevated blood glucose of 349, elevated serum sodium of 172 (normal values 135-145) and elevated serum lactate 2.5 (normal level is less than 2). During the resident's admission assessment, it was noted the resident was not even responsive to painful stimuli. The resident was intubated in the emergency department. She was diagnosed with septic shock related to a complicated urinary tract infection, metabolic encephalopathy related to hypernatremia and sepsis, hyperglycemia, severe malnutrition and acute kidney injury. The resident was also assessed to be severely dehydrated. Interview on 04/08/26 at 3:34 P.M. with CNP #561, revealed after Resident #78's abnormal blood sugar value of 522 mg/dL was reported to her and she ordered a medication intervention (lispro), her expectation was that resident's blood glucose be re-checked in an hour and the nurse would have called her back if the value continued to be elevated. She denied being notified that Resident #78 had a change in condition and was lethargic. She stated her expectation was that the nurse would have obtained a full set of vital signs once the change in condition was noted. CNP #561 revealed with this additional information she would have ordered additional monitoring tests for the resident, including a urinalysis, which would have detected the urinary tract infection the resident had. Interview with RN #270 on 04/09/26 at 9:21 AM revealed the RN confirmed on 03/12/26 she noticed Resident #78 appeared more lethargic than usual. She stated called the provider who said the resident should be closely monitored for the next 24 hours. Following her administration of the ordered intervention (lispro), she stated she re-checked the resident's blood glucose level two hours later and it was still high. She recalled checking again two hours later and it was in the 300's so she called the provider who gave no new orders at that time. She said she thought she checked the resident's vital signs (including temperature) and believed they were normal but stated she could not recall if she recorded any of these values in the resident's medical record. The RN stated even though the resident's blood glucose level had come down, the resident remained very lethargic (abnormal for the resident). RN #270 verified a second call to the provider was not recorded in the resident's medical record. Interview on 04/09/26 at 1:50 PM with Certified Nursing Assistant (CNA) #385 revealed he recalled on 03/12/26, Resident #78 was very tired. He explained the resident would normally speak to staff whenever they entered her room, but that day (03/12/26) she didn't want to talk or lift her head at all. Interview on 04/09/26 at 2:10 P.M. with CNA #387 revealed she recalled caring for Resident #78 on the morning of 03/13/26. She stated she recalled being advised in report from the night shift CNA the resident had a lot of diarrhea the previous night. She said when she visited the resident in her room, the resident appeared very sleepy and would not respond when the CNA greeted her. She stated when she returned about an hour later, the resident wouldn't wake up. She said she alerted the nurse, who indicated she had already notified the medical provider. Interview on 04/09/26 at 2:25 PM with LPN #234, who provided care for Resident #78 on 03/12/26 overnight, revealed she recalled being advised by the day shift nurse that Resident #78 had been very sleepy all day. LPN #234 revealed she was concerned the resident would barely open her eyes and would not speak to her, as she normally did. Interview on 04/09/26 at 2:36 P.M. with LPN #256 revealed she recalled being called by another staff member to Resident #78's room because the resident was unresponsive (on 03/13/26). She stated she obtained a full set of vitals from the resident to provide CNP #561. She revealed she felt Resident #78's vital signs were normal. The resident's vital signs were blood pressure of 110/63 mm hg, pulse of 108 BPM, (an abnormal reading), oxygen saturation 98%, temperature of 99.5 degrees Fahrenheit, (an abnormal reading) and blood glucose of 391 mg/dl, (an abnormal reading for Resident #78). On 04/15/26 at 5:26 P.M. during a subsequent interview with CNP #561 she stated she does now recall being advised by RN #270 that Resident #78 was more lethargic than usual. CNP #561 recalled telling RN #270 to continue monitoring the resident. She stated her expectation was that the nursing staff would have obtained vitals at least every shift and reported to her if they were abnormal. She said she was not made aware that the resident had (new onset) diarrhea. The CNP revealed this was information she would have liked to know because this would be considered a significant change. Review of the facility policy and procedure titled Change in the Resident's Condition or Status, updated 05/01/25 revealed it was the facility's policy the resident's medical provider was notified of changes to the resident's physical, mental or psychosocial status. Following an adequate assessment, the nurse would also document these findings in the resident's medical record. 2. Review of the closed medical record for Resident #88 revealed the resident was admitted to the facility on [DATE]. Resident #88's diagnoses included metabolic encephalopathy, benign prostatic hyperplasia, need for assistance with personal care, and cognitive communication deficit. Review of Resident #88's nursing admission assessment dated [DATE] revealed Resident #88 was incontinent of bowel. Review of Resident #88's nursing evaluation titled, GG Support Assessment, dated 07/08/25, revealed Resident #88 was assessed as requiring substantial to maximal (staff) assistance with toileting hygiene and substantial to maximal (staff) assistance with toilet transfers. Review of Resident #88's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08, indicative of moderate cognitive impairment. Review of Resident #88's care plan dated 07/09/25 revealed Resident #88 was incontinent of bowel and at risk for constipation. The goal was for Resident #88 to have soft bowel movements at least every three days without complications such as constipation. Approaches included to administer medication per physician orders, to check and provide incontinence care as needed, to observe and record bowel movements daily, to observe for signs of constipation, and to provide physical support and assistance for toileting safety. Review of Resident #88's physician orders dated 07/05/25 through 08/26/25 revealed the resident had an order for bisacodyl, a stimulant laxative, extended release, five (5) milligrams (mg), one tablet once daily. Review of Resident #88's Medication Administration Record (MAR) dated 07/05/25 through 08/26/25 revealed Resident #88 received the bisacodyl as ordered. Review of Resident #88's physician orders dated 07/12/25 through 08/26/25 revealed an order for MiraLAX (polyethylene glycol 3350) powder, a laxative, 17 grams per dose, twice daily as needed for no bowel movement per facility protocol. Review of Resident #88's MAR dated 07/12/25 through 08/26/25 revealed the resident received the MiraLAX on 07/12/25 for constipation and on 07/13/25 for constipation. Review of Resident #88's bowel movement documentation from 08/18/25 through 08/26/25 revealed it was documented Resident #88 had a small bowel movement on 08/18/25. Resident #88 was recorded as having no bowel movements from 08/19/25 through 08/26/25. Review of Resident #88's nursing progress notes and skilled nursing notes 08/19/25 through 08/25/25 revealed they were silent for Resident #88 having a bowel movement during this time period. Review of Resident #88's nursing progress note dated 08/26/25 at 10:30 A.M. authored by RN #811 revealed staff alerted RN #811 Resident #88 was non-responsive. Resident #88 was ashen and pale but responded to verbal stimuli. Resident #88 was observed to have beige creamy colored drainage in his urinary catheter bag, and the viscosity was unable to be determined. The resident's oxygen saturation was 86% on room air. Oxygen was applied at four liters per minute via nasal canula and the resident's oxygen saturation increased to 100%. The oxygen was decreased to two liters per minute, and his oxygen saturation was able to be maintained at 96%. The CNP was notified, and emergency services were called due to signs and symptoms of sepsis. A verbal report was given to the hospital destination and the note included Resident #88 remained alert during his transfer to emergency services. Review of Resident #88's hospital record dated 08/26/25 at 3:29 P.M. revealed a cat (CT) scan of Resident #88's abdomen and pelvis revealed moderately stool-distended rectal vault with findings which may reflect developing stercoral colitis. Resident #88 was diagnosed with a fecal impaction with possible stercoral colitis. Resident #88 was given intravenous antibiotics and a fecal disimpaction was ordered. Review of Resident #88's hospital record dated 08/26/25 through 09/05/25 revealed Resident #88 had his bowels disimpacted on 08/28/25 and did not require surgery for his fecal impaction. Interviews with RN Supervisor #412 on 04/14/26 at 7:08 P.M., RN Supervisor #270 on 04/15/26 at 3:51 P.M., LPN Supervisor #234 on 04/16/25 at 8:52 A.M., and LPN Supervisor #258 on 04/16/25 at 8:49 A.M. revealed none of the staff were aware Resident #88 had not had a bowel movement for eight days prior to his discharge to the hospital on [DATE]. Interview on 04/15/26 at 3:45 P.M. with Regional Nurse Consultant #594 confirmed Resident #88 did not have a documented bowel movement from 08/19/25 through 08/26/25. A follow up interview with Regional Nurse Consultant #594 on 04/15/26 at 5:33 P.M. confirmed there was no evidence in the medical record that either CNP #561 or the physician were notified Resident #88 had not had a bowel movement since 08/18/25 until the date of his discharge on [DATE].Interview with CNP #561 on 04/15/26 at 5:22 P.M. revealed she was unaware Resident #88 did not have bowel movements for eight days from 08/19/25 through 08/26/25. CNP #561 confirmed the facility did not notify her Resident #88 had not had a bowel movement from 08/19/25 through 08/25/25. CNP #561 indicated it was her expectation facility staff should notify her within three days of a resident not having a bowel movement so that she could give new orders to treat constipation. On 04/16/26 at 2:15 P.M. an interview with CNA #248, who cared for Resident #88 on 08/25/25 revealed the CNA had not realized Resident #88 was constipated on that date and the CNA did not communicate to the nurse Resident #88's last bowel movement was on 08/18/25. On 04/16/26 at 2:24 P.M., an interview with CNA #385, who cared for Resident #88 on 08/24/25 and 08/25/25 revealed the CNA had not realized Resident #88 was constipated on those dates and the CNA did not communicate to the nurse Resident #88's last bowel movement was on 08/18/25. Review of the facility policy titled, Bowel Protocol, revised on 05/01/25, revealed that any resident identified by the licensed nurse as not having a bowel movement at least once in a three-day period would be considered for a laxative intervention as ordered by the physician. 3. Review of a closed medical record revealed that Resident #91 was admitted to the facility on [DATE] and had diagnoses that included chronic diastolic (congestive) heart failure and hypertension. Resident #91 was discharged from the facility on 01/08/26 to the hospital with complaints of chest pain. Review of Resident #91's hospitalization after visit summary dated 12/22/25 revealed that Resident #91 was ordered to start losartan, a medication used to treat high blood pressure (hypertension), 25 milligrams (mg), 1 tablet nightly beginning on 12/23/25. Review of Resident #91's physician orders dated 12/22/25 through 01/08/26 revealed that there was no physician orders transcribed for losartan. Review of Resident #91's Medication Administration Records dated 12/22/25 through 01/08/26 revealed that Resident #91 did not receive the medication losartan as was prescribed on Resident #91's hospital after visit summary dated 12/22/25. Review of Resident #91's nursing progress notes dated 12/22/25 through 01/08/26 were silent for any of the after-visit summary medications to be discontinued on 12/22/25, and silent for documentation on why losartan was not started on 12/23/25 as ordered. Review of Resident #91's care plan dated 12/29/25 revealed that Resident #91 had a cardiac impairment related to congestive heart failure. A long-term goal was that Resident #91 would maintain her daily routine without chest pain through the review dated. An intervention listed was to administer medications as ordered. A phone call to Resident #91's resident representative on 04/08/26 at 2:11 P.M. revealed that Resident #91's hospitalization on 01/08/26 did not result in any cardiac or cardiovascular diagnoses. Resident #91's complaints of chest pain were related to muscular strain and not related to her heart or cardiovascular health. An interview with Regional Nurse Consultant #594 on 04/09/26 at 11:48 A.M. confirmed that losartan was not started for Resident #91 on 12/23/25 and that the admitting nurse did not transcribe Resident #91's physician orders into Resident #91's medical record correctly. Review of the facility policy titled, Telephone Orders, updated on 05/01/25, revealed that the physician orders must be entered into the electronic medical record by the licensed nurse receiving the order. 4. Review of resident electronic medical record revealed that Resident #55 was admitted to the facility on [DATE] and had diagnoses that included cognitive communication deficit, aphasia, dementia, bilateral open-angle glaucoma, bilateral combined forms of age-related cataracts, and vitreous degeneration of right eye. Review of Resident #55's care plan dated 09/21/18 revealed that Resident #55 was at risk for visual function as he has a diagnosis of cataracts. A long-term goal listed was that Resident #55 would not experience negative consequences of vision loss. Approaches listed to help Resident #55 achieve this goal included to administer medications as ordered, and to obtain ophthalmologist consultations as needed. Review of Resident #55's physician orders revealed that Resident #55 was prescribed brimonidine, an ophthalmic solution to lower eye pressure in glaucoma, 1 drop to both eyes twice daily from 11/11/21 through 11/06/24, and latanoprost, an ophthalmic solution prescribed to reduce high pressure inside the eye, 1 drop to both eyes daily from 11/02/23 through 11/06/24. Review of Resident #55's ophthalmology after visit summary dated 09/01/23 revealed that Resident #55 was ordered Brimonidine 0.2% 1 drop in both eyes twice daily, and latanoprost 0.005% 1 drop in both eyes daily at bedtime. Review of Resident #55's physician orders revealed that Resident #55 was ordered brimonidine drops 0.2% 1 drop to both eyes twice a day as needed for glaucoma from 11/06/24 to 11/19/25, and latanoprost 0.005% 1 drop in both eyes once daily as needed for glaucoma. Review of Resident #55's ophthalmology after visit summary dated 05/08/25 revealed that Resident #55 needs to restart brimonidine 0.2% solution left eye three times daily and to right eye twice daily, restart latanoprost 0.005% solution once daily at night in left eye, and continue dorzolamide timolol, an ophthalmic combination medication used to lower eye pressure for conditions such as open-angle glaucoma and ocular hypertension, 1 drop two times daily in both eyes. Review of Resident #55's nursing progress notes for May 2025 do not mention new orders from the ophthalmologist that were communicated via the ophthalmologist after visit summary on 05/08/25. Review of Resident #55's physician orders revealed that the ophthalmologist's orders for brimonidine 0.2% solution left eye three times daily and to right eye twice daily, latanoprost 0.005% solution once daily at night in left eye and dorzolamide timolol 1 drop two times daily in both eyes were not implemented until 11/19/25. Dorzolamide timolol was ordered as one drop to both eyes twice daily starting on 11/19/25. Review of Resident #55's Medication Administration Record for 05/01/25 through 11/19/25 revealed that Resident #55 continued to have as needed orders for brimonidine drops 0.2% 1 drop to both eyes twice a day, as needed, for glaucoma from 11/06/24 to 11/19/25, and latanoprost 0.005% 1 drop in both eyes once daily, as needed, for glaucoma. Brimonidine and latanoprost were not given from 05/01/25 through 11/18/25. Dorzolamide Timolol was not administered until the start date of 11/19/25. Review of Resident #55's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed that Resident #55 had a Brief Interview for Mental Status score of 6, indicative of severe cognitive impairment. An interview with Regional Nurse Consultant #594 on 04/13/26 at 5:19 P.M. confirmed that there was no evidence that the facility implemented the orders in the medical record for scheduled brimonidine, latanoprost, or dorzolamide timolol that were written on 05/08/25 until 11/19/25. 5. Review of the closed record for Resident #93 revealed an admission date of 01/24/26 and diagnoses including cerebral infarction, dysphagia (difficulty swallowing), diabetes, morbid obesity, asthma, lupus erythematosus, bipolar disorder, hypertension, and pain in thoracic spine. She was admitted from the hospital after treatment for a urinary tract infection, sepsis, and cerebral infarction. Review of a Minimum Data Set assessment completed 01/30/26 revealed the resident had short- and long-term memory problems, required substantial/maximal assistance with eating, toileting, dressing, and personal hygiene. She was incontinent of bowel and bladder. Review of nursing progress notes dated 02/02/26 at 2:14 A.M. revealed daughter wanted to know if resident was given Zofran (medication used for nausea), asked previous nurse but resident is still complaining of nausea and stomach pain throughout the day; daughter advised mother has not been eating well last 48 hours; loose stool 48 hours prior; checked electronic medication record and up opened medication; administered medication; vital signs stable resident warm to touch; fell asleep about 45 minutes later. (Review of the medication administration record revealed the Zofran was given on 02/01/26 at 8:24 P.M. by the nurse who wrote the nursing progress note). There was no evidence that the physician or nurse practitioner was notified of the nausea or stomach pain or that the

Based on closed medical record review, hospital record review, facility policy review and interview, the facility failed to follow physician orders for Resident #88's urinary catheter and failed to develop and implement a comprehensive and individualized plan of care for the urinary (indwelling) catheter including consistent monitoring/assessment of urinary output to prevent a significant complication from catheter use. This affected one resident (#88) of three residents reviewed for urinary catheters. The facility census was 57 residents. Actual harm occurred on 08/26/25, when Resident #88, who was cognitively impaired, was noted to have a change in condition, which included blood and pus observed in his urinary catheter bag. Subsequently, Resident #88 was transported to the hospital on [DATE], where he was admitted and diagnosed with sepsis attributed to a mispositioned urinary catheter, which resulted in a blockage. Prior to the incident, on 08/13/25 Resident #88 had returned from an outpatient urology appointment without a urinary catheter present. On 08/18/25, the Certified Nurse Practitioner (CNP), noted Resident #88 had a urinary catheter in place without physician orders. The CNP indicated in the 08/18/25 and 08/20/25 progress note that orders were given to remove the urinary catheter per urology. Staff provided catheter care between 08/14/25 and 08/26/25 but failed to monitor/record the resident's urinary output from the urinary catheter consistently (only two values recorded) during this time. On 08/22/25, an additional physician order was given to remove the urinary catheter, but this order was not completed.Findings include: Review of the closed medical record revealed Resident #88 was admitted to the facility on [DATE]. Resident #88's diagnoses included metabolic encephalopathy, benign prostatic hyperplasia, need for assistance with personal care, and cognitive communication deficit. Review of Resident #88's nursing admission assessment dated [DATE] revealed Resident #88 did not have a urinary catheter present. Resident #88 was assessed as being continent of bladder function. Review of Resident #88's nursing evaluation titled, GG Support Assessment, dated 07/05/25 revealed Resident #88 was assessed as needing partial to moderate (staff) assistance with toileting hygiene and required substantial to maximal (staff) assistance with toileting transfer. Review of Resident #88's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 08, indicative of moderate cognitive impairment. Review of Resident #88's nursing progress note dated 07/09/25 revealed Resident #88's family voiced concern of Resident #88 not voiding much for the prior two days. New orders were obtained to scan the resident's bladder every shift for 48 hours. Review of Resident #88's nursing progress note dated 07/10/25 indicated a bladder scan at 12:00 P.M. revealed 930 milliliters (ml) of urine in the resident's bladder. A nursing progress note on 07/10/25 at 2:14 P.M. revealed Resident #88 refused to be catheterized to relieve the urine in his bladder. The physician was notified and orders were given to send Resident #88 to the hospital. Review of Resident #88's hospital record dated 07/10/25 revealed Resident #88 was diagnosed with urinary retention and a urinary tract infection. Resident #88 was treated with antibiotics, and had a urinary catheter inserted at the hospital, which remained in place at the time of his discharge back to the facility on [DATE]. Review of Resident #88's Treatment Administration Record (TAR) revealed catheter care was provided as ordered from 07/11/25 through 08/13/25. Review of Resident #88's certified nurse practitioner (CNP) visit note dated 08/12/25 and authored by CNP #561 revealed Resident #88 had benign prostatic hyperplasia, he had a urinary catheter in place and was to follow up at an outpatient urology appointment. Review of Resident #88's outpatient urology progress note dated 08/13/25 revealed Resident #88 did not require a urinary catheter. The resident was not retaining urine, as he had only 30 ml of urine in his bladder. As a result, the urologist determined the resident no longer required a urinary catheter and the catheter was removed. The urologist determined that if Resident #88 were to ever go back into urinary retention, a better option would be a suprapubic catheter rather than a urethral catheter. Resident #88 and his family were given education on voiding dysfunction. The plan was made to observe Resident #88 for signs of urinary retention. Review of Resident #88's physician orders revealed that no new physician orders were entered on 08/13/25 relevant to Resident #88's urinary catheter being removed at his urology appointment. Resident #88's physician orders to provide catheter care twice daily remained in place until 08/25/25. Review of the TAR revealed on the evening of 08/13/25, Resident #88 did not receive catheter care. Starting in the day shift of 08/14/25, Licensed Practical Nurse (LPN) Supervisor # 258 documented on the TAR that Resident #88 received catheter care as ordered, despite the catheter not being present after Resident #88's urology appointment. Other licensed nurses who documented they provided catheter care to Resident #88 included Registered Nurse (RN) Supervisor #270, LPN Supervisor #234, and RN Supervisor #412. Review of Resident #88's nurse practitioner visit notes dated 08/18/25 and 08/20/25 authored by CNP #561 revealed Resident #88 was seen at the urologist office on 08/13/25 and his catheter was removed at that time. The note then included somehow his catheter has been reinserted. CNP #561's progress notes on 08/18/25 and 08/20/25 indicated an order was given to remove his catheter. However, record review revealed no physician orders were made on 08/18/25 to remove the resident's urinary catheter. Resident #88's physician orders to provide catheter care twice daily remained in place until 08/25/25. Review of Resident #88's nursing progress notes from 08/12/25 through 08/25/25 revealed they were silent for any mention of problems with Resident #88's urinary catheter or Resident #88 having any difficulty voiding. Review of the physician orders dated 08/22/25 revealed an order for Resident #88 to have his urinary catheter removed per urology and to remove all associated orders. Review of Resident #88's TAR revealed the removal of the resident's urinary catheter was not completed 08/22/25 through 08/26/25. The associated orders for catheter care remained in place on the TAR 08/22/25 through 08/25/25. Review of Resident #88's urinary output from 08/13/25 through 08/26/25 revealed the resident had urinary output recorded on 08/14/25 as 550 ml, and on 08/24/25 as 400 ml. No other urinary output was recorded in Resident #88's medical record between 08/13/25 and 08/26/25. Review of Resident #88's vital sign record revealed on 08/24/25 (no time identified), Resident #88's blood pressure was 125/78 mm/Hg, his oxygen saturation was 98%, and his temperature was 97.4 degrees Fahrenheit (F). On 08/25/25 (no time identified), Resident #88's blood pressure was 128/75 mm/Hg, his oxygen saturation was 98%, and his temperature was 97.4 degrees F. On 08/26/25 (no time identified), Resident #88's blood pressure was 90/50 mm/Hg, and his temperature was 98.3 degrees F. Review of Resident #88's physician orders dated 08/25/25 revealed Resident #88 was to have a bladder scan every eight hours and document amount. Review of Resident #88's TAR dated 08/25/25 revealed a bladder scan was documented as completed on 08/26/25 at 4:11 A.M.Review of Resident #88's nursing progress note dated 08/26/25 at 4:11 A.M. revealed a bladder scan was completed which showed 300 ml of urine in the resident's bladder. Review of Resident #88's nursing progress note dated 08/26/25 at 10:30 A.M. authored by Registered Nurse (RN) #811(this nurse was no longer employed at the facility) revealed staff alerted RN #811 that Resident #88 was non-responsive. Resident #88 was ashen and pale but responded to verbal stimuli. The note included Resident #88 was observed to have beige creamy colored drainage in his urinary catheter bag, and the viscosity was unable to be determined. The resident's oxygen saturation was 86% (low) on room air. Oxygen was applied at four liters per minute via nasal canula and the resident's oxygen saturation increased to 100%. The oxygen was decreased to two liters per minute, and his oxygen saturation was able to be maintained at 96%. The nurse practitioner was notified, and emergency services were called due to signs and symptoms of sepsis. A verbal report was given to the hospital destination. Review of Resident #88's nursing progress note authored by RN Supervisor #412 on 08/26/25 at 10:30 A.M. revealed Resident #88 was sent to the hospital due to decreased level of consciousness, confusion, and pus and blood noted at his penile meatus at the orders of CNP #561. Review of Resident #88's hospital record dated 08/26/25 at 3:29 P.M. revealed Resident #88's blood pressure upon arrival to the hospital was in the 70's to the 90's systolic (hypotensive). Resident #88's creatinine level was 2.31, which was documented to be consistent with acute kidney injury, with Resident #88's baseline creatinine level at 0.8. Resident #88's urinalysis was concerning for a urinary tract infection. A computed tomography (CT) scan of Resident #88's abdomen and pelvis dated 08/26/25 at 12:28 P.M. revealed severe bladder distention with mild resultant hydronephrosis. There was a malpositioned Foley catheter inflated within the membranous urethra that required removal and repositioning. It was determined by the hospital physician Resident #88 needed to be admitted to the hospital due to acute encephalopathy, urinary tract infection, sepsis and acute kidney injury, due to life threatening organ dysfunction. Further review of Resident #88's hospital record dated 08/26/25 at 5:46 P.M. revealed Resident #88 required removal and repositioning of his urinary catheter. The resident was started on sepsis protocol, but despite this, Resident #88 had progressive shock and was admitted to the intensive care unit (ICU). Review of Resident #88's hospital records dated 08/26/25 through 09/05/25 revealed Resident #88 responded to antibiotic therapy and volume resuscitation. It was believed that his bladder outlet obstruction produced his hydronephrosis renal insufficiency, hyperkalemia and sepsis. Resident #88's creatinine level improved to 0.79 on 08/31/25. Resident #88 was subsequently discharged to an alternate extended care facility with hospice services in stable condition. Interviews with RN Supervisor #412 on 04/14/26 at 7:08 P.M., RN Supervisor #270 on 04/15/26 at 3:51 P.M., LPN Supervisor #234 on 04/16/25 at 8:52 A.M., and LPN Supervisor #258 on 04/16/25 at 8:49 A.M. revealed Resident #88 had a urinary catheter in place during the entire time they had provided care for Resident #88. The interviews revealed staff denied awareness of any (physician) orders to remove Resident #88's urinary catheter per the urologist's orders. The staff interviewed denied knowledge of any complications related to Resident #88's urinary catheter, stated they did not have knowledge of any monitoring concerns of Resident #88's urinary catheter output, they did not reinsert Resident #88's urinary catheter, nor did they obtain orders to reinsert Resident #88's catheter. An interview with Regional Nurse Consultant #594 on 04/15/26 at 3:45 P.M. revealed the facility did not have the urologist after visit summary orders for 08/13/25 available for review, the nurses never discontinued the physician orders for the catheter care on 08/13/25, that there were no progress notes indicating that nursing was aware of the orders to discontinue the urinary catheter on 08/13/25, and that there was no indication that Resident #88 had physician orders to reinsert the urinary catheter after the 08/13/25 catheter removal.An interview with Certified Nurse Practitioner (CNP) #561 on 04/15/26 at 4:07 P.M. revealed on 08/19/25, CNP #561 had reviewed Resident #88's urologist after visit summary (from the 08/13/25 visit) and CNP #561 had learned Resident #88 had passed a voiding trial in the urologist office, and therefore, Resident #88's urinary catheter had been removed. On 08/18/25, CNP #561 had observed Resident #88 had a urinary catheter in place, but she was unaware of any orders to reinsert Resident #88's urinary catheter. CNP #561 noted the facility had physician orders to remove the urinary catheter. CNP #561 revealed she reviewed the call logs to the physician office and no phone calls were made from the facility from 08/13/25 to 08/18/25 regarding obtaining any orders to reinsert Resident #88's urinary catheter. CNP #561 revealed she had brought this issue (date not provided) to the facility's attention. CNP #561 revealed staff turnover at the facility had been high, and miscommunication and subsequent care errors were a concern in August 2025. A follow up interview with Nurse Practitioner #561 on 04/15/26 at 5:22 P.M. revealed sepsis symptoms could become apparent within 24 to 48 hours, but that monitoring vital signs and urinary output was the best indicator for monitoring catheter concerns and infection concerns for residents with cognitive impairments. A follow up interview with Regional Nurse Consultant #594 on 04/15/26 at 5:33 P.M. confirmed there was not consistent monitoring of the urinary catheter output for Resident #88 from 08/13/25 through 08/26/25, there was not a comprehensive assessment of the need of Resident #88's need to reinsert a urinary catheter, that there was not evidence in the medical record why Resident #88 required a bladder scan on 08/25/25, and that the physician order for the removal of Resident #88's urinary catheter on 08/22/25 was not completed as ordered. An interview with Certified Nursing Assistant (CNA) #375 on 04/16/26 at 2:00 P.M. revealed on 08/14/25, CNA #375 was the CNA who provided care for Resident #88. CNA #375 stated that she was not certain, but stated she thought it was possible the nurse on duty 08/14/25 saw that Resident #88's urinary catheter was not in place and assumed that Resident #88 had pulled it out. CNA #375 vaguely recalled the possibility the nurse who worked on 08/14/25 with CNA #375 was the nurse who reinserted Resident #88's urinary catheter on that date. Record review revealed the nurse who had provided care for Resident #88 while CNA #375 was working on 08/14/25 was LPN Supervisor #258. However, during the onsite survey investigation, interview with this LPN denied reinserting Resident #88's urinary catheter after the resident returned from the urologist appointment on 08/13/25 without a urinary catheter in place. An interview with CNA #385 on 04/16/25 at 2:22 P.M. revealed the CNA recalled Resident #88 had a urinary catheter in place the entire time he/she provided care to him (which was on 08/16/25 and 08/17/25). Review of the facility policy titled, Telephone Orders, updated on 05/01/25, revealed it was the facility policy to accept verbal orders in person or via telephone from a provider to promote the continuity of the resident's care. Orders may be reduced to writing or entering into the electronic medical record by the person receiving the order. Review of the facility policy titled, Urinary Catheter Care, updated on 05/09/25, revealed the urine volume in the drainage bag should be observed. If there was a significant increase or decrease in volume during the shift, it should be reported to the nurse. The urine in the drainage bag should be monitored for abnormal appearance, and abnormal findings should be reported to the nurse. An accurate record of the residents' daily output should be maintained. This deficiency represents non-compliance investigated under Complaint Number 2707299 and Complaint Number 2603202.

Based on record review, review of the facility assessment, review of the Administrator Job Description, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This affected 21 residents (#39, #23, #84, #54, #4, #71, #78, #88, #31, #55, #91, #93, #6, #9, #12, #61, #85, #87, #83, #81, #86) and had the potential to affect all 57 residents residing in the facility.Findings include:1.During the course of the annual and complaint survey conducted from 04/06/26 to 04/21/26, the survey team requested information from the facility regarding the administration and leadership changes of the facility.Review of information provided to the survey team on 04/09/26 at 3:46 P.M. revealed the facility had five changes in Administrator since 06/08/23: 06/08/23 to 10/18/24 Administrator #60110/08/24 to 11/10/24 Administrator #60211/11/24 to 11/29/24 Administrator #60312/04/24 to 11/13/25 Administrator #60411/13/25 to 01/26/26 Administrator #60501/27/26 to current date (04/09/26) Current AdministratorNo additional information was provided by the Current Administrator during the survey to support the facility was being administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The information provided to the survey team further revealed there had been seven changes in Director of Nursing (DON) since 06/13/25: 03/20/18 to 06/13/25 DON #60106/24/25 to 07/21/25 DON #60208/25/25 to 09/09/25 Agency DON #60309/10/25 to 09/30/25 Agency DON #60409/30/25 to 01/09/26 DON #60501/09/26 to 03/01/25 Agency DON #60603/02/26 to 03/27/26 Agency DON #60703/05/26 to current date (04/09/26) Current DONNo additional information was provided by the Current DON during the survey to support the facility was being administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. a.The facility failed to have systems in place and administrative oversight to ensure sufficient direct care nursing staff was in place and available to meet the needs of the residents. See findings at F725. Review of the Resident Council Meeting minutes from meetings conducted on 08/20/25, 09/17/25, 10/01/25, 02/18/26 and 03/18/26 all included resident concerns with call light response time, availability of CNA staff for showers, or CNAs being on their phones (rather than helping residents).Review of the Facility Assessment document dated 07/18/25 revealed 27.9% of the residents were determined to be clinically complex. The assessment noted the facility provided all care and services as required in the requirements of participation including but not limited to assistance with activities of daily living (ADL) care, personal care services, medication administration/management, pain management, infection prevention and control, nutrition services, fall and injury prevention, pharmacy, therapy services, etc.Review of the facility Staffing Assessment revealed it was not specific to the number of staff that would be on duty or required to be on duty to meet the total care needs of the residents admitted and/or retained by the facility.b.The following resident and family concerns were voiced during the survey related to facility staffing: Interview with Resident #39 on 04/06/26 at 1:14 P.M. revealed concerns the facility was understaffed. Resident #39 revealed there was often only one nurse aide (CNA) on staff at night for two halls, and that call lights could take over thirty minutes to answer.Interview with Resident #23 on 04/06/26 at 2:05 P.M. revealed concerns the facility was short staffed on the weekend (with an example of dressings/wound care not done on weekend). He stated you have to wait longer at night for the call light to be answered. The resident shared he had waited five hours (date not provided) for his call light to be answered. During observation of a treatment for Resident #23 on 04/07/26 at 9:00 A.M. with Assistant Director of Nursing (ADON) #381, the resident asked if a particular staff person was working as this staff person transferred him with the mechanical lift by herself (which was attributed to a lack of staff).Interview with Resident #84's family member on 04/06/26 at 2:10 P.M. revealed when she came in on Saturday (04/04/26) Resident #84 was lying on the mattress with no sheet and covered with only a sheet and had a pillow. The family member voiced concerns there had been no staff to come in to turn and reposition the resident or get her up.Interview with Resident #54 on 04/06/26 at 3:16 P.M. revealed the resident voiced concerns she didn't feel like there was enough staff, it routinely takes staff a long time to answer her call light.Interview with Resident #4 on 04/06/26 at 4:12 P.M. revealed concerns there were not enough staff, it takes staff a long time to answer the call light. Interview with Resident #71 on 04/07/26 at 8:57 A.M. revealed a concern there was not enough staff especially on afternoons. On Sunday (referring to 04/05/26) it took one to two hours for staff to respond to her call light.Confidential interviews with residents in a special resident council meeting held on 04/08/26 revealed the residents present continued to have concerns regarding staff response to resident needs. One resident said she would see a resident sliding out of their chair and would try to help them since no staff were around. She said she was scolded for helping by a staff member but she didn't know why because she felt if she didn't help the other resident would have fallen. Another resident in the meeting noted she kept her own calendar of when she was helped with showers because she said staff weren't following the shower schedule due to a lack of staff.c. The following staff concerns were lodged during the survey related to facility staffing: Interview with LPN Supervisor #335 on 04/07/26 at 7:50 A.M. revealed sometimes there was only one aide for the 200 hall on dayshift (currently 17 residents on 200 hall). She confirmed there were residents on this hall (including Resident #23) who required being transferred with a mechanical lift. She stated that sometimes the CNA does the mechanical lift by herself. She stated she knows there were to be two staff for a mechanical lift. Interview with CNA #222 on 04/08/26 at 5:38 A.M. revealed on night shift, there were often two to three CNAs on shift in the building. CNA #222 revealed that due to this he could only provide incontinence care three times, turning and repositioning of dependent residents three times, and checks on residents three times during a 12 hour shift. CNA #222 revealed that if a CNA called off with short notice, the CNAs and nurses work short-staffed. CNA #222 revealed at times, if there was not enough staff available, only one person assists residents who are dependent for transfers with a mechanical lift.Interview with LPN Supervisor #258 on 04/09/26 at 8:05 A.M. revealed she heard CNA staff identify they do mechanical lifts with only one staff. She stated that she knew there were supposed to be two staff for a mechanical lift. She stated there were at least three residents on 200 hall who required a mechanical lift for transfers. She stated sometimes there was only one aide for the 200 hall on dayshift. She stated when this happened, they were unable to complete showers, turn and reposition residents every two hours, complete incontinence care every two hours, and residents had to wait longer for their call lights to be answered. Interview with CNA #385 on 04/09/26 at 11:20 A.M. revealed he worked dayshift and worked frequently on the 200 hall. He stated if there are call offs of staff, there was sometimes only one CNA on the 200 hall. He stated if there was only one CNA, the CNA was not able to do incontinence care every two hours and it makes it hard to answer call lights timely. Interview with CNA #323 on 04/13/26 at 8:57 A.M. revealed that until recently, the administration expected staff to work short when there were call offs. Some improvement had been noted with the current DON. However, until the new DON took her position (03/05/2026), there were not enough staff members to transfer dependent residents who required a mechanical lift safely with two staff members. During an interview on 04/15/26 at 5:25 P.M , Certified Nurse Practitioner (CNP) #561 shared her provider group had multiple meetings with the management company for the facility regarding the provider group's concerns for resident care. She attributed some of the facility's challenges to staffing turnover. During the onsite survey, no additional information was provided by facility administrative staff to support the concerns from the provider group had been addressed and/or resolved.2. As a result of the lack of consistent and necessary administrative oversight and due to the increased frequency of administrative changes, the following concerns were identified. The facility's inaction caused serious harm and had the likelihood of causing serious harm or injury to all residents.a. The facility failed to ensure effective systems and administrative oversight were in place to timely identify and seek necessary medical intervention following an acute change in condition for Resident #78.On 03/12/26 at 12:34 P.M., Resident #78 was noted to have lethargy (a reduced level of consciousness), and elevated blood glucose of 522 milligrams per deciliter (mg/dL, normal results 70-99 mg/dL). The resident's blood sugar was not re-checked for four hours and remained elevated at 353 mg/dL when it was rechecked. The resident continued with limited food and fluid intake and lethargy. On 03/13/26 at approximately 8:30 A.M. Resident #78 became unresponsive and could not be awakened by a sternal rub. The nurse notified Certified Nurse Practitioner, (CNP) #561 and the resident was transferred and admitted to the intensive care unit of the hospital with diagnoses of severe sepsis with septic shock, acute encephalopathy, multifactorial in the setting of hypernatremia and sepsis, acute kidney injury, hyperglycemia, urinary tract infection, hypernatremia. The resident remained in the hospital until 03/25/2026 and returned to the facility with hospice services. The resident passed away at the facility on 04/14/26. See findings under F684.b. On 08/21/25 the facility failed to have systems and administrative oversight in place to ensure staff took action when Resident #88, who was cognitively impaired and required substantial to maximal assistance with toileting hygiene and was assessed as being incontinent, had not had a bowel movement documented in three days. There was no evidence Resident #88 had a bowel movement from 08/19/25 until 08/26/25. On 08/26/25, Resident #88 was discharged to the hospital due to a change in his condition. At the hospital on [DATE], Resident #88 received a computed tomography (CT) scan of his abdomen, which revealed a moderately stool-distended rectal vault with findings that he was developing stercoral colitis, a rare but serious inflammation of the colon caused by fecal impaction, which could lead to life-threatening complications if untreated. The resident received treatment and services of disimpaction while in the hospital for 11 days. See findings under F684. In addition, the facility failed to have systems and administrative oversight in place to ensure physician orders were followed for Resident #88 related to the resident's urinary status and urinary catheter. The facility failed to develop and implement a comprehensive and individualized plan of care for the urinary (indwelling) catheter including consistent monitoring/assessment of urinary output to prevent a significant complication from catheter use. See findings under F690. c. The facility failed to have systems in place and administrative oversight to ensure treatments were provided in management of congestive heart failure (CHF), vascular wounds, change in condition related to urinary tract infections, and glaucoma for Residents #23, #31, #55, #78, #88, #91 and #93) of 36 residents reviewed for quality of care and treatment See findings under F684. d. The facility failed to have systems in place and administrative oversight to ensure residents (#6, #9, #12, #61, #85, #87, and #93) who were unable to carry out activities of daily living received the necessary care and services to maintain good nutrition, grooming, and personal hygiene including assistance with eating, nail care, and bathing/showering. See findings under F677.e. The facility failed to have systems in place and administrative oversight to ensure Resident #83, with a pressure ulcer received the necessary care and treatment as ordered to promote healing, prevent infection, and prevent new ulcers from developing. See findings under F686. f. The facility failed to have systems in place and administrative oversight to ensure accurate and timely monitoring of Resident #93's weight, resulting in an undetected and unevaluated significant weight loss. See findings under F692.g. The facility failed to have systems in place and administrative oversight to ensure an infection prevention and control program was in place that provided a safe and sanitary environment that helped to prevent the development and transmission of communicable diseases and infections for Residents #31, #81, #83, #84, and #86. See findings under F880. Review of the job description for a Licensed Nursing Home Administrator dated 12/01/2012 revealed the position supported the development, implementation and monitoring of recruitment and retention plans which lowers turnover. The job description also included the position supported the development of a strong management team among department leaders and supervisory personnel to effectively meet or exceed employee and customer needs.This deficiency demonstrates noncompliance investigated under Complaint Numbers 2603202, 2656395, 2724269, 2723137.

Based on resident interviews, staff interview, record review and facility policy review, the facility failed to promptly respond to resident and family concerns brought up by residents in resident council meetings. This had potential to affect all 57 residents at the facility. The facility census was 57. Findings include:Review of the resident council meeting minutes from August 2025 to March 2025 revealed attendance ranged from six to eleven residents. The minutes noted the following concerns:On 08/20/25 Aides are taking too long to answer call lights. Aides are busy on their phones and/or talking to one another. Aides are not taking food orders and they just drop off the food.On 09/17/25 Call lights and water pass are still a problem mainly on the weekends.On 10/15/25 Residents are concerned with their showers as well as aides being on their cell phones.On 02/18/26 Residents are concerned with not getting showers, beds not being changed. Aids are still not answering call lights, sitting at nurses desk, being on their phones, leaving food trays sit at nurses desk for long periods of time. Aids are still not passing water often enough.On 03/18/26 Some aides are still on their phones and sitting at the nurses desk while call lights are going off.Further review of the resident council meeting minute notes for 08/20/25, 09/17/25, 10/15/25 02/18/26 and 03/18/26 revealed no indication that there was a response from administration regarding the resident concerns expressed during Resident Council meetings.During a Resident Council Meeting held on 04/08/26 from 10:00 A.M. to 11:00 A.M. with five residents present, revealed the residents felt no one in administration acted on concerns raised in Resident Council meetings. They shared that they believed the Activities Coordinator #367 passed on their concerns to management, however, they had not ever received responses to the issues they brought up. Residents in the meeting confirmed they felt that aides being on their phones, call light response times and availability of aides for showers were still issues of concern. Three of the residents made general statements about how they had noticed other residents that appeared to be declining and they felt that the facility took too long to send people to the hospital when there was a change in condition. One resident in the meeting said she was planning on moving to another facility because she was tired of having to ask for assistance over and over. The Resident Council President (Resident #48) said he was fortunate that his daughter was a strong advocate for him when he had concerns that weren't addressed.During an interview on 04/08/26 at 2:13 P.M., Activities Coordinator #367 revealed she submitted the resident council meeting minutes to the administrator every month and would get the form back from the administrator unsigned with no notes or verbal response to the concerns. She revealed the previous administrator had accused her of writing down her own concerns rather than the concerns of the residents.During an interview on 04/08/26 at 2:56 P.M. the Administrator confirmed she was unable to find documentation of previous management follow up to concerns expressed in resident council. She revealed she did not have any documentation of her own response to resident council concerns either.Review of resident council policy titled, Resident Council, dated 05/01/25 revealed the activity director will communicate any areas of concerns to the appropriate department head who will provide timely resolution and follow up regarding the concern.This deficiency represents non-compliance investigated under Complaint Number 2724269.

Based on observations, resident, family, and staff interviews, nurse practitioner interview, record review, review of resident council meeting minutes, and review of the facility assessment, the facility failed to have sufficient nursing staff to meet the needs of the residents. This affected nine residents (#39, #23, #84, #54, #4, #71, #31, #93, and #88) with the potential to affect all 57 residents residing in the facility. Findings include: 1.On 04/06/26 at 8:00 A.M., the survey team entered the facility for the annual recertification and complaint survey. There were one (1) medication tech, one (1) registered nurse (RN), three (3) licensed practical nurses (LPNs), and five (5) certified nurse aides (CNAs) to provide care for 57 residents currently residing in the facility. Review of the list of Directors of Nursing in the past year revealed that the current DON was hired on 03/05/26. Review of the Resident council meeting minutes from meetings on 08/20/25, 09/17/25, 10/01/25, 02/18/26 and 03/18/26 all identified concerns with call light response time, availability of aides for showers, or aides on their phones (rather than helping residents) and staff hiding from completing the work. Review of the Facility Assessment document dated 07/18/25 revealed 27.9% of the residents were determined to be clinically complex. The Assessment noted that the facility provided all care and services as required in the requirements of participation including but not limited to assistance with ADLs, personal care services, medication administration/management, pain management, infection prevention and control, nutrition services, fall and injury prevention, pharmacy, therapy services, etc. Review of the facility Staffing Assessment revealed it was not specific to the number of staff that would be on duty. During an interview on 04/15/26 at 5:25 P.M , Certified Nurse Practitioner (CNP) #561 said her provider group had multiple meetings with the management company for the facility regarding the provider group's concerns for resident care. She attributed some of the facility's challenges to staffing turnover. Review of the job description for a Licensed Nursing Home Administrator dated 12/01/2012 revealed this position supports the development, implementation and monitoring of recruitment and retention plans which lowers turnover. Supports the development of a strong management team among department leaders and supervisory personnel to effectively meet or exceed employee and customer needs. 2. The following resident and family concerns were lodged during the survey related to facility staffing: a. Interview of Resident #39 on 04/06/26 at 1:14 P.M. revealed that the facility is understaffed. Resident #39 revealed that there is often only one nurse aide on staff at night for two halls, and that call lights can take over thirty minutes to answer. b. Interview with Resident #23 on 04/06/26 at 2:05 P.M. (resides on 200 hall) revealed the facility is short staffed on the weekend (dressings not done on weekend). He stated you have to wait longer at night for the call light to be answered. He stated he had waited five hours one time for his call light to be answered. During observation of a treatment for Resident #23 on 04/07/26 at 9:00 A.M. with the Assistant Director of Nursing (ADON) #381. The resident asked if a particular staff person was working as this staff person transferred him with the mechanical lift by herself. c. Interview with Resident #84's family member on 04/06/26 at 2:10 P.M. revealed when she came in on Saturday (04/04/26) Resident #84 was lying on the mattress with no sheet and covered with only a sheet and had a pillow. They have never come in to turn and reposition the resident or get her up. d. Interview of Resident #54 on 04/06/26 at 3:16 P.M. revealed she doesn't feel like there is enough staff, it takes them a long time to answer her call light. e. Interview of Resident #4 on 04/06/26 at 4:12 P.M. revealed there is not enough staff, it takes them a long time to answer the call light. f. Interview of Resident #71 on 04/07/26 at 8:57 A.M. revealed they don't have enough staff especially on afternoons. On Sunday (referring to 04/05/26) it took one to two hours for them to respond to her call light. g. Confidential interviews with residents in a special resident council meeting held on 04/08/26 revealed the residents present continued to have concerns regarding staff response to resident needs. One resident said she would see a resident sliding out of their chair and would try to help them since no staff was around. She said she was scolded for helping by a staff member but she didn't know why because she felt if she didn't help the other resident would have fallen. Another resident in the meeting noted she kept her own calendar of when she was helped with showers because she said they weren't following the shower schedule. 3. The following staff concerns were lodged during the survey related to facility staffing: a. Interview with LPN Supervisor #335 on 04/07/26 at 7:50 A.M. revealed sometimes there is only one aide for the 200 hall on dayshift (currently 17 residents on 200 hall). She confirmed there are residents on that hall who require being transferred with a mechanical lift. She stated that sometimes the aide does the mechanical lift by herself. She stated she knows that there are to be two staff for a mechanical lift. b. Interview with CNA #222 on 04/08/26 at 5:38 A.M. revealed that on night shift, there are often two to three nurse aides on shift in the building. CNA #222 revealed that he provides incontinence care three times, turns and repositions dependent residents three times, and checks on residents three times in a twelve-hour shift. CNA #222 revealed that if an aide calls off with short notice, the aides and nurses may have to work short-staffed. CNA #222 revealed that at times, if there is not enough staff available, only one person assists residents who are dependent for transfers with a mechanical lift. c. Interview with LPN Supervisor #258 on 04/09/26 at 8:05 A.M. revealed she heard aides identify that they do mechanical lifts with only one staff. She stated that she knew there were supposed to be two staff for a mechanical lift. She stated there are at least three residents on 200 hall who require a mechanical lift: Residents #23, #27, and #82. She stated sometimes there is only one aide for the 200 hall on dayshift. She stated when this happens, they are unable to complete showers, turn and reposition residents every two hours, complete incontinence care every two hours, and residents have to wait longer for their call lights to be answered. d. Interview with CNA #385 on 04/09/26 at 11:20 A.M. revealed he works dayshift and works frequently on 200 hall. He stated if there are call offs of staff, there is sometimes only one aide on the 200 hall. He stated there are usually 2-3 aides on 200 hall. He stated if there is only one aide, they are not able to do incontinence care every two hours and it makes it hard to answer call lights timely. e. Interview with CNA #323 on 04/13/26 at 8:57 A.M. revealed that until recently, the facility was expected to work short when there were call offs; however, now that there is a new DON, the staffing has improved. Until the new DON took her position, there were not enough staff members to transfer dependent residents who required a mechanical lift safely with two staff members. 4. During the onsite survey concerns were identified residents were not provided with routine showers/baths, treatments to skin impairment, and safe transfers using a mechanical lift. These concerns were correlated to a lack of staff as noted per the interviews above. a. Review of the record for Resident #23 revealed an admission date of 01/24/26 and diagnoses including morbid obesity, diabetes, heart failure, status post severe sepsis with septic shock and sudden cardiac arrest. Review of a Minimum Data Assessment completed 01/30/26 revealed a Brief Interview for Mental Status (BIMS) score of 11 (moderately impaired cognition). It further stated the resident was dependent upon staff for bed mobility. Review of a history and physical by the physician on 03/06/26 revealed that the resident had peripheral vascular disease with chronic bilateral lower extremity wounds. The note stated the wound team was to follow. However, review of wound consultant notes for 03/10/26, 03/17/26, 03/31/26, and 04/07/26 revealed the lower legs were not addressed. Review of physician's orders revealed orders dated 03/06/26 to cleanse left and right leg with wound cleanser, apply Xeroform, pad ankles and weeping areas with ABD pads, wrap with kerlix and ace wraps daily (on dayshift). Observations on 04/06/26 at 9:50 A.M. revealed Resident #23 to be in bed. The dressings on his right and left legs were dated 04/02/26 (4 days prior). Interview with Assistant Director of Nursing #381 on 04/06/26 at 9:52 A.M. confirmed the dressings on Resident #23's legs were dated 04/02/26. She verified the dressings were ordered to be changed daily. Review of the April 2026 treatment administration record for Resident #23 revealed the treatments to the left and right leg were not documented as completed on 04/03/26. On 04/04/26 (Saturday) and 04/05/26 (Sunday) the treatments to the left and right leg were documented as completed by LPN Supervisor #258. Interview with LPN Supervisor #335 on 04/07/26 at 7:50 A.M. confirmed she worked dayshift on 04/03/26. She confirmed she did not do the treatments to Resident #23's legs that day as ordered. She stated that the 200 hall has a heavy load of treatments and she was too busy to get the treatments done for the resident. She stated that sometimes there is only one nurse for the 100 (currently 24 residents) and 200 (currently 17 residents) halls and it makes it difficult to get all the treatments and medications done. Interview with LPN Supervisor #258 on 04/09/26 at 8:05 A.M. confirmed that she documented that Resident #23's leg treatments were completed on 04/04/26 and 04/05/26 when they were not. She stated she was unable to do the treatments on one of the days because there was an admission of another resident. She stated it is difficult to get all the treatments done on the 200 hall. She stated there have been times when there are call offs of staff and she has had to work two halls at the same time (200 and 300 hall). 200 hall currently had 17 residents and 300 hall currently had 16 residents. She stated that she normally signs off that all of the treatments are done before she does rounds. Then if she does not get the work done, she would normally go back and document that it was not completed. She stated that she did not go back and indicate the treatments were not done for Resident #23's legs. In addition, review of the treatment administration record for March 2026 revealed there were five times that the left leg treatment was not documented as done and four times that the right leg treatment was not documented as done. b. Review of the medical record for Resident #31 revealed an admission date of 12/4/25 and diagnoses including Parkinson's disease, bipolar disorder, diabetes, heart failure, atrial fib, cardiac murmur, and hypertension. Review of a Minimum Data Set assessment completed 02/03/26 indicated a BIMS score of 15 (intact cognition). It documented the resident was incontinent of bowel and bladder and dependent upon staff for toileting and transfers. Interview with Resident #31 on 04/06/26 at 1:18 P.M. (resides on 200 hall) revealed he sometimes has to wait 2-4 hours to have his call light answered. He stated he mostly puts it on to get changed. He stated he has to lay for long periods of time while wet from urine. He also stated he likes to get up around 9:30 A.M. He stated they don't get him up until around 11:00 A.M. He stated the aides say it is because they don't have enough help. He stated he requires the use of a mechanical lift to get up. Review of the facility policy titled Hoyer Lift dated 05/01/25 revealed guidelines included having two staff members present when using the lift. One to operate the lift and the other to guide the resident in the sling. c. Review of the closed record for Resident #93 revealed an admission date of 01/24/26 and diagnoses including cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, and osteoarthritis. (Resided on the 200 Hall). Review of a Minimum Data Set assessment completed 01/30/26 revealed the resident had short- and long-term memory problems. The resident required substantial/maximum assistance with personal hygiene and was dependent upon staff for showers. The resident was always incontinent of bowel and bladder. Review of the plan of care dated 02/03/26 revealed an intervention to provide assistance as needed with activities of daily living. Review of point of care history and shower records revealed between 01/24/26 and 02/10/26 the resident received one bed bath on 01/28/26 and one shower on 02/09/26. (bathed twice in 18 days). Interview with Regional Nurse Consultant #594 on 04/15/26 at 7:39 A.M. revealed residents are to be bathed twice weekly and Resident #93 had not been bathed twice in 18 days. Interview with Regional Nurse #583 on 04/15/26 at 10:15 A.M. confirmed there was no evidence of any further showers/baths for Resident #93. d. Review of medical record revealed that Resident #88 was admitted to the facility on [DATE]. Resident #88's diagnoses included metabolic encephalopathy, benign prostatic hyperplasia, need for assistance with personal care, and cognitive communication deficit. Review of Resident #88's nursing evaluation titled, GG Support Assessment, dated 07/05/25 revealed that Resident #88 was assessed as needing partial to moderate assistance with toileting hygiene and required substantial to maximal assistance with toileting transfer. Review of Resident #88's hospital record dated 07/10/25 revealed that Resident #88 was diagnosed with urinary retention and a urinary tract infection. Resident #88 was treated with antibiotics, and had a urinary catheter inserted at the hospital, which remained in place at the time of his discharge back to the facility on [DATE]. Review of Resident #88's Treatment Administration Record (TAR) revealed that Resident #88's catheter care was provided as ordered from 07/11/25 through 08/13/25. Review of Resident #88's nurse practitioner visit notes dated 08/12/25 and authored by CNP #561 revealed that Resident #88 had benign prostatic hyperplasia and that he had a urinary catheter in place and was to follow up at an outpatient urology appointment. Review of Resident #88's outpatient urology progress notes dated 08/13/25 revealed that Resident #88 did not require a urinary catheter. He was not retaining urine, as he had only 30 ml of urine in his bladder. As a result, the urologist determined that he no longer required a urinary catheter. The urologist determined that if Resident #88 were to ever go back into urinary retention, a better option would be a suprapubic catheter rather than a urethral catheter. Resident #88 and his family were given education on voiding dysfunction. The plan was made to observe Resident #88 for signs of urinary retention. Review of Resident #88's physician orders revealed that no new physician orders were entered on 08/13/25 relevant to Resident #88's urinary catheter being removed. Resident #88's physician orders to provide catheter care twice daily remained in place until 08/25/25. Review of Resident #88's TAR revealed that on the evening of 08/13/25, Resident #88 did not receive catheter care. Starting in the day shift of 08/14/25, Licensed Practical Nurse (LPN) Supervisor # 258 signed off on the TAR that Resident #88 received catheter care as ordered, despite the catheter not being present after Resident #88's urology appointment. Other licensed nurses that provided catheter care to Resident #88 included Registered Nurse (RN) Supervisor #270, LPN Supervisor #234, and RN Supervisor #412. Review of Resident #88's nursing progress notes dated 08/12/25 through 08/19/25 were silent for any record of Resident #88 going to his urology appointment, Resident #88's catheter being removed on 08/13/25, or discontinuing Resident #88's orders for catheter care twice daily. Review of Resident #88's nurse practitioner visit notes dated 08/18/25 and 08/20/25, authored by CNP #561, revealed that Resident #88 was seen at the urologist office on 08/13/25 and his catheter was removed at that time. Somehow his catheter has been reinserted. CNP #561's progress notes on 08/18/25 and 08/20/25 indicated that an order was given to remove his catheter. Review of Resident #88's physician orders dated 08/22/25 revealed that Resident #88 was to have his urinary catheter removed per urology and to remove all associated orders. Review of Resident #88's TAR revealed that the removal of his urinary catheter was not completed 08/22/25 through 08/26/25. The associated orders for catheter care remained in place on the TAR 08/22/25 through 08/25/25. Review of Resident #88's nursing progress notes authored by RN Supervisor #412 on 08/26/25 at 10:30 A.M. revealed that Resident #88 was sent to the hospital due to decreased level of consciousness, confusion, and pus and blood noted at his penile meatus at the orders of CNP #561. Interviews with RN Supervisor #412 on 04/14/26 at 7:08 P.M., RN Supervisor #270 on 04/15/26 at 3:51 P.M., LPN Supervisor #234 on 04/16/25 at 8:52 A.M., and LPN Supervisor #258 on 04/16/25 at 8:49 A.M. revealed that Resident #88 had a urinary catheter in place during the entire time that they had provided care for Resident #88. The interviews revealed that they were unaware with any orders to remove Resident #88's urinary catheter per the urologist's orders, they did not have knowledge of any complications related to Resident #88's urinary catheter, they did not have knowledge of any monitoring concerns of Resident #88's urinary catheter output, they did not reinsert Resident #88's urinary catheter, and they did not obtain orders to reinsert Resident #88's catheter. An interview with Certified Nurse Practitioner (CNP) #561 on 04/15/26 at 4:07 P.M. revealed that the staff turnover at the facility had been high, and miscommunication and subsequent care errors were a concern in August of 2025. This deficiency represents non-compliance investigated under Master Complaint Number 2744632 and Complaint Numbers 2723137, 2705832, and 2603202.

Based on observations, record review, staff interview and policy review, the facility failed to maintain an infection prevention and control program that provided a safe and sanitary environment that helped to prevent the development and transmission of communicable diseases and infections. This affected five (Residents #31, #81, #83, #84, and #86) 37 sampled residents sampled in the course of the survey. The facility census was 57. Findings include:1. Review of the record for Resident #83 revealed an admission date of 04/05/26 with diagnoses including acute and subacute infective endocarditis (infection of the heart's inner lining). The admission nursing note stated Resident #83 was admitted on [DATE] at 12:10 P.M. from the hospital with a peripherally inserted central line (PICC) and was going to be on intravenous (IV) antibiotics until 05/07/26. Review of hospital records revealed Resident #83 was diagnosed with Clostridioides difficile (C. diff), a bacterium causing severe diarrhea, fever, and colon inflammation often triggered by antibiotic use on 04/02/26. He was placed on Contact plus precautions in the hospital on [DATE]. Contact plus precautions are enhanced infection control measures used, alongside standard precautions, to prevent the spread of highly contagious pathogens, particularly C. diff. He was started on antibiotic treatment for the C. diff on 04/02/26 which was to conclude on 04/15/26. Review of the point of care history in Resident #83's record revealed he was incontinent of bowel on 04/05/26 at 1:28 P.M. and 5:44 P.M. and on 04/06/26 at 1:45 A.M. and 4:09 P.M. During the initial tour of the facility on 04/06/26 at approximately 10:00 A.M., no signage for contact precautions was observed outside Resident #83's room. Record review revealed that a physician's order was obtained and started for contact precautions on 04/06/26 (the day after admission to the facility). Interview with Regional Nurse Consultant #594 on 04/08/26 at 10:50 A.M. confirmed Resident #83 was not placed on contact precautions until 04/06/26. She confirmed he should have been placed on contact precautions on admission on [DATE]. Observations on 04/06/26 at 2:47 P.M. revealed Certified Nursing Assistant (CNA) #420 entered Resident #83's room. She did not apply a gown when entering the room (gloves only). There was a sign outside the room indicating contact precautions and indicating that staff were to wear a gown and gloves when entering the room. She remained in the room for approximately five minutes. When she exited the room, she stated that, while in the room, she fixed his feet, raised the bed, moved his bedside table, and removed juice glasses from his room (she was observed to have two glasses in her hands). She confirmed she did not wear a gown into the room to provide care. She stated he was new and she did not know he was on contact precautions even though there was a sign outside the door indicating contact precautions. Interview with Regional Nurse Consultant #594 on 04/08/26 at 10:50 A.M. confirmed staff were to wear a gown when entering Resident #83's room. Review of the facility policy titled Isolation-Categories of Transmission-Based Precautions updated 07/01/25 revealed in addition to standard precautions, implement contact precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Examples of infections requiring contact precautions include diarrhea associated with C. diff. The policy stated to wear a gown when entering the resident's room and remove the gown before leaving the resident's environment. After removing the gown, do not allow clothing to contact potentially contaminated surfaces. Signs will be used to alert staff of the implementation of contact precautions. Place a sign on the door or outside the resident's room to inform visitors of appropriate personal protective equipment to wear prior to entering the resident's room. 2. Review of the record for Resident #31 revealed a nursing note on 04/14/26 at 7:12 A.M. which stated physician's orders had been obtained to complete a chest x-ray and swab for influenza and respiratory syncytial virus (RSV). The note stated the resident would be placed on droplet precautions until the test results were obtained. A physician's order was obtained on 04/14/26 for droplet precautions. Interview with Regional Nurse Consultant #594 on 04/14/26 at 7:30 A.M. revealed Resident #31 was placed on droplet precautions as a precaution due to complaints of a cough. She confirmed testing was being completed to rule out influenza and RSV. Observations on 04/14/26 at 8:05 A.M. revealed a sign outside Resident #31's door which stated he was on droplet precautions, and staff should wear a mask and gloves to enter the room. Observations revealed Minimum Data Set (MDS) Nurse #379 in Resident #31's room. She was not wearing a mask or gloves. When she exited the room, she confirmed she did not wear a mask or gloves while in the room. She stated she thought the sign outside the door was for enhanced barrier precautions (EBP) and not droplet precautions. She confirmed the sign did say droplet precautions. Review of the facility policy titled Isolation-Categories of Transmission-Based Precautions updated 07/01/25 revealed, in addition to standard precautions, implement droplet precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning. Examples of infections requiring droplet precautions include but are not limited to: Influenza and mycoplasma pneumonia. 3. On 04/14/26 at 10:09 A.M. observation of incontinence care to Resident #81 by CNA #385 and CNA #387 revealed they washed their hands and put on gloves, explained the procedure to Resident #81, and removed the resident's brief. CNA #385 washed down the right side of the groin, changing position of the washcloth and washed down the left side of the groin, then spread the labia and washed downward. CNA #385 the rinsed in the same order with a new washcloth. Resident #81 was turned on her right side, and CNA #385 washed from front to back changing positions on the washcloth. There were smears of bowel movement (BM) noted on the washcloth. CNA #385 then rinsed from front to the back changing position on the washcloth and patted dry. CNA #385 and CNA #387 removed their gloves and put on new gloves without washing their hands. CNA #385 placed cream on Resident #81's coccyx and buttocks. CNA #385 and CNA #387 removed their gloves and put on new gloves without washing their hands and put on a new brief. On 04/14/26 at 10:35 A.M. interview with CNA #385 and CNA #387 verified they had not washed their hands in between glove changes. Review of the facility Hand Washing-Hygiene policy dated 05/01/2024 revealed it is the facility policy for employees to conduct proper hand hygiene that will aid in the prevention and transmission of infectious disease. Hand washing with soap and water/alcohol/antimicrobial hand rub be used between after removing gloves. 4, Review of Resident #84's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included orthopedic aftercare, fall with fracture (at home), pain, dementia, osteoarthritis, high blood pressure, and gastroesophageal reflux disease (GERD). No MDS 3.0 assessment was completed because she was a new admission. Further review revealed no documentation as of 04/09/26 the tuberculosis (TB) test (skin test to test if an individual has been exposed to tuberculosis) had been completed. An interview on 04/09/26 at 1:40 P.M. with the Regional Corporate Nurse #594 verified the TB test was not completed within 48 hours of admission per facility policy for Resident #84. Review of the facility Tuberculosis Screening: Administration and Interpretation of Tuberculin Skin Tests dated 05/01/2025 revealed a qualified healthcare professional will inject the purified derivative intradermally on the forearm within 48 hours of admission. 5. Review of the medical record revealed Resident #86 was admitted to the facility on [DATE]. Diagnoses included displaced fracture of anterior wall of right acetabulum, Alzheimer's disease, vascular dementia, peripheral vascular disease, wedge compression fracture of T5-T6 vertebra, chronic embolism and thrombosis of left iliac vein, wedge compression fracture of fifth lumbar vertebra, unspecified fracture of right pubis, unspecified fracture of upper end of left humerus, abdominal aortic aneurysm, calculus of gallbladder and bile duct with cholecystitis, unspecified, without obstruction, hyperosmolality and hypernatremia, LT femoral neck deformity, presence of right artificial hip joint, and presence of left artificial hip joint. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #86 was dependent on staff for eating, oral hygiene, toileting, rolling left to right, moving from sitting to lying and lying to sitting. She required substantial /maximum assistance for upper body dressing, lower body dressing and putting on footwear. Review of the physician orders for Resident #86 revealed an order dated 08/14/25 for Mantoux step one (tuberculosis test) to be administered that day. Review of the Medication Administration Record (MAR) for August 2025 for Resident #86 revealed a blank space with no nurse sign off in the section where Mantoux was to be documented as administered. There was no documentation within the MAR to explain why the tuberculosis test was not administered. Review of the progress notes for August 2025 for Resident #86 revealed no notes that indicated why the tuberculosis test was not administered. During an interview on 04/15/26 at 8:15 A.M., Regional Nurse Consultant #594 confirmed that there was no documented evidence that Resident #86 had been given Mantoux step 1. Review of the facility policy titled, Tuberculosis Infection Control Program, dated 05/01/25 revealed the facility's TB infection Control Program includes the early identification, isolation and transfer of individuals with active tuberculosis. The program incorporates screening and surveillance of residents and employees for latent tuberculosis infection. This deficiency represents non-compliance investigated under Complaint Number 2707299.

Based on record reviews, observations, staff and resident interviews and facility policy review, the facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary care and services to maintain good nutrition, grooming, and personal hygiene including assistance with eating, nail care, and bathing/showering. This affected seven (Residents #6, #9, #12, #61, #85, #87, and #93) of 12 residents reviewed for activities of daily living. The facility census was 57.Findings include: 1. Review of the closed medical record for Resident #93 revealed an admission date of 01/24/26 with diagnoses including cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, and osteoarthritis. Review of the Minimum Data Set (MDS) 3.0 assessment completed 01/30/26 revealed Resident #93 had short- and long-term memory problems. The resident required substantial/maximum assistance with personal hygiene and was dependent on staff for showers. The resident was always incontinent of bowel and bladder. Review of the care plan dated 02/03/26 revealed an intervention to provide Resident #93 with assistance as needed with activities of daily living. Review of point of care history and shower records revealed between 01/24/26 and 02/10/26 the resident received one bed bath on 01/28/26 and one shower on 02/09/26 (bathed twice in 18 days). Interview with Regional Nurse Consultant #594 on 04/15/26 at 7:39 A.M. revealed residents are to be bathed twice weekly. Interview with Regional Nurse #583 on 04/15/26 at 10:15 A.M. confirmed there was no evidence of any further showers/baths for Resident #93. Resident #93 was transferred to the hospital on [DATE] and did not return to the facility. 2. Review of the medical record for Resident #6 revealed an admission date of 02/28/25 with diagnoses including hemiplegia (paralysis of one side of the body), dysphagia (difficulty swallowing) following cerebral infarction (stroke), and aphasia (impaired speaking). He received all of his nutrition through a gastrostomy tube (feeding tube leading into the stomach). Review of the MDS 3.0 assessment completed 01/23/26 revealed Resident #6 had short- and long-term memory problems, had a feeding tube, and was dependent on staff for bathing and personal hygiene. Review of the care plan dated 03/21/25 revealed Resident #6 had an impaired ability to perform or participate in daily activities of daily living care. Interventions included providing assistance with all activities of daily living care as needed, providing nail care and shampooing hair with showers per weekly schedule, and encouraging and assisting the resident with oral care twice daily and as needed. Observations on 04/06/26 at 2:55 P.M. and 04/07/26 at 2:30 P.M. revealed Resident #6 was in bed. His bottom lip had large pieces of dry skin on it. On 04/08/26 at 8:05 A.M. and on 04/09/26 at 8:20 A.M. he was observed in bed. His bottom lip was dry. Interview with Certified Nursing Assistant (CNA) #385 on 04/09/26 at 11:20 A.M. confirmed Resident #6 has dry lips. He stated the staff use Chapstick for his dry lips but could not show the surveyor any Chapstick in the resident's room. Observations on 04/13/26 at 8:45 A.M. revealed Resident #6 to have long fingernails with a dark substance underneath the nails on both hands. Review of the shower records revealed Resident #6 last received a shower on 04/09/26. The section of the shower record to indicate fingernails were cleaned and trimmed if necessary was blank. Interview with CNA #385 on 04/13/26 at 8:45 A.M. revealed he gave Resident #6 his shower on 04/09/26 but did not clean or trim his nails. Interview with Regional Nurse Consultant #812 on 04/13/26 at 9:00 A.M. confirmed Resident #6's fingernails were long with a dark substance underneath. She confirmed he was dependent on staff for all care and would have needed his nails trimmed with his shower on 04/09/26. 3. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, cognitive communication deficit, reduced mobility, and cerebral infarction. Review of the care plan dated 05/05/25 revealed Resident #9 was at risk for altered nutrition status related to variable intakes, a history of diabetes mellitus type II, a mechanically altered diet, a history of significant weight loss on 03/13/26, and a need for supplemental enteral tube feedings. A goal was for Resident #9 to receive adequate nutrition to meet her estimated nutritional needs. An approach listed was to provide Resident #9's diet as ordered. Review of the physician orders dated 09/17/25 revealed Resident #9's prescribed diet was mechanical soft food textures and thin liquids. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 07 out of 15, indicating severe cognitive impairment. Resident #9 was assessed as being dependent on staff for personal hygiene, transfers, eating, and bathing. Review of the care plan dated 03/16/26 revealed Resident #9 had impaired ability to perform or participate in daily activities of daily living care (ADL) related to hemiplegia and hemiparesis status post cerebrovascular accident. Resident #9's goal was to participate with her ADL care as much as possible, to remain clean and dry without decline. Approaches included providing assistance with ADL care and mobility as needed, and providing showers per weekly schedule. A continuous observation of the hall dining service on 04/06/26 from 4:17 P.M. to 5:15 P.M. revealed that Resident #9 was not offered her dinner meal, and therefore not offered feeding assistance with her dinner meal. An interview with CNA #242 on 04/06/26 at 5:23 P.M. revealed that no residents refused their dinner meal. An interview with Resident #9 on 04/06/26 at 5:30 P.M. confirmed that she was not offered her dinner tray; however, Resident #9 stated that she was not feeling hungry and would have refused her meal tray if she had been offered. An interview with the Administrator on 04/06/26 at 5:32 P.M. revealed that the Administrator refused to confirm that Resident #9 was not offered her dinner meal. The Administrator stated that CNA #242 had offered Resident #9 her dinner meal, and that Resident #9 had refused. An interview with Resident #9's representative on 04/07/26 at 9:18 A.M. revealed that Resident #9 does not get showers twice weekly. Review of the showers documented from 03/02/26 through 04/09/26 in the medical record revealed that Resident #9 had a shower on 03/05/26, 03/14/26, 03/21/26, 03/28/26, and 04/02/26. Review of the shower sheet book at the nursing station from 03/02/26 through 04/09/26 revealed that Resident #9 had also had a shower on 04/04/26. Review of the shower schedule 03/02/26 through 04/09/26 revealed that Resident #9 was scheduled for a shower on 03/04/26, 03/07/26, 03/11/26, 03/14/26, 03/18/26, 03/21/26, 03/25/26, 04/01/26, 04/04/26, and 04/08/26. An interview with CNA #287 on 04/09/26 at 8:43 A.M. revealed that Resident #9 does not refuse showers or baths. CNA #287 revealed that all showers given to Resident #9 would be documented in the shower book and confirmed that Resident #9 had six instead of ten scheduled showers. 4. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, muscle weakness, and vascular dementia. Review of Resident #12's comprehensive care plan dated 09/01/22 revealed that Resident #12 had an impaired ability to perform or participate in ADL care related to weakness and cognitive deficit. A long-term goal was to have Resident #12 participate in ADL care as much as possible, to remain clean, dry and neat in appearance. An approach included providing nail care with showers per weekly schedule. Review of the MDS 3.0 assessment dated [DATE] revealed a BIMS score of 08 out of 15, indicating Resident #12 had moderate cognitive impairment. Resident #12 was assessed as being dependent on staff for personal hygiene. Observations on 04/06/26 at 9:43 A.M., 04/07/26 at 8:37 A.M. and 04/09/26 at 10:27 A.M. revealed that Resident #12's fingernails were long and had a brown substance caked underneath the nails. Interviews with Resident #12 on 04/06/26 at 9:43 A.M. and on 04/09/26 at 10:27 A.M. revealed that he preferred his nails to be short and clean. An interview with CNA #387 on 04/09/26 at 10:23 A.M. revealed Resident #12 does not refuse care. An interview with Licensed Practical Nurse (LPN) Supervisor #365 on 04/09/26 at 10:27 A.M. confirmed that Resident #12's fingernails were long and had brown substance caked under the nails. An interview with Assistant Director of Nursing (ADON) #381 on 04/09/26 at 10:29 A.M. revealed that she would file and clean Resident #12's nails for him. An observation on 04/09/26 at 2:07 P.M. revealed that Resident #12's nails were short, clean, and smooth. An interview with Resident #12 on 04/09/26 at 2:07 P.M. revealed that he was happy that his nails were trimmed and cleaned. 5. Review of the medical record for Resident #61 revealed she was admitted to the facility 12/11/25 with diagnoses including chronic obstructive pulmonary disorder (COPD), metabolic encephalopathy, diabetes, depression, congestive heart failure, high blood pressure, fibromyalgia, and cognitive communication deficit. Review of the ADL plan of care dated 03/11/26 revealed Resident #61 had impaired ability to perform or participate in daily ADL care. Provide every day, when needed or per resident request nail care with showers per weekly schedule Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #61's cognition was severely impaired (BIMS 6). She required supervision/touching assistance with eating, substantial/maximal assistance with oral hygiene, toileting, dressing, personal hygiene, and turning and repositioning and dependent on staff for showers/bathing. She was always incontinent of her bladder and frequently incontinent of her bowel and received hospice services. Observations on 04/07/26 at 10:55 A.M., 2:36 P.M. and 4:00 P.M. revealed Resident #61's fingernails were long with a brown substance up under them. On 04/08/26 at 7:55 A.M. and 2:20 P.M. her fingernails were still long with a brown substance under them. On 04/09/26 at 9:30 A.M. her fingernails remained long with brown substance under them. This was verified during an interview with Regional Nurse Consultant #583. Review of the Nail Care Finger/Toe policy and procedure dated 05/01/2025 revealed it is the policy of the facility to clean, trim and maintain nail care to enhance the residents state of well-being. 6. Review of the medical record revealed Resident #85 was admitted to the facility on [DATE] and was discharged on 08/11/26. Diagnosis included fracture of the left elbow, injured in motor vehicle accident, displaced fracture of the right tibia, osteoporosis with current pathological fractures, fracture of the right radius, wedge compression fractures, tendon disorder of the right wrist, COPD, and chronic respiratory failure. Review of the discharge MDS 3.0 assessment dated [DATE] revealed Resident #85's memory was intact. She was independent with eating, oral hygiene, toileting and personal hygiene. Supervision or touching assistance was required with showers/bathing, and she was frequently incontinent of bowel and bladder. She had one fall since admission with no injury. Further review revealed no documentation or bath or showers in the medical record. On 04/15/26 at 2:13 P.M. interview with the Administrator revealed they could find no shower/bath documentation for Resident #85 while here at the facility. 7. Review of the medical record revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including fusion of spine, muscle weakness, dysphagia, generalized anxiety, major depressive disorder, hypertension, hyperlipidemia, chronic kidney disease, encephalopathy. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #87 had impaired cognition evidenced by a BIMS score of 09 out of 15. Resident #87 resident required moderate staff assistance with bathing, toileting and mobility. Review of the facility's shower record for Resident #87 revealed she received showers on the following dates: 01/28/26, 02/11/26, and 02/25/26. Resident #87 was offered, but declined showers on 01/14/26, 01/21/26 and 02/04/26. During an interview on 04/15/26 at 10:25 A.M. with Regional Nurse Consultant #583 confirmed that per the facility's records, Resident #87 only received one shower per week. This deficiency represents noncompliance investigated under Master Complaint Number 2744632 and Complaint Numbers 2724269, 2707299, 2705832, and 2603202.

Based on medical record review, staff interview and facility policy review, the facility failed to ensure a complete and accurate medical record for five (Residents #9, #23, #74, #84 and #88) of 37 sampled residents reviewed in the course of the survey. The facility census was 57.Findings include:1. Medical record review revealed Resident #74 was admitted to the facility on [DATE] at 7:52 P.M. and discharged to the hospital on [DATE]. Pertinent diagnoses including multiple sclerosis, other osteonecrosis left femur, unilateral primary osteoarthritis left hip, fatigue and post-traumatic stress disorder (PTSD). Review of physician orders for Resident #74 revealed an order dated 01/07/26 for Modafinil 200 milligrams to be given twice a day to promote wakefulness. Review of a progress note dated 01/08/26 at 12:52 A.M. revealed Resident #74 did not have meds at the facility. The author noted they called the pharmacy, and the pharmacy stated that resident wasn't in their system. The author called the provide and confirmed that the resident wasn't in their system either. The author updated the provider that the resident was a new admit and got her entered into their system. Resident #74 complained of pain. The provider was contacted for a new prescription. The prescription was sent to the pharmacy, and staff contacted pharmacy to get an update on medication status. The resident's Gabapentin (nerve pain medication) was on the next tote. Staff requested a pull code for Oxycodone (opioid pain medication) and Gabapentin. Unable to get a pull code for Oxycodone. A pull code was obtained for the Gabapentin. Review of the January 2026 Medication Administration Record (MAR) for Resident #74 revealed that on 01/07/26, 01/08/26, 01/09/26, the morning of 01/10/26, the morning and evening of 01/12/26, and the morning and evening of 01/15/26, the nurses charted that the Modafinil was not administered because it was unavailable. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 was cognitively intact and required substantial/maximum assistance with showering/bathing, lower body dressing, putting on/taking off footwear and was dependent on staff for toileting, rolling left and right and transfers. Further review of the January 2026 MAR for Resident #74 revealed that the Modafinil was signed off as having been administered on the evening of 01/10/26, during the morning and evening administration on 01/13/26 and during the morning and evening medication administration on 01/14/26. During an interview on 04/09/26 at 1:38 P.M., Regional Nurse Consultant #594 said she was unable to locate documentation of the Modafinil administration (Modafinil is a controlled substance requiring additional tracking). The Regional Nurse Consultant said she then spoke with the pharmacy and confirmed the facility never received the Modafinil from the pharmacy to administer to Resident #74. Regional Nurse Consultant #594 then verified that five nurses had indicated that they had administered the medication to Resident #74 and should not have documented that a medication was administered when it wasn't. She noted those nurses were no longer employed at the facility, and one was an agency nurse. Review of the facility policy titled, Medication Administration General Guidelines, dated May 2020, revealed if a dose of regularly scheduled medicine is withheld, refused, not available or given at a time other than the scheduled time (i.e., the resident is not in the facility at scheduled dose time, a starter dose of antibiotic is needed, etc.) that dosage administration is flagged and documented accordingly. 2. Review of a resident record revealed that Resident #9 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, cognitive communication deficit, reduced mobility, and cerebral infarction. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 07 out of 15, indicating severe cognitive impairment. Resident #9 was assessed as being dependent on staff for personal hygiene, toileting hygiene, transfers, and bathing. Review of the care plan dated 03/16/26 revealed Resident #9 had impaired ability to perform or participate in daily activities of daily living (ADL) care related to hemiplegia and hemiparesis status post cerebrovascular accident. Resident #9's goal was to participate with her ADL care as much as possible, to remain clean and dry without decline. Approaches included to provide assistance with ADL care and mobility as needed, and providing showers per weekly schedule. Review of the showers documented from 03/02/26 through 04/09/26 in Resident #9's medical record revealed that Resident #9 had a shower on 03/05/26, 03/14/26, 03/21/26, 03/28/26, and 04/02/26. Review of the shower sheet book at the nursing station from 03/02/26 through 04/09/26 revealed that Resident #9 also had a shower on 04/04/26. Review of the shower schedule 03/02/26 through 04/09/26 revealed Resident #9 was scheduled for a shower on 03/04/26, 03/07/26, 03/11/26, 03/14/26, 03/18/26, 03/21/26, 03/25/26, 04/01/26, 04/04/26, and 04/08/26. An interview with Certified Nursing Assistant (CNA) #287 on 04/09/26 at 8:43 A.M. revealed that Resident #9 does not refuse showers or baths. CNA #287 revealed that all showers given to Resident #9 would be documented in the shower book. CNA #287 confirmed that Resident #9 had six instead of ten scheduled showers. Observation of presented shower sheets on 04/09/26 at 2:45 P.M. revealed that there were additional shower sheets filled out for 03/02/26, 03/09/26, 03/11/26 and 03/18/26 which were all initialed with the same initials (the initials of CNA #242), no nurse signature, and in the same handwriting on the same sheet. Additionally, the 04/04/26 shower sheet that had been observed and confirmed previously with CNA #287 on 04/09/26 at 8:43 A.M. now had an additional entry listed for 04/08/26 and initialed by CNA #353. An interview with CNA #353 on 04/09/26 at 3:15 P.M. confirmed that the shower sheet that she had filled out for 04/08/26 was filled out on 04/09/26 when the Director of Nursing (DON) approached her earlier that day. CNA #353 stated that she did not actually give Resident #9 her shower; however, she did assist a nursing aide in transferring Resident #9 into a shower chair on 04/08/26, so CNA #353 signed the shower sheet dated 04/08/26 on 04/09/26, under the suggestion of the DON. An interview with the DON on 04/09/26 at 3:15 P.M. confirmed that she had filled out the 03/02/26, 03/09/26, 03/11/26, and 03/18/26 shower sheets for Resident #9, initialing the shower sheets with CNA #242's initials. The DON stated that she had called CNA #242 at home on [DATE] and asked her if she had given Resident #9 showers on those dates. 3. Review of medical record revealed Resident #88 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, benign prostatic hyperplasia, need for assistance with personal care, and cognitive communication deficit. Review of the MDS 3.0 comprehensive assessment dated [DATE] revealed Resident #88 had a BIMS score of 08 out of 15, indicating moderate cognitive impairment. Resident #88 had a urinary catheter present. Review of Resident #88's outpatient urology progress notes dated 08/13/25 revealed Resident #88 no longer required a urinary catheter. He was not retaining urine, as he had only 30 milliliters (ml) of urine in his bladder. As a result, the urologist determined that he no longer required a urinary catheter. The urologist determined that if Resident #88 were to ever go back into urinary retention, a better option would be a suprapubic catheter rather than a urethral catheter. Resident #88 and his family were given education on voiding dysfunction. The plan was made to observe Resident #88 for signs of urinary retention. Review of Resident #88's Treatment Administration Record (TAR) revealed that on the evening of 08/13/25, Resident #88 did not receive catheter care. Starting on the day shift of 08/14/25, Licensed Practical Nurse (LPN) Supervisor #258 signed off on the TAR that Resident #88 received catheter care as ordered, despite the catheter not being present after Resident #88's urology appointment. Other licensed nurses that documented that they provided catheter care to Resident #88 included Registered Nurse (RN) Supervisor #270, LPN Supervisor #234, and RN Supervisor #412. Review of Resident #88's nursing progress notes dated 08/12/25 through 08/19/25 were silent for any record of Resident #88 going to his urology appointment, Resident #88's catheter being removed on 08/13/25, or discontinuing Resident #88's orders for catheter care twice daily. Review of Resident #88's physician orders revealed that no new physician orders were entered on 08/13/25 relevant to Resident #88's urinary catheter being removed at his urology appointment. No physician orders were made on 08/18/25 to remove his urinary catheter. Resident #88's physician orders to provide catheter care twice daily remained in place until 08/25/25. An interview with Certified Nurse Practitioner (CNP) #561 on 04/15/26 at 4:07 P.M. revealed that on 08/19/25, CNP #561 reviewed Resident #88's urologist's after visit summary dated 08/13/25, and CNP #561 learned that Resident #88 had passed a voiding trial in the urologist office, and therefore, Resident #88's urinary catheter was removed. An interview with Regional Nurse Consultant #594 on 04/15/26 at 3:45 P.M. confirmed that they did not have the urologist after visit summary orders for 08/13/25 available for review as part of the medical record, the nurses never discontinued the physician orders for the catheter care on 08/13/25, there were no progress notes indicating that nursing was aware of the orders to discontinue the urinary catheter on 08/13/25, and that there was no indication that Resident #88 had physician orders to reinsert the urinary catheter after the 08/13/25 catheter removal. 4. Review of the record for Resident #23 revealed an admission date of 01/24/26 with diagnoses including morbid obesity, diabetes, heart failure, status post severe sepsis with septic shock and sudden cardiac arrest. Review of a MDS 3.0 assessment completed 01/30/26 revealed a BIMS score of 11 out of 15, indicating moderately impaired cognition. It further stated Resident #23 was dependent upon staff for bed mobility. Review of the history and physical by the physician dated 03/06/26 revealed Resident #23 had peripheral vascular disease with chronic bilateral lower extremity wounds. Review of the physician's orders revealed orders dated 03/06/26 to cleanse the left and right legs with wound cleanser, apply Xeroform, pad ankles and weeping areas with abdominal (ABD) pads, wrap with Kerlix gauze and Ace wraps daily (on dayshift). Observation on 04/06/26 at 9:50 A.M. revealed Resident #23 was in bed. The dressings on his right and left legs were dated 04/02/26 (four days prior). Interview with Assistant Director of Nursing (ADON) #381 on 04/06/26 at 9:52 A.M. confirmed the dressings on Resident #23's legs were dated 04/02/26. She stated the dressings were ordered to be changed daily. Review of the April 2026 TAR for Resident #23 revealed the treatments to the left and right legs were documented as completed on 04/04/26 and 04/05/26 by LPN Supervisor #258. Interview with LPN Supervisor #258 on 04/09/26 at 8:05 A.M. confirmed that she documented that Resident #23's leg treatments were completed on 04/04/26 and 04/05/26 when they were not. She stated she was unable to do the treatments on one of the days because there was an admission of another resident. She stated it was difficult to get all the treatments done on the 200 hall. She stated there have been times when there were staff call-offs and she had to work two halls at the same time (200 and 300 hall). She stated that she normally signs off that all of the treatments were done before she does rounds. Then if she does not get the work done, she would normally go back and document that it was not completed. She stated that she did not go back and document that the treatments were not done for Resident #23's legs. 5. Review of Resident #84's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included orthopedic aftercare, fall with fracture (at home), pain, dementia, osteoarthritis, high blood pressure, and gastroesophageal reflux disease (GERD). No MDS was completed because she was a new admission. Review of the orders on admission dated 04/03/26 revealed orders for Resident #84 to wear bilateral thigh high thrombo-Embolic Deterrent (TED) hose for three weeks then discontinue, Oxybutynin 5 (milligrams) mg (anticholinergic medication to treat overactive bladder) twice daily. Resident #84 was also admitted with a urinary catheter and orders to cleanse the right hip with normal saline, pat dry and apply a dry dressing daily and as needed. Review of the MAR for April 2026 revealed the Oxybutynin 5 mg was not documented as administered in the evening (7:00 P.M. to 11:00 P.M. dose) on 04/04/26 and 04/05/26. Review of the TAR for April 2026 revealed the bilateral thigh high TED hose were not documented as on for 04/03/26, 04/04/26 and 04/05/26. Catheter care was not documented as provided for 04/03/26, 04/04/26, and 04/05/26. The dressing change was not documented as completed on 04/05/26 and 04/06/26. On 04/09/2026 at 1:40 P.M. interview with Regional Nurse Consultant #594 verified the treatments and medications were not documented as completed. This deficiency substantiates Complaint Number 2723137 and Complaint Number 2603202.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed treat the resident with respect and dignity to promote and enhance their quality of life. This affected one (Resident #84) of two residents reviewed for indwelling catheters. The census was 57.Findings include:Review of Resident #84's medical record revealed she was admitted tot he facility on 04/03/26. Diagnoses included orthopedic aftercare, fall with fracture (at home), pain, dementia, osteoarthritis, and high blood pressure. Review of the physicians orders revealed orders dated 04/06/26 for an indwelling urinary catheter for urinary retention/possible bladder outlet obstruction and ensure catheter care is provider every shift.On 04/06/2026 at 9:59 A.M., Resident #84 was observed up in the TV lounge area in a wheelchair and a hospital gown. The resident's catheter bag was hanging from the wheelchair uncovered with urine exposed. Residents and staff were observed passing the area at the time of observation. On 04/06/2026 at 10:01 A.M., interview with Regional Corporate Nurse #594 verified the catheter bag was uncovered and in view. Review of the undated policy Catheter Care, Urinary revealed staff were to monitor that the urinary drainage bag was kept in a privacy bag or utilize a decorative drainage bag that does not expose the urine contents in the drainage bag. This deficiency demonstrates noncompliance investigated under Complaint Number 2596634

Based on observations, record review, staff interview, resident interview, policy review, and family interview, the facility failed to comprehensively assess residents in the areas of activities and dental status. This affected two residents (#6, #13) of 37 residents reviewed for accuracy of assessments. The facility census was 57.Findings include:1. Review of the record for Resident #6 revealed an admission date of 02/28/25 and diagnoses including hemiplegia (paralysis of one side of the body), dysphagia (difficulty swallowing) following cerebral infarction (stroke), and aphasia (impaired speaking). He received all of his nutrition through a gastrostomy tube (feeding tube leading into the stomach). Review of a Minimum Data Set assessment completed 01/23/26 revealed the resident had short and long term memory problems, had a feeding tube, and was dependent upon staff for mobility, including transfers. Review of an admission activity assessment completed 03/09/25 revealed the resident's previous occupation was a cook. It stated he was not active in religion. It stated participation barriers included mobility and physical endurance. It stated his general activity preferences included music and watching television. It indicated the assessment was completed with the resident. Review of a Preferences for Customary Routine and Activities assessment completed 01/23/26 revealed the primary respondent for the assessment was the resident's family or significant other (did not specify who). The assessment indicated that it was not very important for the resident to have family or close friend involved in discussions about your care, not very important to listen to music you like, do your favorite activities, go outside for fresh air, or participate in religious services. It did not comprehensively assess the residents current activity interests. Observations on 04/06/26 at 2:55 P.M., 04/07/26 at 2:30 P.M., 04/08/26 at 8:05 A.M., and 04/09/26 at 8:20 A.M. and 10:59 A.M. revealed Resident #6 to be in bed. The television had a message on the screen that said press ok on your remote to start watching tv and there was no type of activity occurring. Interview with Certified Nursing Assistant (CNA) #385 on 04/09/26 at 11:20 A.M. revealed Resident #6 only gets up for showers (twice weekly). He stated it was not a daily routine for him to get out of bed. He stated the resident was not supposed to leave his room with a tube feeding. He stated he had not seen the resident attend or participate in any activities. He stated the resident was unable to use a remote to turn on the television. Interview with Licensed Practical Nurse (LPN) Supervisor #258 on 04/09/26 at 11:40 A.M. revealed she did not know if Resident #6 was supposed to get out of bed daily. She stated she knew that he gets up for showers but was not aware after that. Interview with Regional Nurse Consultant #812 on 04/13/26 at 12:35 P.M. revealed she would need to speak to his family to know his preferences on getting up each day. Interview with LPN Supervisor #256 on 04/13/26 at 2:15 P.M. revealed Resident #6 would not be able to use a remote to watch television. She stated she had never seen him attend or participate in any activities. Interview with Regional MDS Nurse #612 on 04/13/26 at 2:55 P.M. revealed she did not know what the expectation was for getting Resident #6 out of bed. Interview with Resident #6's daughter/Power of Attorney on 04/13/26 at 2:29 P.M. revealed the facility did not ask her any questions about his preferences or routines. She stated he had a stroke prior to admission and his condition has been the same since admission. She stated they do not get him up unless she calls ahead and asks them to get him up and then they don't always do that. She stated he is always in bed when she visits. She stated she would like for him to get up and out of bed at least twice weekly (in addition to showers). She stated the television is not usually on when she visits unless she turns it on. She stated his previous interests included church, music, and he was a chef. She thinks he would be interested in going to activities such as church and group activities that included performers. She stated she did not think the staff try to get him to go to activities. Interview with Resident #6 on 04/14/26 at 8:00 A.M. (while he was in bed) revealed he nodded his head yes and said uh huh when asked if he liked to get up every day. He did the same when asked if he like to watch tv and if he liked church. Interview with Regional Nurse Consultant #594 on 04/13/26 at 7:50 A.M. confirmed there was no evidence as to which family member participated in the preference assessments on admission or on 01/23/26 as the activity director completed the assessments and she is not longer employed by the facility. Interview with Activity Assistant #252 on 04/13/26 at 1:49 P.M. confirmed the facility did not currently have an activity director. She stated Resident #6 was not able to talk or make choices. She stated she had asked families before what residents prefer to do but not him specifically. She confirmed there was no evidence of an assessment for specific activity interests since 03/09/25. Review of the facility policy titled Resident Activity Preference dated 03/01/19 revealed the facility will accommodate resident activity preferences through the comprehensive assessment and care planning process. Resident activity preferences will be obtained upon admission through the comprehensive assessment process by conducting resident and or resident representative interview with the MDS section F Preferences for customary routine and activities per the RAI schedule. Resident activity preferences will be care planned per the comprehensive assessment process per the RAI manual guidelines. Resident activity preferences will be readdressed throughout the resident's stay in the facility during the care conference process and/or comprehensive assessment process and revised as indicated. 2. Review of the record for Resident #13 revealed an admission date of 11/06/25 with diagnoses including diabetes, chronic kidney disease, and hypertension. Review of an admission nursing assessment completed 11/07/25 revealed if any dental issues including no natural teeth or tooth fragments, obvious or likely cavity or broken natural teeth were present, the nurse was to mark the issues. The nurse marked none of the above were present. The assessment was completed by LPN #317. Interview with LPN #317 on 04/13/26 at 11:20 A.M. revealed she did not remember if she checked Resident #13's teeth when she did the admission assessment and was not aware of her current dental status. Review of a Minimum Data Set assessment completed 11/12/25 revealed a Brief Interview for Mental Status score of 14, indicating intact cognition. It further stated the resident had obvious or likely cavities or broken natural teeth. Review of a quarterly MDS observation assessment of dental status with an observation date of 02/04/26 and a completed date of 03/01/26 revealed if any dental issues including no natural teeth or tooth fragments, obvious or likely cavity or broken natural teeth were present, the nurse was to mark the issues. The nurse marked none of the above were present. Interview with Resident #13 on 04/06/26 at 3:13 P.M. revealed she only has roots left of her top teeth and has missing teeth on the bottom. She stated that her husband knocked some of her teeth out. She stated she had been asked by the facility if she wanted to see the dentist but has not seen one yet. She stated that she would like to see a dentist. On 04/13/26 at 12:30 P.M. the resident stated that not having many teeth makes it difficult for her to chew her food and says it is embarrassing not to have teeth. Observations on 04/13/26 at 12:30 P.M. revealed Resident #13 had no teeth on top with only root tips visible and was missing front teeth on the bottom. Interview with Corporate Registered Nurse #583 on 04/13/26 at 1:30 P.M. confirmed Resident #13 had missing teeth and you can only see small tips of the teeth on top. She further confirmed that the dental assessments completed on admission and on 02/04/26 were not comprehensive or accurate.

Based on record review, staff interviews and facility policy review, the facility failed to execute a timely discharge for a resident. This affected one resident (#41) of eight residents reviewed for the discharge process. The facility's census was 57.Findings include:Record review for Resident #41 revealed this resident was admitted to the facility on [DATE] with diagnoses including: Parkinson's Disease, hypertension, coronary artery disease and dementia Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 08. This resident was assessed to be require supervision or touching assistance, along with his walker or cane, for mobility. Review of the nursing progress notes in Resident #41's medical record revealed on 12/09/25 he was identified as being a high fall and high elopement risk. Review of the nursing progress notes in Resident #41's medical record revealed on 10/21/25, Resident #41's family advised staff that the resident was having increased hallucinations. On 12/01/25 the resident was noted to be attempting to leave the facility at night. When staff attempted to redirect the resident, he became agitated and began throwing objects in his room. Between 02/03/26 and 02/10/26, three documented observations by staff of the resident pacing and wandering throughout the facility. He was observed on 02/10/26 as attempting to open the facility's exit doors. Review of Resident #41's care conference notes dated 02/11/26 revealed staff discussed Resident #41's increased elopement attempts with the resident's family. The family requested further information about transferring the resident to a facility with a secured unit. Review of the nursing progress notes revealed on 03/01/26 Resident #41 attempted to elope from the facility. On 03/06/26, Resident #41 attempted to elope by following facility visitors to the exit. When facility staff escorted the resident to his room, he threw his cane at a nurse. Review of the care plan of Resident #41, dated 03/03/26, revealed the resident exhibited verbal aggression and wandering behaviors, which put the resident at risk of harm to self and others. Interventions for this behavior included encourage resident and family to discuss care and behavior treatments for safety and care conferences. Review of the social services progress notes revealed on 03/06/26 Social Services Coordinator (SSC) #208 contacted Resident #41's family regarding the continued elopement attempt behaviors. SSC #208 advised she would start referrals to memory care facilities. On 03/06/26 one referral was sent, but the resident was not accepted. Between 03/09/26 and 03/10/26 two additional referrals were sent, but the resident was not accepted at these facilities either. No further social service progress notes were made regarding the discharge of the resident to a facility to a secured unit from 03/11/26- 04/07/26. During an interview with Social Services Coordinator #208 on 04/07/26 at 3:31 P.M. she stated she had sent out eight or nine referrals, but the facilities have not accepted Resident #41 due to either his behaviors or because he does not have a dementia diagnosis. She said she is currently working with the facility's psychiatrist to screen the resident for dementia. When asked if she had documentation of the referral attempts, she was not able to provide further evidence than the three referrals sent between 03/08/26 and 03/10/26. She was also not able to provide a timeline of when the psychiatrist would assess the resident. During an interview with Licensed Practical Nurse, (LPN) #234 on 04/08/26 at 8:30 A.M. she confirmed Resident #41 gets very fidgety during the night. During an interview on 04/08/26 at 2:19 P.M. Regional Nurse Consultant #594 confirmed Resident #41 has not been able to successfully elope, but has had some close calls. During an interview on 04/08/26 at 2:22 P.M. with the Director of Nursing (DON), the DON confirmed that the facility's psychiatrist had visited Resident #41 that day and a dementia diagnosis was made. Review of the social services progress notes revealed on 04/14/26 Resident #41 had been accepted into a facility with a secure memory care unit. Review of the facility's policy Discharge Planning updated 10/16 states all discharge planning discussions and arrangements should be documented in the progress notes.

Based on review of medical record, staff interview and review of facility policy, the facility failed to report an injury of unknown origin to the State in a timely manner. This affected one resident (#88) out of five residents reviewed for abuse. The facility census was 57 residents. Findings include: Review of a closed medical record revealed Resident #88 was admitted to the facility on [DATE] and had diagnoses that included metabolic encephalopathy, need for assistance with personal care, disorientation and cognitive communication deficit. Review of Resident #88's admission skin assessment dated [DATE] revealed that Resident #88 was admitted to the facility with bruising to his bilateral upper extremities, dry scaly skin to his bilateral lower extremities below the knee, and a cancerous lesion that was removed prior to admission on his upper left back area. Review of Resident #88's Minimum Data Set comprehensive assessment dated [DATE] revealed he had a Brief Interview for Mental Status score of 08, indicative of moderate cognitive impairment. Resident #88 was assessed as needing partial to moderate assistance for rolling left to right, for sitting to lying, for sitting to standing, for transferring chair to bed, and as needing substantial to maximal assistance with lying to sitting and for toilet transfers. Resident #88 was assessed as not able to walk due to medical condition or safety concerns. Review of Resident #88's care plan dated 07/09/25 revealed that Resident #88 was at risk for bruising related to potential side effects of anticoagulant medication. A goal listed was to have no signs or symptoms of bruising. Approaches included observe and report and adverse side effects, such as unexplained bruising, note any skin discolorations or bruising, to encourage resident to report any bumping or bruising, report to nurse any bruising, and to report any ecchymotic areas to doctor. Review of Resident #88's nursing progress notes dated 07/06/25 at 12:00 P.M. revealed Resident #88 was confused, agitated and restless, with newly noted bruising to his right eye. No known or reported falls. The physician and Director of Nursing (DON) were noted to be notified of the new bruise to Resident #88's right eye. Review of the Ohio Department of Health Application Gateway revealed that no incidents for an injury of unknown origin for Resident #88 were reported to the State on 07/06/25. Review of Resident #88's nursing progress notes dated 07/07/25 at 11:05 A.M. and authored by the DON revealed the DON concluded Resident #88's right eye was showing redness on 07/05/25, and after conferring with Resident #88's resident representative and observing photos that Resident #88's representative had taken during the admission process on 07/05/25. An interview with Regional Nurse Consultant #594 on 04/14/26 at 5:59 P.M. confirmed that although the DON came to a conclusion on 07/07/25 about the injury of unknown origin that was discovered on 07/06/25 to Resident #88's right eye, it was not reported to the State in a timely manner. Review of a facility policy titled, Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property, updated 05/01/25, revealed that an injury of unknown source is defined as when the source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury, the location of the injury or the incidence of injuries over time. All injuries of unknown sources must be reported immediately to the Ohio Department of Health.

Based on review of concern tracking logs, policy review, record review, staff interview, and resident interview, the facility failed to make prompt efforts to resolve complaints/grievances by resident/family members. This affected three residents (Residents #31, #55, and #93) of three residents reviewed for concerns and had the potential to affect all residents of the facility due to the lack of policy/procedure and system in place. The facility census was 57. Findings include: Review of facility Concern Tracking Logs revealed the logs listed the date, resident name, nature of concern, department, and date of resolution. The log did not give specifics of the nature of the concerns. Three residents (Residents #31, #55, and #93) were chosen for review of logged concerns as follows: a. On 03/02/26 it was noted that a concern for Resident #31 was submitted regarding response time. The date of resolution was 03/02/26. No further specifics were documented. Review of the record for Resident #31 revealed an admission date of 12/04/25. Review of a Minimum Data Set assessment completed 02/03/26 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. It further stated he was always incontinent of bowel and bladder and was dependent upon staff for toileting. Interview with Resident #31 on 04/06/26 at 1:18 P.M. revealed that he sometimes has to wait 2-4 hours to have his call light answered and has to lay long periods of time while wet from urine. He indicated his concerns had not been resolved. There was no documented evidence of a resolution to his concern on 03/02/26. b. On 02/09/26 it was noted that a concern for Resident #93 was submitted by her daughter regarding daily routine. The date of resolution was 02/10/26. No further specifics were documented. Review of the medical record for Resident #93 revealed nothing documented in the record regarding concerns by family on 02/09/26. On 02/10/26 the resident was transferred to the hospital due to a change in condition and did not return to the facility. There was no documented evidence of a resolution to her concern. c. On 02/16/26 it was noted that a concern for Resident #55 was submitted by family concerning missing clothes. The date of resolution was 02/19/26. No further specifics were documented. Review of the missing items policy updated 05/01/25 stated missing items are reported by residents and/or their representatives to staff who document the information on a Resident Concern Form and is signed by a resident, family member, visitor, or employee. All missing items must be investigated promptly and referred to the Director of Social Services in a timely manner. The Director of Social Services is responsible for reviewing the concern form, initiating an investigation, and following up with the resident or family. Follow up is documented on the Customer Concern Form. All documentation regarding missing or lost items shall be filed in the office of the Social Service Director. Interview with Social Services Coordinator #208 on 04/13/26 at 10:40 A.M. revealed if missing items are reported, she reports it to the Administrator and there is a form to fill out. She stated administration handles those. Interview with Administrator #404 on 04/13/26 at 10:50 A.M. revealed Social Services handles missing item reports. She stated Social Services should have a log of missing items. Interview with Administrator #404 on 04/14/26 at 8:49 A.M. revealed missing items are logged with resident concerns on the concern log. There was no evidence that a Resident Concern Form had been filled out per facility policy. There was no evidence an investigation was completed regarding the missing clothing for Resident #55. Interview with Administrator #404 on 04/14/26 at 8:49 A.M. revealed when a concern of any type is reported, a form is filled out and given to the appropriate department to follow up and resolve. She stated the resolution is documented on the concern form. Interview with Administrator #404 on 04/14/26 at 9:50 A.M. revealed there were no concern forms filled out for Residents #31, #55, and #93 and no evidence of any follow up taken on the concerns. Interview with Administrator #404 on 04/14/26 at 3:08 P.M. revealed the facility did not have a policy on following up on resident concerns that were not missing items. This deficiency represents non-compliance investigated under Complaint Numbers 2724269, 2707299, 2596634, and 2591210.

Based on medical record review, staff interview and policy review, the facility failed to notify the provider of significant weight change and weight refusals for Resident #95. This affected one resident (#95) of 37 residents reviewed for notifications. The facility census was 57.Findings include:Resident #95 was admitted to the facility on [DATE]. Pertinent diagnoses included chronic systolic heart failure, chronic obstructive pulmonary disease, Type II diabetes mellitus, other specified anxiety disorders, pneumonia, pleural effusion.Review of the quarterly Minimum Data Set (MDS) 3.0 dated 03/24/25 for Resident #95 revealed Resident #95 was cognitively intact and required supervision or touching assistance with eating, toileting, showering, lower body dressing, putting on footwear, moving from sitting to lying, lying to sitting, chair transfer, toilet transfer and shower transfers. The MDS indicated there were no instances where Resident #95 rejected evaluation or care.Review of the provider orders for Resident #95 revealed an order dated 02/28/25 for daily weights and that the physician or nurse practitioner should be notified if there was a two pound weight gain overnight or five pounds in one week.Review of the care plan for Resident #95 dated 04/07/25 revealed no documentation that Resident #95 had habit of refusing care or evaluation.Review of the March 2025 Treatment Administration Record for Resident #95 revealed on 03/06/25, 03/09/25, 03/13/25, 03/14/25, 03/17/25, 03/18/25, 03/25/25 a nurse marked Resident #95 had refused to be weighed.Further review of the March 2025 Treatment Administration Record for Resident #95 revealed a recorded weight of 200 pounds on 03/30/25 and a recorded weight of 202.2 pounds on 03/31/25.Review of the April 2025 Treatment Administration Record for Resident #95 revealed on 04/01/25, 04/06/25, 04/08/25, 04/09/25 and 04/10/25 nurses marked the resident had refused to be weighed.Further review of the April 2025 Treatment Administration Record for Resident #95 revealed on 04/04/25 Resident 95's weight was recorded to be 205.6 and on 04/05/25, the resident's weight was noted to be 208.8.Review of the progress notes for Resident #95 revealed no documentation in the progress notes the provider or family representative was notified of the 2 pound weight gain on 03/31/25, the 3.2 pound weight gain on 04/05/25, or any of the recorded refusals of weight measurement.During interview on 04/13/26 at 2:20 P.M. Regional Nurse Consultant #594 confirmed there was no evidence of any notification to the nurse practitioner on 04/05/26 for the 3.2 pound weight gain. She also confirmed the entries in which the nurse documented the resident refused to be weighed and there was no documentation that the provider was notified of the refusals. She said that the nurse should have let the provider know if the resident was refusing to be weighed.During an interview on 04/15/26 at 5:25 P.M. Certified Nurse Practitioner (CNP) #561 revealed she was not notified of the weight gain on 04/05/26 nor the refusals. She said she would expect the nurses to notify her any time the resident refused because if they did, she would go talk to the resident and stress the importance of why they were asking for the weight. She confirmed she was never told that Resident #95 had refused to be weighed.Review of the facility policy titled, Change in the Residents Condition or Status, dated 05/01/25, revealed it is the facility's policy to ensure that the resident's attending physician and the resident's authorized representative or interested family member are notified of changes in the resident's physical, mental or psychosocial status.Review of the undated facility policy titled, Weight/Reweigh Policy, revealed the family, resident and physician shall be notified of any significant weight variance by the nursing staff. This notification to family and physician shall be documented in the EMR. The policy further states daily weights are taken by nursing staff for residents with diagnosis of CHF or as designated by physician orders.Review of the facility policy titled, Refusal of Treatment, dated 05/01/25, revealed should the resident refuse to accept treatment, detailed information relating to the refusal must be entered into the resident's medical record. The attending physician must be notified of such refusal, in a time frame determined by the resident's condition and potential serious consequences of the refusal.This deficiency represents non-compliance investigated under Complaint Number 2744632.

Based on observations, record review, staff interview, family interview, and policy review, the facility failed to ensure a resident/responsible party had the right to choose activities and schedules consistent with their interests, assessments, and care plan. This affected one resident (#6) of 37 sampled residents. The facility census was 57. Findings include:Review of the record for Resident #6 revealed an admission date of 02/28/25 and diagnoses including hemiplegia (paralysis of one side of the body), dysphagia (difficulty swallowing) following cerebral infarction (stroke), and aphasia (impaired speaking). He received all of his nutrition through a gastrostomy tube (feeding tube leading into the stomach). Review of the plan of care dated 03/21/25 revealed the resident had impaired cognition related to stroke and memory loss. Interventions included to involve the resident in daily care and decision making as much as possible. It stated to ask simple yes/no questions when able and as needed. The plan of care stated to involve resident in daily care and decision making as much as possible. The plan of care stated to use a mechanical lift for transfers out of bed. It stated the resident uses a wheelchair for mobility. The plan of care did not address any preferences the resident/responsible party had regarding the frequency of getting out of bed. Review of a Minimum Data Set (MDS) assessment completed 01/23/26 revealed the resident had short and long term memory problems, had a feeding tube, and was dependent upon staff for mobility, including transfers. Review of a Preferences for Customary Routine and Activities assessment completed 01/23/26 revealed the primary respondent for the assessment was the resident's family or significant other (did not specify who). The assessment indicated that it was not very important for the resident to choose his own bedtime, have family or close friend involved in discussions about his care, or to do favorite activities. Observations on 04/06/26 at 2:55 P.M., 04/07/26 at 2:30 P.M., 04/08/26 at 8:05 A.M., and 04/09/26 at 8:20 A.M. and 10:59 A.M. revealed Resident #6 to be in bed. Interview with Certified Nursing Assistant (CNA) #385 on 04/09/26 at 11:20 A.M. revealed Resident #6 only gets up for showers (twice weekly). He stated it was not a daily routine for him to get out of bed. He stated the resident was not supposed to leave his room with a tube feeding. Interview with Licensed Practical Nurse (LPN) Supervisor #258 on 04/09/26 at 11:40 A.M. revealed she did not know if Resident #6 was supposed to get out of bed daily. She stated she knew that he gets up for showers but was not aware after that. Interview with Regional Nurse Consultant #812 on 04/13/26 at 12:35 P.M. revealed she would need to speak to his family to know his preferences on getting up each day. Interview with Regional MDS Nurse #612 on 04/13/26 at 2:55 P.M. revealed she did not know what the expectation was for getting Resident #6 out of bed. Interview with Resident #6's daughter/Power of Attorney on 04/13/26 at 2:29 P.M. revealed the facility did not ask her any questions about Resident #6's preferences or routines, such as getting out of bed. She stated the facility did not get him up unless she called ahead and asked them to get him up, and then they don't always do that. She stated Resident #6 was always in bed when she visits. She stated she would like for him to get up and out of bed at least twice weekly (in addition to showers). Interview with Regional Nurse Consultant #594 on 04/13/26 at 7:50 A.M. confirmed there was no evidence as to which family member participated in the preference assessments on admission or on 01/23/26 as the activity director completed the assessments and she is not longer employed by the facility. During a subsequent interview on 04/13/26 at 3:30 P.M., Regional Nurse Consultant #594 confirmed there was no plan in place for how often Resident #6 was to get out of bed. Interview with Resident #6 on 04/14/26 at 8:00 A.M. (while he was in bed) revealed he nodded his head yes and said uh huh when asked if he liked to get up every day. Review of the facility policy titled Resident Activity Preference dated 03/01/19 revealed the facility will accommodate the resident's activity preferences through the comprehensive assessment and care planning process. Resident activity preferences will be obtained upon admission through the comprehensive assessment process by conducting resident and or resident representative interview with the MDS section F Preferences for customary routine and activities per the resident assessment instrument (RAI) schedule. Resident activity preferences will be care planned per the comprehensive assessment process per the RAI manual guidelines. Resident activity preferences will be readdressed throughout the resident's stay in the facility during the care conference process and/or comprehensive assessment process and revised as indicated.

Based on review of resident medical record, resident family interview, and staff interview, the facility failed to notify the resident representative of a change in treatments. This affected one resident (Resident #55) out of thirty-seven residents reviewed during the annual survey process. The facility census was 57. Findings include: Review of the electronic medical record revealed Resident #55 was admitted to the facility on [DATE] and had diagnoses that included cognitive communication deficit, aphasia, dementia, bilateral open-angle glaucoma, bilateral combined forms of age-related cataracts, and vitreous degeneration of the right eye. Review of Resident #55's care plan dated 09/21/18 revealed that Resident #55 was at risk for decreased visual function as he had a diagnosis of cataracts. A long-term goal listed was that Resident #55 would not experience negative consequences of vision loss. Approaches listed to help Resident #55 achieve this goal included to administer medications as ordered and to obtain ophthalmologist consultations as needed. Review of Resident #55's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed that Resident #55 had a Brief Interview for Mental Status score of 06, indicative of a severe cognitive impairment. Review of Resident #55's physician orders revealed that Resident #55 was prescribed Brimonidine (an ophthalmic solution to lower eye pressure in glaucoma) apply one drop to both eyes twice daily from 11/11/21 through 11/06/24, and Latanoprost (an ophthalmic solution prescribed to reduce high pressure inside the eye) apply one drop to both eyes daily from 11/02/23 through 11/06/24. Review of Resident #55's ophthalmology after visit summary dated 09/01/23 revealed that Resident #55 was ordered Brimonidine 0.2% one drop in both eyes twice daily, and Latanoprost 0.005% one drop in both eyes daily at bedtime. Review of Resident #55's physician orders revealed that Resident #55 was ordered Brimonidine drops 0.2% one drop to both eyes twice a day as needed for glaucoma from 11/06/24 to 11/19/25, and Latanoprost 0.005% one drop in both eyes once daily as needed for glaucoma from 11/06/24 to 11/19/25. Review of Resident #55's nursing progress notes dated 11/01/24 through 11/06/24 were silent for notification to Resident #55's representative that Resident #55's Brimonidine and Latanoprost were changed on 11/06/24 to scheduled medications to as needed medications. An interview with Resident #55's representative on 04/06/26 at 11:32 A.M. revealed that she was upset that she was not notified by the facility when Resident #55's Brimonidine and Latanoprost eye drops were changed from scheduled administrations to as needed administrations. An interview with Regional Nurse Consultant #594 on 04/13/26 at 5:19 P.M. confirmed there was no evidence that Resident #55 nor Resident #55's representative were notified when Latanoprost and Brimonidine were changed from scheduled medications to as needed medications on 11/06/24. This deficiency represents non-compliance investigated under Complaint Numbers 2596634 and 2723137.

Based on observation, record review, staff interview and review of the facility policy, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevent program to ensure residents were thoroughly assessed, interventions were initiated timely and in place as planned and/or staff timely identified the development new pressure ulcers. This affected two residents (#216 and #213) of six residents reviewed for pressure ulcers. The facility census was 61. Actual Harm occurred on 08/04/24 when Resident #216, who was at risk for pressure ulcer development and dependent on staff for activities of daily living, was assessed to develop an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the sacrum. On 08/13/24 the wound physician assessed the pressure ulcer to be a Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). The resident was admitted to the facility on [DATE] with intact skin. The facility failed to ensure adequate interventions were in place to prevent the develop of this unstageable pressure ulcer and to timely identify the ulcer before it was found unstageable. Findings include: 1. Review of the medical record for Resident #216 revealed an admitted [DATE] with diagnoses including arthritis, urinary tract infection, acute kidney failure, muscle weakness, spinal stenosis, and body mass index (BMI) of 42. Review of local hospital documentation from the resident's hospitalization from [DATE] to 07/31/24 revealed no documentation supporting Resident #216 had any type of skin impairment/sacral pressure ulcer prior to discharge from the hospital/prior to admission to the facility. Review of an admitting nurse progress note dated 07/31/24 revealed a skin assessment was completed with no noted concerns for skin impairments. Review of nursing admission assessment completed 07/31/24 revealed the assessment contained a Braden skin assessment that indicated the resident scored a 16 placing her at mild risk for skin breakdown based on the following scoring criteria: the resident was slightly limited in mobility, skin was occasionally moist, the resident was chair fast, the resident had adequate nutrition, and the resident was at mid friction/shear risk. These factors left the resident at mild risk for skin impairment and injuries. Additionally, the resident was receiving steroid medication therapy, which recognized the resident as a high risk for skin breakdown. The admission assessment documented the resident had no skin alterations. Review of a baseline care plan revealed a wound goal was not applicable with no wound prevention and/or treatment approaches added for the resident at the time of admission or based on her assessed risk for skin breakdown. Review of a skilled nursing note dated 08/02/24 revealed Resident #216's skin was intact, warm, and dry. Review of wound grid documentation dated 08/04/24 revealed Resident #216 had an in-house acquired unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure injury (to the sacrum) measuring 24 centimeters (cm) in length by 15 cm in width by an undetermined depth. The wound description indicated a wound bed with 70% slough present, moderate serous exudate present, with deep tissue injury noted to the surrounding sacrum wound bed. Review of the physician's orders revealed a new order dated 08/04/24 to cleanse sacrum with normal saline, pat dry, apply calcium alginate, and then place dry dressing. Review of Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. The assessment revealed the resident was dependent (on staff) for toileting, hygiene and bed mobility. The assessment also revealed the resident was at risk for developing pressure ulcers/injuries and exhibited no behaviors or rejection of care. Review of the wound physician notes dated 08/13/24 revealed Resident #216 developed a Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcer, first found by facility staff on 08/04/24. Resident #216 was evaluated by the wound physician on 08/13/24. During the assessment, the wound was classified as a Stage IV pressure ulcer located on the sacrum, measuring eight cm in length by eight cm width with five cm depth, resulting in a total surface area of 64 cm. A procedure was completed where the doctor surgically excised 12.8 cm of devitalized tissue, and necrotic periosteum and bone were removed at a depth of five cm. The nonviable tissue in the wound bed decreased from 30 percent to 10 percent. There was a treatment ordered to apply calcium alginate and Santyl, and apply a gauze island with a border once daily for 30 days. Review of a physician's progress note dated 08/16/24 revealed new diagnosis of pressure injury of sacral region of back: noted on 08/06/24. During an interview on 09/25/24 at 8:01 A.M. with Resident #216, the resident verified staff identified she had a wound to her sacrum after she admitted to the facility. Interview on 09/25/24 at 11:24 A.M. with Registered Nurse (RN) #304 revealed she completed the admitting skin assessment on Resident #216 on 07/31/24, however she stated she did not thoroughly assess the resident's buttocks area due to a concern for an invasion of privacy. RN #304 revealed the facility policy required a second nurse from management to complete a second skin assessment 24 hours after admission. Interview on 09/25/24 at 11:26 A.M. with the Director of Nursing (DON) verified the facility assessed Resident #216's sacral wound as being in-house acquired because it was identified five days after admission. During the interview, the DON confirmed the lack of interventions to prevent pressure ulcer development at the time of admission. Interview on 09/26/24 at 11:36 A.M. with the DON, Regional Nurse Consultant #300, and Assistant Director of Nursing #238 confirmed if a resident was identified at risk when completing a Braden assessment, interventions should be implemented, such as an air mattress, offloading supports, and frequent turns to prevent acquiring a wound. They confirmed Resident #216 was admitted to the facility on [DATE] with a nursing assessment documenting the absence of pressure areas. Staff confirmed Resident #216 was assessed to have an unstageable pressure ulcer on 08/04/24. During the interview, the DON confirmed facility staff also failed to complete a second skin check per skin policy and implement dressings and interventions timely. Interview on 09/26/24 at 11:39 A.M. with Wound Physician (WP) #307 confirmed facility staff first identified a pressure ulcer on Resident #216's sacrum approximately five days after admission. Attempts to observe the resident's skin/wound care were made during the onsite survey; however, staff, who were aware of the surveyor's request to observe the area/wound care completed wound care without allowing the surveyor to observe. Review of the facility undated policy titled Pressure Injuries: Assessment, Prevention and Treatment revealed it was the facility policy to identify residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries and provide care for existing pressure injuries. Review of the facility undated policy titled Admission Skin Assessment Protocol revealed the Assistant Director of Nursing would complete a second skin assessment the following business day (after admission) and document any new findings in the clinical record. 2. Review of the medical record for Resident #213 revealed an admitted [DATE] with diagnoses including osteoporosis, left femur nailing, muscle weakness, need for assistance with personal care, fracture of upper end of left humerus and history of falls. Review of the Braden skin assessment dated [DATE] revealed Resident #213 was at moderate risk for skin breakdown, necessitating close monitoring and intervention. Review of a functional limitation of the range of motion assessment completed on 09/09/24 revealed Resident #213 had limitation on one leg, with partial loss of voluntary movement. The summary identified significant challenges in ability to complete activities of daily living. Review of admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #213 had severe cognitive impairment, required substantial (staff) assist with bed mobility and was at risk for pressure ulcer development. Review of the care plan dated 09/25/24 revealed Resident #213 was at risk of skin breakdown related to impaired mobility, cognitive challenges, and poor nutritional intake. Care approaches included applying skin prep to bilateral heels as ordered to prevent skin injury and encouraging/assisting the resident to float her heels as tolerated, alongside implementing bilateral offloading boots. Review of physician's orders dated 09/18/24 revealed an order for off-loading boots to both heels while in bed to promote healthy skin integrity due to the resident's limited mobility. During an interview on 09/23/24 at 10:31 A.M. with Resident #213 and the resident's family concerns were voiced related to facility staff not placing support boots under the resident's feet while she was in bed. Observation at the time of the interview revealed the resident was in bed without any type of off-loading boots in place. Observations on 09/24/24 at 3:15 P.M., 4:26 P.M., and 5:20 P.M. revealed the resident was in bed and did not have off-loading boots in place at the time of these observations. Interview on 09/24/24 at 5:22 P.M. with Licensed Practical Nurse (LPN) #306 confirmed Resident #213 required off-loading pressure boots while in bed and acknowledged they were not being utilized at that moment. LPN #306 emphasized the need for the boots due to the resident's high risk of skin issues and impaired mobility. Review of the facility undated policy titled Pressure Injuries: Assessment, Prevention and Treatment revealed it was the facility policy to implement interventions to prevent the development of pressure injures which included floating heels or keeping heels off the bed.

Based on medical record review, staff interview, and resident interview, the facility failed to implement an effective and individualized pain management program for Resident #50 per physician's orders. This affected resident (#50) of three sampled residents. The facility census was 60. Actual harm occurred on 02/25/24 when Resident #50 experienced significant physical pain when her ordered narcotic pain medication was not administered for over 26 hours. The resident indicated during this time period, the pain which she reported was to her feet was rated a nine on a scale of one to 10 (with 10 being the most severe pain) limiting her ability to get out of bed and eat and causing her to cry. Findings include: Review of the medical record for Resident #50 revealed an admitted [DATE] and diagnoses including chronic pain, paresthesia (a tingling or prickly pins and needles sensation), and fibromyalgia. Review of the plan of care dated 11/03/23 revealed has pain related to paresthesia of fingers/toes related to fibromyalgia. The goal included resident would verbalize they are comfortable everyday. Interventions included administer pain medications as ordered and observe for effectiveness, remind resident that reporting pain early may improve effectiveness of pain medication (level 4 or less on pain scale or before pain becomes moderate), observe for episodes of breakthrough pain and medicate as ordered, and contact physician as needed. Record review revealed a physician's order dated 11/10/23 for Oxycodone (a narcotic pain medication) 5 milligrams every eight hours (scheduled at 6:00 A.M., 2:00 P.M., and 10:00 P.M.). Review of a physician's progress note dated 01/11/24 revealed the resident requested to be seen for pain management and paresthesia. The note stated chronic pain stable and no indication to increase Oxycodone. History of opioid abuse. Resident reports ongoing bilateral foot pain that is not improving with any medication. Describes as burning with lightening bolts type pain. Review of a Minimum Data Set assessment for Resident #50 completed 01/27/24 revealed a brief interview for mental status score of 15, indicating intact cognition. Interview with Resident #50 on 03/04/24 at 11:05 A.M. revealed the weekend before last, the facility ran out of her Oxycodone pain medication. She stated she did not get the medication for 26 hours. She stated that not receiving the medication caused her to have severe pain which she described as a 9 out of 10, with ten being the worst pain and causing her to cry. On 03/06/24 at 12:05 P.M. Resident #50 stated the pain she experienced was in her feet. She stated when her pain medication was not available, she just stayed in bed and the pain got worse as the day went on. She stated it affected her appetite and she was only able to eat some of her food. Review of the medication administration record for February 2024 revealed Oxycodone 5 milligrams was scheduled to be given every eight hours at 6:00 A.M., 2:00 P.M., and 10:00 P.M. for chronic pain. Record review revealed a dose was given at 10:00 P.M. on 02/24/24 by Registered Nurse (RN) #70. Review of the Controlled Drug Receipt/use disposition form revealed when RN #70 gave the dose of Oxycodone on 02/24/24 10:00 P.M. (signed out at 9:30 P.M.) it was the last pill available (30 pills had been received on 02/14/24). Review of the medication administration record revealed on 02/25/24 at 6:00 A.M. RN #70 documented that the Oxycodone was not given at that time. On 02/25/24 at 2:00 P.M. Licensed Practical Nurse (LPN) #89 documented the Oxycodone was given. However, interview with LPN #89 on 03/06/24 at 11:20 A.M. revealed, even though she documented it was given (on 02/25/24 at 2:00 P.M.), she did not administer the Oxycodone to Resident #50 at that time because it was not available to give. She stated the facility had ran out of Oxycodone for Resident #50 and she was unable to get a dose out of the emergency supply because the pharmacy was unable to give authorization to do so due to a glitch in their system. She stated Resident #50 did experience pain in her feet and back during this time that she described as a level of 2. Review of the treatment administration record revealed an order to assess pain every shift on a scale of 0-10. On 02/25/24 LPN #89 documented that Resident #50 had 0 pain from 7:30 A.M. to 7:30 P.M. Interview with LPN #89 on 03/06/24 at 11:20 A.M. confirmed that this was not an accurate documentation since Resident #50 did have pain on that shift when her pain medication was not available all day. LPN #89 further stated she did not notify the physician when Resident #50's pain medication was not available. Review of the medication administration record revealed on 02/25/24 at 10:00 P.M. RN #70 documented that the Oxycodone was not given at that time. A note at 9:17 P.M. by RN #70 stated the medication was pending delivery and the pharmacy computer was not able to give authorization. Review of a nursing progress note on 02/26/24 at 12:30 A.M. revealed the pharmacy delivered the Oxycodone and it was given late at that time (for the 10:00 P.M. dose on 02/25/24). Review of the Controlled Drug Receipt/Disposition Form revealed a quantity of 30 Oxycodone pills were received on 02/26/24 with the first dose signed out on 02/26/24 at 12:15 A.M. by RN #80. Review of the treatment administration record for 02/25/24 for 7:30 P.M. to 7:30 A.M. revealed RN #80 also documented that Resident #50 had no pain during the shift. Interview with RN #80 on 03/06/24 at 12:30 P.M. confirmed she gave the last dose of Oxycodone that was available to Resident #50 on 02/24/24 for the 10:00 P.M. dose. She stated a refill sticker should be faxed to the pharmacy a couple of days before a medication runs out so the pharmacy has time to refill and deliver it before the resident runs out. She stated she did not remember if the sticker had been removed when she gave the last dose or if she removed the sticker and faxed it to the pharmacy when the last dose was administered. She stated she called the pharmacy to authorize getting a dose out of the emergency supply for the dose at 6:00 A.M. on 02/25/24 but the pharmacy was unable to authorize this due to a glitch in their system. She stated the Oxycodone was not delivered from the pharmacy until 02/26/24. She stated she then gave the 02/25/24 10:00 P.M. dose late at 12:15 A.M. on 02/26/24. She confirmed that, although she documented that Resident #50 had no pain during the shift, the resident had chronic pain so she was having pain. She stated she did not know what level of pain the resident had. Interview with the Director of Nursing on 03/06/24 at 11:40 A.M. confirmed Resident #50 did not receive her scheduled pain medication (Oxycodone) from 10:00 P.M. on 02/24/24 to 12:15 A.M. on 02/26/24 (over 26 hours). She stated she did not know why the facility ran out. She stated the nurse was to reorder the medication soon enough that the pharmacy has time to deliver it. This deficiency represents non-compliance investigated under Complaint Number OH00151307.

Based on record review and interview, the facility failed to monitor a resident for worsening shingles and failed to administer as needed stool softeners to prevent a bowel obstruction. This affected one resident (#13) of three residents reviewed for constipation and altered mental status. The facility census was 66. Actual harm occurred on 12/18/23 when Resident #13 was diagnosed with shingles and staff failed to monitor the resident for neurological complications resulting in a neurological change in condition requiring hospitalization and treatment. In addition, on 12/28/23 actual harm occurred to Resident #13, with a diagnosis of constipation, when facility staff failed to assess and monitor the resident and failed to provide ordered medical treatment when the resident did not have a bowel movement for six days resulting in the resident experiencing a bowel obstruction requiring hospitalization and treatment. Findings included: Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, hypertension, type II diabetes, chronic obstructive pulmonary disease, hyperlipidemia, and constipation. Additional diagnoses were added on 01/01/24 including encephalopathy and abdominal distention. Review of a quarterly Minimum Data Set (MDS) assessment completed on 10/03/23 revealed Resident #13 had intact cognition, no behaviors, was always incontinent of bowel, and was dependent on staff for toileting assistance. a. Review of a nursing note dated 12/18/23 at 4:56 P.M. by Licensed Practical Nurse (LPN) #101 revealed Resident #13 called Licensed Practical Nurse (LPN) #101 into her room regarding red, raised areas to her face which appeared to be filled with fluid, and Resident #13 reported they burned and itched. Resident #13 was sent to the emergency department for evaluation for possible shingles. Review of a hospital note from 12/18/23 revealed Resident #13 presented to the emergency department with a facial rash that began three days prior which was consistent with shingles. Resident #13 was discharged from the emergency department back to the facility on [DATE] with a prescription for an anti-viral medication, Valtrex, one 1,000 mg tablet by mouth three times a day for seven days. There was no documented evidence Resident #13 was being monitored to assess her condition related to the diagnosis of shingles to her face and possible neurological complications. Review of a nursing note dated 12/23/23 at 10:29 A.M. by LPN #102 revealed a skin check was completed and no new skin areas or issues were noted for Resident #13. There was no documented evidence the condition of the resident's shingles was assessed. b. Review of Resident #13's care plan revealed Resident #13 was incontinent of bowel and at risk for altered dignity, skin breakdown, diarrhea, and constipation with a goal of having a soft bowel movement at least every three days without any complications including constipation. Interventions included administer medications per physician orders, assess quarterly and as needed for changes in elimination pattern, observe and record bowel movements daily for amount and consistency, and observe and report any diarrhea, constipation, change in bowel movement, and abdominal distention or discomfort. Review of physician's orders revealed orders from 01/01/24 for Dulcolax suppository once a day, Milk of Magnesia (MOM) 400 milligrams (mg) per five milliliters (ml) give 15 ml at bedtime, Miralax 17 grams twice a day, and Sennosides-Docusate Sodium 8.6-50 mg one tablet twice a day. Review of a medication administration record (MAR) from December 2023 revealed Resident #13 had an order started on 11/21/23 for Miralax 17 grams twice a day which one dose was not administered on 12/01/23, 12/07/23, and 12/09/23 due to condition. There was no evidence or explanation of what due to condition meant. Resident #13 had an order for Senna 8.6 mg twice a day ordered on 11/21/23 which one dose was not administered on 12/01/23, 12/07/23, 12/09/23 or 12/10/23 due to condition. There was no evidence or explanation of what due to condition meant. Resident #13 also had an as needed order for Dulcolax suppository 10 mg once a day ordered on 11/21/23 which was not administered in December 2023, Lactulose solution 20 ml twice a day as needed ordered on 11/21/23 which was not administered in December 2023, and Sennosides-Docusate Sodium 8.6-50 mg once a day as needed ordered on 11/22/23 which was not administered in December 2023. Review of Bowel Movement Reports for December 2023 revealed Resident #13 did not have a bowel movement on 12/17/23, 12/19/23, 12/20/23, 12/23/23, 12/24/23, 12/25/23 or 12/26/23. Resident #13 had a small bowel movement on 12/16/23, a medium bowel movement on 12/18/23, a small bowel movement on 12/21/23, a large bowel movement on 12/22/23, and a large bowel movement on 12/27/23. Review of Bowel Control Reports from December 2023 revealed Resident #13 was incontinent. Review of a nursing note dated 12/23/23 at 10:29 A.M. by LPN #102 revealed a skin check was completed and no new skin areas or issues were noted for Resident #13. There was no documented evidence the condition of the resident's shingles was assessed. Review of a nursing note dated 12/28/23 at 10 A.M. by LPN #102 revealed Resident #13 had decreased strength in her right arm, a fixed stare, unable to follow directions, and responded to questions with mumbled and nonsensical speech. A new order was received to send Resident #13 to the emergency department. Review of a hospital note from 12/28/23 revealed Resident #13 presented to the emergency department for altered mental status. Resident #13 was admitted to the hospital with a diagnosis of encephalopathy and abdominal distention. A CT scan of Resident #13's abdomen and pelvis revealed Resident #13 had severe diffuse dilation of the colon and a large amount of stool associated with a chronic obstruction. The resident was admitted to the hospital for treatment. Review of a hospital discharge from 01/01/24 revealed it was undetermined if the encephalopathy was caused by herpes simplex virus or severe constipation. Due to the treatment of constipation, a lumbar puncture would expose the resident to iatrogenic infection. After discussion with the interdisciplinary team a 14 day course of Acyclovir, an anti-viral, was prescribed for treatment as well as Senna S twice daily and Milk of Magnesia. Review of a history and physical completed on 01/03/24 by Physician #300 revealed Resident #13 was treated for constipation with bowel regimen during admission to the hospital from 12/28/23 through 01/01/24. Results of an abdomen radiograph completed on 12/30/23 was reviewed and showed large stool burden predominantly within the distal large bowel, redemonstration of gaseous distention of large bowel, and development of dilated gas-filled small bowel loops which were likely secondary to upstream dilation from the large bowel findings. All findings were likely due to severe constipation of colonic ileus. Interview on 01/16/24 at 1:09 P.M. with Resident #13 revealed before she went to the hospital, Resident #13 went two weeks without having a bowel movement. Resident #13 reported she would let the aides know she had not had a bowel movement when they would come to change her, but no one ever gave her additional medications to help. Resident #13 stated she was still struggling with constipation, but the facility had started to administer stool softeners which has helped. Resident #13 revealed she was now having a bowel movement daily. Interview on 01/16/24 at 3:00 P.M. with the Director of Nursing (DON) revealed there was not a protocol that was followed for constipation specifically. The facility attempts to give the resident prune juice first, then moves on to contacting the physician for orders. The DON reported the resident was flagged after three days of having no bowel movement then administered softeners if it was not their normal bowel pattern. The DON reported water was passed at a minimum of once per shift and staff encourage fluids intakes and offer flavor packets if needed. The DON also reported Resident #13 was sent to the hospital at first due to shingles on her face and wanting to ensure it did not spread to her optic nerve. The DON stated Resident #13 was placed in a private room on isolation until the pustules crusted over. Once Resident #13 was out of isolation, she then had stroke-like symptoms and was sent to the hospital again. The DON reported the facility did track how many days Resident #13 was on isolation precautions but did not have a monitoring system for worsening signs or symptoms of shingles. The DON reported she did not think the nurses put any documentation in the chart regarding monitoring of the pustules to determine if they have crusted over. The DON reported Resident #13 returned from the hospital on 12/18/23 with an order for an anti-viral medication and the medication did not start until 12/20/23 because it had to be delivered from their pharmacy which was located in [NAME] (Ohio). The DON stated two days was the typical wait time for a medication they do not have in the building. The DON confirmed Resident #13 had several days without a bowel movement, but she did have one on 12/18/23, 12/21/23 and 12/27/23. The DON confirmed constipation was not addressed between 12/21/23 and 12/27/23 which was longer than normal. The DON confirmed as needed stool softeners were not given and she was unsure of what not administered due to condition meant for Miralax and Senna. The DON confirmed there were no nursing notes explaining what due to condition meant. The DON stated she was unaware of Resident #13 having an impaction because the hospital and Resident #13's brother did not ever call to let them know. The DON stated she was unaware of the treatment Resident #13 received at the hospital. The DON stated she was unsure why the hospital gave Resident #13 additional doses of an anti-viral to complete. Review of an undated Bowel (Lower Gastrointestinal Tract) Disorders Protocol revealed assessment and recognition of bowel disorders should be assessed by change in mental status or level in consciousness, presence of fecal impaction, signs of dehydration, abdominal assessment, digital rectal exam, all current medications, active diagnoses, and labs. Review of Complications of Shingles dated 05/10/23 from the Center for Disease Control website revealed shingles can also lead to infection of the lungs, hearing problems, brain inflammation (encephalitis), and death. People with weakened immune systems are more likely to have complications from shingles. This deficiency represents non-compliance investigated under Complaint Number OH00149782.

Based on interview, record review, hospital documentation review, and policy review the facility failed to ensure one resident (Resident #63) was free from significant medication errors. This resulted in actual harm to Resident #63 when she was administered Resident #64's medications resulting in Resident #63 requiring transfer to the local emergency room , intubation, and admission to the intensive care unit. This affected one of three residents reviewed for medication errors. The facility census was 62. Findings Include: Closed record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #63 was identified as being allergic to [MEDICATION NAME], and [MEDICATION NAME]. Resident #63 was admitted to the facility with the following physician orders: Tylenol 325 milligrams (mg) as needed for pain every four hours, [MEDICATION NAME] Tablet (a medication used to treat irregular heartbeats) 200 mg one tablet daily, [MEDICATION NAME] (a medication used to treat high blood pressure) 100 mg one tablet one time daily, [MEDICATION NAME] (a medication used to treat anxiety)5 mg two times daily, [MEDICATION NAME] (an antibiotic) 500 mg every eight hours, Vitamin D3(a supplement) 5,000 units daily, [MEDICATION NAME] Sodium (a laxative)100 mg two times daily, Eliquis (a medication used to prevent blood clots) 2.5 mg two times daily , [MEDICATION NAME]-[MEDICATION NAME] (a Schedule II pain tablet) 5-325 mg every eight hours as needed for pain, [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] disorders) 125 micrograms (mcg) daily, [MEDICATION NAME] adhesive patch 5% one patch to lower back in morning and off in evening for pain, liothyronine (used to treat [MEDICAL CONDITION] disorders) 5 mcg daily, losartan (a medication used to treat high blood pressure) 100 mg daily, [MEDICATION NAME] (used to treat depression) 40 mg daily, [MEDICATION NAME] (a stool softener) 17 gram daily, [MEDICATION NAME] (a medication used to decrease inflammation) 20 mg daily, and Senna Plus (a stool softener) 8.6-50 mg daily as needed. Review of the nursing progress notes dated 01/10/20 at 8:30 P.M. indicated Resident #63 arrived at the facility and was a two person assist with transfer to bed. The Physician was notified and medications were verified. Resident #63 denied pain at this time, a skin assessment completed, and staff would continue to monitor. A review of the observation detail note dated 01/11/20 at 8:29 P.M. identified Resident #63 was alert to person, place and time. No cardiac or respiratory concerns were identified, and skin described as warm and moist. The next progress note for Resident #63 was dated 01/13/20 at 11:11 [NAME]M. and indicated Resident #63 was lying in bed, the physician was at the facility and was made aware Resident #63 was lethargic. A new order was received to send Resident #63 to the emergency room for evaluation. The resident and responsible were party notified. Vital signs were documented as blood pressure 60/40, respirations 14, pulse 68 and temperature 97.5 degrees (*) Fahrenheit (F). A review of the facility post acute transfer form dated 01/13/20 at 1:45 [NAME]M. indicated Resident #63 was transferred to the local emergency room per ambulance due to being lethargic, wrong medications administered. A review of facility blood pressure monitoring for Resident #63 indicated on 01/13/20 at 9:00 [NAME]M. blood pressure was 147/81 and at 9:30 [NAME]M. blood pressure was 90/62. On 01/13/20 at 9:38 [NAME]M. blood pressure documentation indicated 106/52 and emesis, at 10:00 [NAME]M. blood pressure was 100/60. On 01/13/20 at 10:30 [NAME]M. blood pressure listed as 80/60 and at 11:00 [NAME]M. blood pressure was 80/52. Review of the medication error report indicated on 01/13/20 at 8:30 [NAME]M., Resident #63 was administered Calcium [MEDICATION NAME] (a dietary supplement) 500 mg, Carvedilol (an antihypertensive medication) 25 mg, [MEDICATION NAME] Silver (a supplement) 0.4 mg - 300 mcg - 250 mcg, [MEDICATION NAME] (an antidepressant) 40 mg, [MEDICATION NAME] HCl (a medication used to treat high blood pressure) 0.1 mg, [MEDICATION NAME] (a diuretic) 20 mg, [MEDICATION NAME] (an anticonvulsive medication) 200 mg, [MEDICATION NAME]-[MEDICATION NAME] (a medication used to treat high blood pressure) 20-12.5 mg, Magnesium oxide ( a supplement) 400 mg, [MEDICATION NAME] (a diabetic medication) 500 mg, [MEDICATION NAME] (a pain medication) 500 mg, [MEDICATION NAME] (a schedule II pain medication) 5 mg, [MEDICATION NAME] (a dietary supplement) 40 mg and Potassium Chloride (a electrolyte replacement) 20 meq. Resident #63 was administered these medications in error as the medications were ordered for her roommate, Resident #64. Review of a statement written by the Assistant Director of Nurses (ADON) on 01/13/20 at 8:55 [NAME]M. indicated Licensed Practical Nurse (LPN) #101 reported she had administered wrong medications to Resident #63. LPN #101 stated she assessed the resident and she appeared fine at this time. The ADON went to Resident #63's room and found the resident out of bed, working with therapy. The resident stated she would like to continue therapy and shower. The ADON noted she then contacted Certified Nurse Practitioner (CNP) #150 who ordered to check Resident #63 blood pressure every 30 minutes for four hours and the nurse practitioner reported she would be at the facility to assess Resident #63. The guardian was also notified and requested the facility to keep her updated on Resident #63's condition. Review of progress note by CNP #150 dated 01/13/20 (no time) indicated Resident #63 was seen due to wrong medications being administered, acute decline in mental status and condition. Resident #63 was evaluated at her bedside and was determined to be medically unstable. Blood pressure documented as 60/palpation and continued to drop. Staff were unable to place intravenous catheter and initiate immediate treatment. Resident #63 had received [MEDICATION NAME] which was identified as an Allergen and multiple anti-hypertensive medications and [MEDICATION NAME]. Resident #63 was noted to have kidney disease and required evaluation in the emergency room with a work up and interventions that were unable to be provided in the facility. Resident #63 was sent out by Emergency Medical Services (EMS), condition was unstable and at risk for [MEDICAL CONDITION]. Review of LPN #101's statement dated 01/14/20 indicated therapy staff had requested pain medication for Resident #64 and LPN #101 had prepared all of Resident #64's morning medications at that time with the addition of obtaining pain medication. LPN #101 reported when she entered the room, therapy was working with Resident #63 and she administered the medications to Resident #63 without checking the resident's identifying wrist band or asking the resident her date of birth. LPN #101 reported she immediately recognized the error and immediately reported to the ADON. Review of the EMS transport record dated 01/13/20 indicated Resident #63 was seen at the facility at 11:57 [NAME]M. at which time blood pressure was 86/48, pulse 72 and respirations 12. Review of the emergency room admission record indicated due to Resident #63 being hypotensive, intravenous (IV) fluids and 500 micrograms (mcg) of [MEDICATION NAME] IV was administered. Resident #63 was noted as becoming a bit more somnolent with a blood pressure in the low 50s systolic. Initial electrocardiogram (EKG) showed a paced rhythm, however, repeat EKG showed significant ectopy and rhythm was widened. Resident #63's blood pressure improved, however, dropped again. Resident #63 was started on [MEDICATION NAME], however, blood pressure remained in the upper 40s and low 50s. When intensive care unit (ICU) staff came to the emergency room to evaluate Resident #63, it was determined to intubate the resident before transporting to ICU due to unstable nature of current condition. Shortly after intubation, Resident #63 was transferred to ICU in critical condition. Review of ICU documentation dated 01/13/20 indicated upon arrival to ICU, a central line was inserted and Resident #63 remained intubated and sedated with family at bedside. During an interview with the Director of Nurses (DON) and Corporate Registered Nurse (RN) #174 on 01/28/20 at 10:37 [NAME]M. they reported on 01/13/20 at 8:30 [NAME]M., Resident #63 was administered Resident #64's medications in error. The DON stated LPN #101 immediately recognized the error and reported it to ADON. The ADON then assessed the resident and called the CNP #150 and notified of the medications administered. CNP #150 ordered Resident #63 to be placed on every 30 minute blood pressure monitoring. The DON and RN #174 reported Resident #63 was then documented to go to therapy and therapy assisted with showering. The DON stated during the shower, Resident #63 had a small amount of emesis and reported she was very tired. Therapy staff assisted Resident #63 back to the room. The DON stated CNP #150 then assessed Resident #63 and had another physician, Physician #151 to assess the resident also. It was at this time the facility received an order to send Resident #63 to the local emergency room ; 911 was called and Resident #63 was transported to the emergency room . On 01/28/20 at 2:16 P.M. interview with the ADON revealed she recalled the incident involving Resident #63. The ADON stated when she arrived at the facility, LPN #101 immediately came to her office and reported she had administered the wrong medication to Resident #63. The ADON reported she asked LPN #101 if she had assessed Resident #63 and she stated yes. LPN #101 reported Resident #63 was wanting to continue therapy. The ADON reported she and LPN #101 assessed Resident #63 and no concerns were immediately identified. The ADON reported she immediately notified CNP #150 and an order to start blood pressure checks every 30 minutes was received and CNP #150 reported she would be in the facility to assess the resident. The ADON reported she and LPN #101 contacted the guardian to inform of the situation. The ADON reported LPN #101 continued to monitor blood pressure and when Resident #63 returned from therapy, noted a change in condition. CNP #150 and Physician #151 were present in the facility and assessed Resident #63 and determined to transfer out of facility for treatment. During an interview with CNP #150 on 01/28/20 at 2:21 P.M., CNP #150 reported she remembered the medication error situation with Resident #63 and had ordered transfer from facility to emergency room for evaluation and treatment. CNP #150 reported the facility had notified her of wrong medications being administered to Resident #63 and she had ordered every 30 minute blood pressure monitoring and was coming to the facility to assess the resident. CNP #150 stated when she assessed Resident #63, found her to be minimally responsive and blood pressure in the 60's. CNP#150 reported Physician #151 was present in the facility and also assessed resident and determined in best practice to transfer immediately to acute care emergency room . On 01/28/20 at 2:40 P.M. during an interview with LPN #101 she stated staff had informed her Resident #64 was requesting pain medication and was with therapy. LPN #101 stated she prepared Resident #64's daily medication and pain medication. LPN #101 stated when she entered the room, therapy staff were working with Resident #63 who appeared tearful and in pain. LPN #101 stated she called Resident #63 by Resident #64's name and offered medications. Resident #63 took the medications, and LPN #101 stated she would return with the [MEDICATION NAME] injection. At this time, Resident #63 stated she had not received any injections since discharged from hospital. LPN #101 stated this alerted her to a possible medication concern and when she returned to the medication cart, she realized she had administered Resident #64's medications to Resident #63. LPN #101 stated she had previously removed a hospital band from Resident #63's arm per resident request, however, did not look at the resident's name on the band since she responded to Resident #64's name. LPN #101 confirmed she had not looked at the resident's identification bracelet and later discovered the bracelet was on Resident #63's upper arm instead of wrist. LPN #101 stated she immediately informed the ADON who notified CNP #150 and blood pressure monitoring occurred every 30 minutes. LPN #101 reported Resident #63 went to therapy, however, after returning, her blood pressure started dropping and that was when CNP #150 was present and ordered Resident #63 transferred to acute care facility. Review of facility policy titled Medication Administration, dated 09/08/17, revealed medications would be administered as prescribed and in accordance with written orders of the attending physician. Residents were to be identified before medication administered by checking identification band, check photograph attached to medical record, call resident by name and if necessary, verify resident identification with other facility personnel. This deficiency substantiates Complaints Number OH 752, OH 598.