Every finding on record at Altercare of Navarre CTR for Rehab & NRSG Care

Based on closed record review, facility investigation review, interviews and facility policy review, the facility failed to comprehensively assess and seek necessary medical intervention following an acute change in condition for Resident #93. This resulted in Immediate Jeopardy and serious injury, harm, significant impairment or death beginning on [DATE] at 7:00 P.M. when Resident #93, who was cognitively intact, was observed with slurred speech, a dazed/altered presentation, reported emesis, and an inability to independently operate his motorized wheelchair. Despite the identified acute change in condition, nursing staff failed to comprehensively assess the resident and notify the medical provider for direction and/or treatment. Following the change in condition, the resident received scheduled sedative medications, and experienced additional episodes of vomiting. He was placed on his Bi-pap (oxygen via a special mask that forces air into the lungs) machine without appropriate assessment or medical evaluation despite signs and symptoms of a change in condition. Resident #93 was found deceased on [DATE] at 6:30 A.M. with vomit present in his bi-pap mask. This affected one resident (Resident #93) of four residents reviewed for condition change. The facility census was 90.On [DATE] at 2:00 P.M. the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Regional Nurse Consultant (RNC) #607 were notified Immediate Jeopardy began on [DATE] when Resident #93 exhibited an acute change in condition and was not comprehensively assessed nor was the resident's status reported to the medical provider. The resident was administered multiple sedating medications despite neurological changes and vomiting. The resident was then placed on his BiPap machine without a nursing assessment. Resident #93 was subsequently found deceased the next morning at 6:30 A.M. with vomit in his Bi-Pap mask. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions:On [DATE] at 7:03 A.M., Nurse Practitioner #600 was notified that Resident #9 expired. On [DATE] at 7:03 A.M., Resident #9's family was notified that the resident expired. On [DATE] at 9:00 A.M., Regional Nurse Consultant (RNC) #607 began the investigation and staff interviews. This included staff assigned to Resident #9's care on [DATE] from 2:30 P.M. to [DATE] at 6:30 A.M. (Registered Nurse (RN) #410: Licensed Practical Nurse (LPN) #230, #600, #288: Certified Medication Aide (CMA) #256 and #389; and Certified Nursing Assistant (CNA) #424 and #335). On [DATE] at approximately 2:30 P.M., the RNC #607 interviewed Assisted Living Resident #7 who was noted to be visiting with Resident #9 on [DATE]. AL Resident #7 stated she provided alcohol to Resident #9. RNC #607 provided education to AL Resident #7 regarding not bringing alcohol into the facility. On [DATE] LPN #100 was suspended pending the investigation. LPN #100 resigned on [DATE]. On [DATE] at 1:30 P.M., the Director of Nursing (DON) audited all 88 in-house residents for the previous 14 days to ensure that if any change in resident condition was identified, the resident was assessed and the medical provider was notified of the change in condition and the notification was documented in the medical record. On [DATE] at 3:30 P.M RNC #607 completed a root cause analysis (RCA). The root cause identified was a change in the resident's condition and the medical provider was not notified for further direction. On [DATE] from 11:00 A.M. to [DATE] at 9:30 P.M. education was given via lecture and text by the DON for all licensed nurses on the facility's Change in Condition policy with emphasis on assessment of the resident, notifying the provider of any change in resident condition and documenting the notification in the medical record. This education was provided to 13 in-house LPNs, and four in house RNs. Additionally, two agency LPNs (LPN #609 and #610) and two agency RNs (RN #605 and #608) were educated. Upon hire, all new registered and licensed nurses will be educated by the DON/designee during orientation. Agency staff will receive education prior to their scheduled shift. On [DATE] at 1:30 P.M., an in-person Ad Hoc (not scheduled) Quality Assurance (QA) meeting was completed with the Administrator, DON, RNC #607, and Medical Director #800 were in attendance related to the event with discussion of the plan including education, root cause, and audits. MD #800 agreed with the plan and no changes were made. On [DATE] at 11:30 A.M., RNC #607 reviewed all 88 in-house residents' medical records from [DATE] to [DATE] to ensure that if any change in resident condition was identified that the provider was notified and notification was documented in the medical record. No concerns were identified. Beginning on [DATE], the DON/designee will review all current in-house residents medical record daily for seven days, then three times a week for three weeks and then as needed (PRN) to ensure any resident with a change in condition had the provider notified timely and that notification was documented in the medical record On [DATE] at 11:00 A.M., education was initiated via lecture and text by the Assistant Director of Nursing (ADON) for all Certified Medication Aides (CMA) on notifying the nurse of a change in condition with a resident prior to medication administration. This was completed for all seven of the CMAs that work in the facility. Upon hire, all new CMAs will be educated by the DON/designee on the above information. On [DATE] at 4:00 P.M. the DON audited all in-house residents for the previous 14 days to ensure that if any change in resident condition was identified that an assessment was completed prior to administration of medications and the findings documented in the medical record. No concerns were identified. Beginning on [DATE], the DON/designee with review all current in-house residents' (with Bi-Pap orders) medical record daily for seven days, then three times a week for three weeks and then PRN to ensure that if any change in resident condition was identified that an assessment was completed prior to applying the resident's Bi-Pap mask and is documented in the medical record. Currently Residents #1, #2, #3, #4, #5 and #6 have Bi-Pap orders. Starting on [DATE], the DON/designee with review all current in-house residents' medical record daily for seven days, then three times a week for three weeks and then PRN to ensure that if any change in resident condition was identified, an assessment is completed prior to administering medications and the assessment is documented in the medical record. Any concerns identified with the audits will be forwarded to Quality Assurance Performance Improvement (QAPI) committee weekly for four weeks and as needed for immediate follow-up. The Administrator will be responsible for ongoing compliance.Although the Immediate Jeopardy was removed on [DATE], 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: Closed record review revealed Resident #93 was admitted to the facility on [DATE] with diagnoses including quadriplegia, neurogenic bladder (a lack of bladder control related to brain, nerve or spinal cord damage), chronic respiratory failure, type two diabetes, depression, anxiety, chronic obstructive pulmonary disease (COPD), and asthma. Resident #93's advanced directive was Do Not Resuscitate Comfort Care Arrest (DNRCC-A) (a resident receives full medical care and life-saving treatments until their heart or breathing stops. Once cardiac or respiratory arrest occurs, resuscitation is stopped and only comfort care (pain relief and symptom management) is provided). Review of Resident #93's activities of Daily Living (ADL) care plan dated [DATE] revealed Resident #93 was dependent on staff for all cares, had limited range of motion of all extremities, used a touch pad call light and used an electric wheelchair for mobility (independently) related to quadriplegia. Resident #93 also received medications for depression, anxiety, chronic pain, and insomnia. Further review of the care plan revealed Resident #93 was at risk for impaired gas exchange and required the use of a BiPAP while asleep, dated [DATE]. Review of Resident #93's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 (out of a possible score of 15). The assessment revealed Resident #93 was dependent on staff for activities of daily living (ADL) tasks including transfers, eating, had limited range of motion of all extremities, had a urinary catheter, and used a bi-level positive airway pressure (BiPAP) (non-invasive medical device that uses a mask and pressurized air) for assistance in breathing while asleep. Review of Resident #93's [DATE] physician orders revealed orders to include Xanax 0.5 milligrams (mg) give one half tab twice a day, Lyrica 150 mg administer two capsules twice a day, Tizanidine 4 mg administer two tablets at bedtime, Ambien 5mg administer one capsule at bedtime and Trazadone administer 50 mg tablet at bedtime. Additionally, the resident had an order to wear his BiPap at night for obstructive sleep apnea. Review of Resident #93's progress notes, dated [DATE] at 8:00 P.M. and authored by LPN #600, revealed the resident received a package at the facility and the nurse went to notify him (outside in the courtyard) Resident #93 was acting strange, and staff manually pushed Resident #93 back to his room (he was in his motorized wheelchair). The DON instructed the nurse to change the resident's suprapubic catheter (to obtain a urine specimen due to the resident's change in condition) but the resident refused. He also refused his scheduled medications and to be assisted to bed. Further review of the nurse progress notes revealed no documentation regarding the resident's status, medical practitioner notification or follow-up related to the resident's condition change. Review of Resident #93's [DATE] Medication Administration Record (MAR) revealed he received Ambien (induces sleep), Xanax (anti-anxiety medication), Tizanidine (muscle relaxant) Trazadone (anti-depressant also used to induce sleep) and Lyrica on [DATE] at bedtime. Review of the Treatment Administration Record (TAR) for [DATE] revealed the resident's BiPap was applied by CMA #256 at bedtime on [DATE]. Review of Resident #93's progress note dated [DATE] at 6:00 A.M. and authored by LPN #288, revealed Resident #93 had an emesis last night at approximately 10:00 P.M. Slept through the night with no further emesis. Review of Resident #93's progress note dated [DATE] at 6:30 A.M. and authored by LPN #288, revealed a nurse aide entered Resident #93's room and he was not responding to verbal and touch stimuli. LPN #288 checked for heartbeat and blood pressure; vital signs had ceased. Review of Resident #93's progress note dated [DATE] at 7:03 A.M. and authored by LPN #288, revealed Resident #93's mother was notified and Certified Nurse Practitioner (CNP) #606 was notified. Review of Resident #93's progress note dated [DATE] at 8:03 A.M. and authored by RN #605 revealed Resident #93's body was released to the funeral home. Review of the facility investigation related to Resident #93, initiated [DATE], revealed a root cause analysis (RCA) was completed by RNC #607. Review of the RCA revealed that after review of the incident, it was determined that the licensed nurse (LPN #600) did not notify the provider after identifying a change in Resident #93's condition. The primary root cause was a failure to follow the facility's change in condition notification policy related to not following the directive of a supervisor to notify the provider. The cause of this, based on the licensed nurse's statement, is that she did not recall being given the directive although based on further conversation, the licensed nurse (LPN #600) stated she should have notified the provider (of the resident's condition change). Further review of the investigation revealed the following staff statements were obtained: Review of LPN #600's statement dated [DATE] revealed she worked from 2:30 P.M. to 8:00 P.M. on [DATE] (it was identified through the onsite investigation, the LPN clocked out at 10:51 P.M.), on the 200 unit. Around 7:00 P.M., she went to the front desk and realized Resident #93 had a package delivered to the facility and she delivered the package to the resident's room. After she delivered the package to his room, she found the resident sitting outside in the courtyard and she went out to notify him she placed the package in his room. She noticed that he was slurring his words and seemed strange. At that time, CMA #256 also came outside to check on the resident and LPN #600 asked the CMA if his speech was usually slurred and the CMA said yes since he didn't have his teeth in place. LPN #600 placed the resident's motorized wheelchair in manual mode because he seemed to not understand what was occurring. She and the CMA took Resident #93 back to his room. LPN #600 noticed RN #410 was on the unit so LPN #600 asked the RN to come to the resident's room. RN #410 said to get a set of vital signs and as the LPN was leaving Resident #93's room, the CMA was taking the resident's vital signs. LPN #600 returned to her unit. LPN #600 called the DON at 7:24 P.M. but there was no answer. The DON returned her call at 7:47 P.M. and, from what the LPN could remember, she informed the DON Resident #93 was acting strange. The DON told her Resident #93 had an order to change his catheter and to obtain a urinalysis. The DON instructed LPN #600 to do that (since he was acting strange). LPN #600 denied the DON told her to contact the medical provider. The LPN went to Resident #93's room to explain to him she needed to change his catheter, but the resident refused and asked LPN #600 why she was mad at him. LPN #600 identified the resident had a suprapubic catheter and she asked RN #410 to assist her, but the RN said she would just notify the night shift nurse to complete the catheter change. The CMA came to LPN #600 with the medication cart keys and reported she was going on break. CMA #256 reported Resident #93 refused his pills and (refused) to go to bed. The LPN reported CMA #256 retrieved her keys after break and LPN #600 remained on her assigned unit until her shift was finished. She reported when it was time to clock out, CMA #256 reported Resident #93 seemed much better. She said he had one emesis but took his medications and went to bed. LPN #600 left the building after that. Review of CMA #256's statement, dated [DATE], revealed she was the CMA passing medications on 400 unit (Resident #93's unit) on [DATE], second shift (3-11 shift). She stated the resident was in bed (like his normal) when she started her shift. She and a CNA went to his room around 3:00 P.M. to get him out of bed. Once he was up, he went outside to the courtyard. When he came inside at dinnertime, he didn't feel like eating and went to the therapy gym. Around 5:00 P.M. he went to his room, and the CNA (unidentified) fed him dinner. Around 5:30 P.M. he told the CMA he was going back outside to sit in the courtyard. Around 7:00 P.M. the CMA went out to check on him, and LPN #600 was outside with Resident #93. LPN #600 told the CMA that Resident #93 was acting strange. He seemed different to CMA #256. Per the statement, the CMA said the resident was kind of dazed and he told me he didn't feel good. Around 7:30 P.M., LPN #600 pushed him, in his wheelchair, back to his room. Resident #93 kept telling us he was fine and he just wanted to go to bed. The other nurse, RN #410, happened to be on the unit, so she came to check on Resident #93, too. RN #410 told LPN #600 to call the on-call provider to report the change (in condition) and to get vital signs. The CMA took vital signs right away and his blood pressure was 87/57 millimeters (mm) of mercury (Hg) (normal is 120/60 mmHg). The CMA stayed with the resident and took his vital signs a few more times and then the CMA and the CNA laid him down per his request. Around 8:20 P.M. the CMA went on her lunch break and gave LPN #600 the keys (to the medication cart) and the resident's vital signs (she had taken). When the CMA returned around 8:50 P.M., she checked on Resident #93 who was sleeping. She went and got her keys from LPN #600 and the LPN asked if the CMA had checked Resident 93 recently. The CMA reported the resident was sleeping and LPN #600 said she hadn't called the on-call provider yet. Around 10:00 P.M. the unidentified CNA went to the resident's room to check on him, and he said he was going to throw up. The CNA yelled for CMA #256 to come to the resident's room. They got him a basin, and he threw up one time. The CMA reported the resident was back to acting like himself and reported he felt better after throwing up. The resident wanted his BiPap on but per the CMA, staff asked him to wait (because of vomiting) but he said no, that he wanted it on. The staff left the head of his bed up before leaving the resident's room (and applied his BiPap). When the CMA was clocking out (at the end of her shift), she saw LPN #600 at the time clock. The LPN asked if Resident #93 was ok and the CMA told LPN #600 he seemed better but had thrown up once. The CMA reported she asked LPN #600 if she had contacted the on-call (medical provider) and the LPN said yes. The CMA left the facility. Review of RN #410's statement dated [DATE] revealed she was working second shift on the 300 unit and at 7:00 P.M. she went to the 400 unit to pull a medication from the starter box (get a medication from their off hours stock medication system) and noted LPN #600 and CMA #256 were in Resident #93's room. LPN #600 asked the RN to give her opinion on how the resident was acting. When the RN entered the room, the resident seemed to be upset asking everyone why they were mad at him. He was slurring his words and not making much sense. RN #410 said she told LPN #600 to call the on-call medical provider and get the resident's vital signs. When RN #410 left the room, LPN #600 was on the phone (and the RN assumed the LPN was contacting the medical provider) and the CMA was getting the resident's vital signs. The RN returned to her unit. RN #410 stated LPN #600 asked if she would assist with changing Resident #93's catheter to which the RN replied she would after her break, but LPN #600 never came back to RN #410's unit so she assumed the task was completed. As she was clocking out, she heard CMA #256 tell LPN #600 that Resident #93 seemed much better and was mentally back to baseline. Review of CNA #335's statement dated [DATE] revealed she was the CNA who worked on the 400 hall on [DATE], night shift. She got report that Resident #93 had thrown up one time around 10:0 P.M. but stated he felt better and was sleeping in bed with his BiPap on. The CNA stated she went into the resident's room around 11:00 P.M. and he was sleeping. Around 5:30 A.M. she emptied his catheter and reported he was sleeping when she was in the room at that time and there were no signs of anything wrong. Review of LPN # 288's statement dated [DATE] revealed she was the nurse for night shift on [DATE] scheduled to work on the 400 unit. During report she was told the resident had one episode of emesis around 10:00 P.M. on second shift. She checked on him around 1:00 A.M. and he was sleeping with his BiPap on and his head slightly elevated. Around 6:30 A.M. CNA #389 told her she needed to come to Resident #93's room and the resident was without signs of life. Review of CNA #389's statement dated [DATE] revealed she entered Resident #93's room around 6:35 A.M. at the start of her shift (on [DATE]). When she first walked in, she thought the resident was sleeping but she walked up to the bed and realized he had passed away. He had his BiPap on and was lying on his back. She took off his BiPap and noticed there was some vomit in the mask. She yelled for the other aide to go get the nurse. LPN #288 came into the room and determined that he passed away. Interview on [DATE] at 9:09 A.M. with CMA #256 revealed Resident #93 had gotten up from being in bed and went outside at approximately 3:30 P.M., then came back into the facility for dinner. CMA #256 obtained Resident #93's blood pressure reading of 90/55 mmHg and held Resident #93's medication baclofen per physician order. Resident #93 didn't want to eat dinner immediately, so he went to the therapy gym, then came back to his room, and requested dinner. CNA #335 fed Resident #93 dinner and then he went back outside to the courtyard with a peer resident (Resident #88). At approximately 6:30 P.M., an Assisted Living resident (AL Resident #7) came in and requested staff assistance for Resident #93 for complaints about not feeling well. LPN #600 was already outside in the courtyard with Resident #93. Resident #93 had slurred speech, had a dazed look and was complaining of not feeling well. Resident #93 reported he had vomited two times prior to staff coming out to the courtyard and kept saying he was hot, but his skin was cool to touch. Resident #93 could not control his electric wheelchair, and it had to be put in manual mode to push Resident #93 into his room. Registered Nurse (RN) #410 was on the unit when Resident #93 was brought inside from the courtyard. RN #410 advised LPN #600 to notify the on-call Certified Nurse Practitioner concerning Resident #93's change in condition. Resident #93 requested to stay in his wheelchair for approximately 20 minutes and then was placed in bed by staff where Resident #93 promptly went to sleep. CMA #256 stated Resident #93's night medications were held and not given until CMA #256 had received clarification from LPN #600 to administer the medications. At 9:30 P.M. Resident #93 woke up and CMA #256 administered his night medications including Xanax, Lyrica, Tizanidine, Ambien and Trazadone. CMA #256 stated LPN #600 had not notified CNP #606 of Resident #93's change in condition but she administered Resident #93's night medications so they would not be late for administration. At approximately 10:00 P.M. Resident #93 activated his call light with complaints of not feeling well and began to vomit. After two episodes of vomiting Resident #93 said he felt better and requested the BiPap to be put in place. CNA #335 attempted to education Resident #93 of the risks of wearing his BiPap with being sick, but Resident #93 insisted on wearing the BiPap mask and CNA #335 put the mask in place. The CMA verified the nurse was not aware of the emesis (until the end of the shift) or the resident's request to wear his BiPap mask. Interview on [DATE] 11:41 A.M. with LPN #600 revealed at approximately 6:15 P.M. on [DATE], she noticed a package in the front lobby addressed to Resident #93. LPN #600 took the package to Resident #93's room but he wasn't there so LPN #600 placed the package in the room and went to find Resident #93 to notify him what had been done. LPN #600 observed Resident #93 outside in the courtyard with a peer resident (Resident #88) and an assisted living resident (AL Resident #7). Resident #93 was acting strange with slurred speech and the inability to control his electric wheelchair. LPN #600 and CMA #256 put the electric wheelchair in manual mode and pushed Resident #93 to his room. Resident #93 continually asked the staff if they were mad at him. RN #410 directed LPN #600 to notify the on-call CNP concerning how Resident #93 was acting. LPN #600 stated the DON notified LPN #600 to change Resident #93's urinary catheter to obtain a urinalysis and urine culture to be sent to the laboratory because the resident was acting strange. At approximately 8:30 P.M. CMA #256 gave the 400 hallway medication cart keys to LPN #600 and went on lunch break. CMA #256 returned from lunch break and asked LPN #600 if the on-call CNP had been notified of Resident #93's change in condition and if she was able to administer Resident #93's night medications. LPN #600 verified the on-call CNP had not been notified, and it was OK to administer Resident #93's night medications. LPN #600 verified she had not completed an assessment for Resident #93's change in condition. At 10:00 P.M., CMA #256 notified LPN #600 Resident #93 had vomited two times but there was no assessment completed or notification to the medical provider. The LPN confirmed she left the facility around 10:30 P.M. Interview on [DATE] at 8:31 A.M. with assisted living (AL) Resident #7 revealed during the afternoon at approximately 3:45 P.M. on [DATE] she had poured a shot (per the AL resident, approximately half of a 16 ounce (oz) Styrofoam cup) of Fireball Liquor for Resident #93 to consume. AL Resident #7 stated the two of them had gone outside to the back entrance of the facility. AL Resident #7 held the cup for Resident #93 as he consumed the liquor through a straw and stated Resident #93 was acting his usual self at that time. They both went back into the facility for dinner. Later in the evening, AL Resident #7 stated she had gone outside to the courtyard and observed Resident #93 acting strange, so she went to get staff to come and help Resident #93. AL Resident #7 stated she had witnessed Resident #93 vomit one time while she was outside in the courtyard. The resident shared she did not inform staff she had provided alcohol to the resident on the date of the incident but did tell the staff (did not identify who) during a conversation at a later date. Interview on [DATE] at 3:58 P.M. with Resident #88 revealed in the evening of [DATE] at approximately 5:45 P.M. she and Resident #93 went outside to the courtyard and sat in the direct sunlight for approximately an hour. Resident #88 stated Resident #93 began to state he was not feeling well and Resident #93 vomited a small amount at that time. Resident #88 called AL Resident #7 to come out to the courtyard to help Resident #93. AL Resident #7 came outside to the courtyard and Resident #93 vomited again (into a trash bag). AL Resident #7 went inside the facility to get staff to help Resident #93. LPN #600 and CMA #256 responded. LPN #600 and CMA #256 placed Resident #93's electric wheelchair in manual mode and pushed him into the facility. Resident #93 kept stating he did not need the staff members' help. Resident #88 stated Resident #93 was fine when they went outside and never reported consuming alcohol. Interview on [DATE] at 11:00 A.M. with CNA #389 revealed on the morning of [DATE] at 6:30 A.M., CNA #389 entered Resident #93's room to begin morning care and get him up. The CNA observed Resident #93's head slightly elevated and he was not responding or breathing. CNA #389 stated Resident #93 was cold to touch, his BiPap mask was in place, the machine was turned on, and emesis was noted in the mask. CNA #389 immediately notified LPN #288. Interview on [DATE] at 4:00 P.M. with LPN #288 revealed she received report of Resident #93's vomiting at 10:00 P.M. on [DATE]. At approximately 1:00 A.M. on [DATE], LPN #288 peeked in on Resident #93, who appeared to be sleeping. At 6:30 A.M. on [DATE], LPN #288 was notified by CNA #389 that Resident #93 was unresponsive and not breathing. LPN #288 entered Resident #93's room and observed CNA #389 standing beside the bed with Resident #93's BiPap mask removed from his face and emesis noted in the mask. LPN #288 assessed Resident #93 and identified the resident was cool to touch, had no respirations, heart rate or blood pressure. LPN #288 notified the ADON and the on-call CNP of Resident #93 being found deceased . Interview on [DATE] at 12:04 P.M. with LPN #600 revealed, at the time Resident #93 was observed with slurred speech, she had asked the two residents accompanying Resident #93 in the courtyard if they had given him any drugs or alcohol. Resident #88 denied providing either substance, but AL Resident #7 did not respond. LPN #600 further reported she was suspended pending the investigation into Resident #93's death but she called back to the facility a few hours later (after her suspension) and resigned. The LPN shared she was busy the night of the incident and didn't have the time to do everything she needed to complete. LPN #600 verified she was aware the resident had a condition change, and it had not been reported to the medical provider but should have been. Interview on [DATE] at 10:36 A.M. with Certified Nurse Practitioner (CNP) #606 revealed she was not notified the evening on [DATE] concerning Resident #93's acute change in condition. CNP #606 stated there are expectations of the nurses to notify her of changes in condition of the residents. CNP #606 stated with the symptoms Resident #93 presented with that evening, she would have ordered for him to be sent out to the hospital and would have directed staff to not administer his medications because they were high risk medications (induce sedation, drowsiness). Interview on [DATE] at 7:45 A.M. with the DON verified the staff failed to complete a comprehensive assessment regarding Resident #93's acute condition change, failed to notify the medical provider of the resident's condition and to obtain guidance or orders on how to proceed with care for Resident #93 on [DATE]. The DON also confirmed the resident did not have a follow-up evaluation related to additional emesis or an assessment of the resident's status related to the use of the resident's BiPap machine, however, this would have been her expectation. The DON confirmed the resident was deceased the following morning and the medical provider was unaware of his condition the night before. The DON also confirmed AL Resident #7 informed her and the RNC she provided Resident #93 with alcohol the night of [DATE]. Review of the facility's policy titled Change in the Resident's Condition or Status dated [DATE] revealed the nurses will immediately notify the resident; consult with the resident's attending physician, on call physician, nurse practitioner, physician assistant or clinical nurse specialist and notify the resident's authorized representative or interested family member when there is: a significant change in the resident's physical, mental, or psychological status. Review of the facility Provider Notification Protocol dated 06/2023 revealed the following are examples of situations requiring immediate notification: any significant change in physical or mental status from baseline. Before calling the provider, please do a complete physical assessment and use SBAR. This deficiency represents non-compliance investigated under Master Complaint Number 3132376 and Complaint Numbers 3132194, and 3124350.

Based on closed record review, interview, job description review, policy review and Ohio Board of Nursing standards of practice review the facility failed to ensure nursing services met professional standards of quality care when a licensed practical nurse failed to assess and report changes in a resident's condition to the medical provider. This affected one resident (Resident #93) of four residents reviewed for condition change. The facility census was 90. Findings Include:Closed record review revealed Resident #93 was admitted to the facility on [DATE] with diagnoses including quadriplegia, neurogenic bladder (a lack of bladder control related to brain, nerve or spinal cord damage), chronic respiratory failure, type two diabetes, depression, anxiety, chronic obstructive pulmonary disease (COPD), and asthma. The resident was discharged from the facility on [DATE].Review of Resident #93's comprehensive care plan revealed a problem dated [DATE]. Resident #93 utilized a touch pad call light related to bilateral upper extremity impairment with interventions including check frequently in (his) room. Further review of the care plan revealed a problem dated [DATE] related to the resident had cardiac impairment related to hypertension with interventions including observe for complaints of dizziness, elevated blood pressure, pulse or respirations; obtain vital signs as ordered and as needed; Report to physician any complaints of nausea or dizziness. Review of Resident #93's progress notes, dated [DATE] at 8:00 P.M. and authored by Licensed Practical Nurse (LPN) #600, revealed the resident received a package at the facility and the nurse went to notify him (outside in the courtyard) Resident #93 was acting strange, and staff manually pushed Resident #93 back to his room (he was in his motorized wheelchair). The DON instructed the nurse to change the resident's suprapubic catheter (to obtain a urine specimen due to the resident's change in condition) but the resident refused. He also refused his scheduled medications and to be assisted to bed. Further review of the nurse progress notes revealed no documentation regarding the resident's status, medical practitioner notification or follow-up related to the resident's condition change.Review of Resident #93's progress note dated [DATE] at 6:00 A.M. and authored by LPN #288, revealed Resident #93 had an emesis last night at approximately 10:00 P.M. Slept through the night with no further emesis.Review of Resident #93's progress note dated [DATE] at 6:30 A.M. and authored by LPN #288, revealed a nurse aide entered Resident #93's room and he was not responding to verbal and touch stimuli. LPN #288 checked for heartbeat and blood pressure; vital signs had ceased. Review of the facility investigation related to Resident #93, initiated [DATE], revealed a root cause analysis (RCA) was completed by Regional Nurse Consultant (RNC) #607. Review of the RCA revealed that after review of the incident, it was determined that the licensed nurse (LPN #600) did not notify the provider after identifying a change in Resident #93's condition. The primary root cause was a failure to follow the facility's change in condition notification policy related to not following the directive of a supervisor to notify the provider. The cause of this, based on the licensed nurse's statement, is that she did not recall being given the directive although based on further conversation, the licensed nurse (LPN #600) stated she should have notified the provider (of the resident's condition change).Review of Certified Medication Aide (CMA) #256's statement, dated [DATE], revealed she was the CMA passing medications on 400 unit (Resident #93's unit) on [DATE], second shift (3-11 shift). LPN #600 told the CMA that Resident #93 was acting strange. He seemed different to CMA #256. Per the statement, the CMA said the resident was kind of dazed and he told me he didn't feel good. The other nurse, Registered Nurse (RN) #410, happened to be on the unit, so she came to check on Resident #93, too. RN #410 told LPN #600 to call the on-call provider to report the change (in condition) and to get vital signs. The CMA took vital signs right away and his blood pressure was 87/57 millimeters (mm) of mercury (Hg) (normal is 120/60 mmHg). Around 8:20 P.M. the CMA went on her lunch break and gave LPN #600 the keys (to the medication cart) and the resident's vital signs (she had taken). When the CMA returned around 8:50 P.M., she checked on Resident #93 who was sleeping. She went and got her keys from LPN #600 and the LPN asked if the CMA had checked Resident 93 recently. The CMA reported the resident was sleeping and LPN #600 said she hadn't called the on-call provider yet. Review of RN #410's statement dated [DATE] revealed she was working second shift on the 300 unit and at 7:00 P.M. she went to the 400 unit to pull a medication from the starter box (get a medication from their off hours stock medication system) and noted LPN #600 and CMA #256 were in Resident #93's room. LPN #600 asked the RN to give her opinion on how the resident was acting. When the RN entered the room, the resident seemed to be upset asking everyone why they were mad at him. He was slurring his words and not making much sense. RN #410 said she told LPN #600 to call the on-call medical provider and get the resident's vital signs. When RN #410 left the room, LPN #600 was on the phone (and the RN assumed the LPN was contacting the medical provider) and the CMA was getting the resident's vital signs. The RN returned to her unit. As she was clocking out, she heard CMA #256 tell LPN #600 that Resident #93 seemed much better and was mentally back to baseline.Interview on [DATE] at 9:09 A.M. with CMA #256 revealed Resident #93 had gotten up from being in bed and went outside at approximately 3:30 P.M., then came back into the facility for dinner. CMA #256 obtained Resident #93's blood pressure reading of 90/55 mmHg and held Resident #93's medication baclofen per physician order. At approximately 6:30 P.M., an Assisted Living resident (AL Resident #7) came in and requested staff assistance for Resident #93 for complaints about not feeling well. LPN #600 was already outside in the courtyard with Resident #93. Resident #93 had slurred speech, had a dazed look and was complaining of not feeling well. Resident #93 reported he had vomited two times prior to staff coming out to the courtyard and kept saying he was hot, but his skin was cool to touch. Resident #93 could not control his electric wheelchair, and it had to be put in manual mode to push Resident #93 into his room. Registered Nurse (RN) #410 was on the unit when Resident #93 was brought inside from the courtyard. RN #410 advised LPN #600 to notify the on-call Certified Nurse Practitioner concerning Resident #93's change in condition. CMA #256 stated Resident #93's night medications were held and not given until CMA #256 had received clarification from LPN #600 to administer the medications. At 9:30 P.M. Resident #93 woke up and CMA #256 administered his night medications including Xanax, Lyrica, Tizanidine, Ambien and Trazadone. CMA #256 stated LPN #600 had not notified CNP #606 of Resident #93's change in condition but she administered Resident #93's night medications so they would not be late for administration. At approximately 10:00 P.M. Resident #93 activated his call light with complaints of not feeling well and began to vomit. After two episodes of vomiting Resident #93 said he felt better and requested the BiPap to be put in place. Certified Nursing Assistant (CNA) #335 attempted to education Resident #93 of the risks of wearing his BiPap with being sick, but Resident #93 insisted on wearing the BiPap mask and CNA #335 put the mask in place. The CMA verified the nurse was not aware of the emesis (until the end of the shift) or the resident's request to wear his BiPap mask.Interview on [DATE] 11:41 A.M. with LPN #600 revealed at approximately 6:15 P.M. on [DATE], she noticed a package in the front lobby addressed to Resident #93. LPN #600 took the package to Resident #93's room but he wasn't there so LPN #600 placed the package in the room and went to find Resident #93 to notify him what had been done. LPN #600 observed Resident #93 outside in the courtyard with a peer resident (Resident #88) and an assisted living resident (AL Resident #7). Resident #93 was acting strange with slurred speech and the inability to control his electric wheelchair. LPN #600 and CMA #256 put the electric wheelchair in manual mode and pushed Resident #93 to his room. Resident #93 continually asked the staff if they were mad at him. RN #410 directed LPN #600 to notify the on-call CNP concerning how Resident #93 was acting. LPN #600 stated the DON notified LPN #600 to change Resident #93's urinary catheter to obtain a urinalysis and urine culture to be sent to the laboratory because the resident was acting strange. At approximately 8:30 P.M. CMA #256 gave the 400 hallway medication cart keys to LPN #600 and went on lunch break. CMA #256 returned from lunch break and asked LPN #600 if the on-call CNP had been notified of Resident #93's change in condition and if she was able to administer Resident #93's night medications. LPN #600 verified the on-call CNP had not been notified, and it was OK to administer Resident #93's night medications. LPN #600 verified she had not completed an assessment for Resident #93's change in condition. At 10:00 P.M., CMA #256 notified LPN #600 Resident #93 had vomited two times but there was no assessment completed or notification to the medical provider. The LPN confirmed she left the facility around 10:30 P.M. Interview on [DATE] at 4:00 P.M. with LPN #288 revealed she received report of Resident #93's vomiting at 10:00 P.M. on [DATE]. At approximately 1:00 A.M. on [DATE], LPN #288 peeked in on Resident #93, who appeared to be sleeping. At 6:30 A.M. on [DATE], LPN #288 was notified by CNA #389 that Resident #93 was unresponsive and not breathing. LPN #288 entered Resident #93's room and observed CNA #389 standing beside the bed with Resident #93's BiPap mask removed from his face and emesis noted in the mask. LPN #288 assessed Resident #93 and identified the resident was cool to touch, had no respirations, heart rate or blood pressure. Interview on [DATE] at 12:04 P.M. with LPN #600 revealed she was suspended pending the investigation into Resident #93's death but she called back to the facility a few hours later (after her suspension) and resigned (she did not say why). The LPN shared she was busy the night of the incident and didn't have the time to do everything she needed to complete. LPN #600 verified she was aware the resident had a condition change, and it had not been reported to the medical provider but should have been. Interview on [DATE] at 10:36 A.M. with Certified Nurse Practitioner (CNP) #606 revealed she was not notified the evening on [DATE] concerning Resident #93's acute change in condition. CNP #606 stated there are expectations of the nurses to notify her of changes in condition of the residents. CNP #606 stated with the symptoms Resident #93 presented with that evening, she would have ordered for him to be sent out to the hospital and would have directed staff to not administer his medications because they were high risk medications (induce sedation, drowsiness).Interview on [DATE] at 7:45 A.M. with the DON verified the staff (LPN #600) failed to complete a comprehensive assessment regarding Resident #93's acute condition change, failed to notify the medical provider of the resident's condition, despite direction by RN #410, and to obtain guidance or orders on how to proceed with care for Resident #93 on [DATE]. The DON also confirmed the resident did not have a follow-up evaluation related to additional emesis or an assessment of the resident's status related to the use of the resident's BiPap machine, however, this would have been her expectation. The DON confirmed the resident was deceased the following morning and the medical provider was unaware of his condition the night before. Review of the facility's LPN job description dated [DATE] revealed knowledge of professional nursing theory and practice, supervising, perform and evaluate resident care.Review of the Ohio Board of Nursing Standards of Practice Relative to Registered Nurse or Licensed Practical Nurse Chapter 4723-4 revealed the following under Ohio Administrative Codes (OAC):OAC 4723-4-08 indicates the nursing process is cyclical in nature so that the nurse's actions respond to the patient's changing status throughout the process. (A)(1) (a)-(b) indicates the LPN must accurately and timely collect/document health status data and report that data to the directing RN or healthcare provider. OAC 4723-4-04(C)(2) indicates an LPN shall demonstrate competence and accountability in all areas of practice in which the nurse is engaged which includes, but is not limited to recognition, referral or consultation, and intervention, when a complication arises. An LPN shall, in a timely manner report to and consult as necessary with other nurses or other members of the health care team and make referrals as necessary.OAC 4723-4-06(E) and (H) A licensed nurse shall, in an accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the patient and the patient's response to that care. A licensed nurse shall implement measures to promote a safe environment for each patient. This deficiency represents non-compliance investigated under Master Complaint Number 3132376 and Complaint Numbers 3132194, and 3124350.

Based on review of the medical record and interview, the facility failed to ensure laboratory tests for urine culture and sensitivity were obtained timely and as ordered for Resident #90. This effected one resident (#90) of three reviewed for bowel and bladder. The facility census was 91.Findings Include: Review of the medical record revealed Resident #90 was admitted to the facility on [DATE]. Diagnoses included quadriplegia, extended spectrum beta lactamase, neurogenic bowel, chronic respiratory failure, urinary tract infection, neuromuscular dysfunction of bladder, chronic pain syndrome, gastro-esophageal reflux disease without esophagitis, hypotension, cachexia, chronic idiopathic constipation, polyneuropathy, irritable bowel syndrome with constipation, hyperlipidemia, generalized anxiety disorder, diabetes, major depressive disorder, personal history of urinary (tract) infections, generalized hyperhidrosis, localized edema, insomnia, hypertension, seizures, and hydronephrosis with ureteral stricture.Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #90 had intact cognition and had an indwelling catheter. Review of the Progress Note dated 05/19/26 at 4:37 P.M. revealed Resident #90 was diaphoretic, had an elevated blood pressure, his catheter was draining cloudy and odorous urine. His catheter was flushed without difficulty and was draining. Urology was called and was awaiting a call back at this time. The Nurse Practitioner was notified and new order received for completed blood count and a basic metabolic panel. The resident and his responsible party were notified of the new orders.Review of the Progress note dated 05/20/26 at 9:27 A.M. revealed urology called back and ordered for them to change his suprapubic catheter in house, collect his urine to be sent for culture, fax the results to urology and initiate minocycline 100 milligrams every 12 hours for seven days due to his symptoms. The resident and responsible party were updated. Review of the May 2025 physician's orders revealed Resident #90 had an order to collect a urine to be sent out for a culture dated 05/20/26.Review of the Progress Note dated 05/20/26 at 2:39 P.M. revealed the suprapubic catheter was changed for Resident #90 and the specimen was collected for the lab and placed in the specimen refrigerator. Further review of the medical record revealed no culture and sensitivity results dated 05/20/26 through 05/29/26. On 05/29/26 at 10:55 A.M. the Corporate Director of Nursing verified they never received the results from the laboratory concerning the urine culture and sensitive. She also indicated she had just called the laboratory today and they had no record of the urine culture and sensitivity for Resident #90 being picked up by the laboratory. This deficiency represents non-compliance investigated under Complaint Number 2998973.

Based on observation, record review, interview, and review of facility policy, the facility failed to provide sufficient nursing staff to meet resident needs including answering call lights in a timely manner and operating mechanical lift devices in a safe manner. This affected three residents (#17, #40, and #61) and had the potential to affect all 89 residents in the facility. Findings include:On 04/13/26 at 10:44 A.M., an interview with Resident #39 stated there was not enough staff on first and second shifts, and call lights took a while to answer. On 04/13/26 from 11:06 A.M. through 11:32 A.M., observation and interview revealed Resident #40 was on airborne precautions for Covid with personal protective equipment (PPE) located outside the resident's closed door. At 11:06 A.M. Resident #40 activated her call light. The call light remained on at 11:11 A.M. Facility staff were observed going up and down hall past the resident's room while the light was on including Regional Registered Nurses (RRN) #648 and #649. The Assistant Director of Nursing also went up and down the hall without stopping. Resident #40's call light remained on at 11:17 A.M., 11:21 A.M., 11:25 A.M., and 11:30 A.M. At 11:32 A.M. this surveyor asked RRN #649 why the resident's call light had not been responded to since 11:06 A.M. RRN #649 replied she was just going to check on the resident now. RRN #648 then told RRN #649 he would go in and check on the resident, put on the required PPE and entered the room. On 04/13/26 at 11:12 A.M., an interview with Resident #2 stated care was rushed and it took an hour to answer call lights. On 04/13/26 at 11:27 A.M., an interview with Resident #13 stated it took a half hour to answer his call light and an hour total to address his need. Resident #13 stated this primarily happened on night shift. On 04/13/26 at 1:29 P.M., an interview with Resident #22 stated there was not enough staff, call lights took an hour to answer, and medications were administered late. On 04/13/26 at 3:07 P.M., an interview with Resident #110 stated staff did not come when the call light was pressed, sometimes taking more than two hours, and it happened more on night shift. On 04/13/26 at 3:27 P.M., an interview with Resident #7 stated there was not enough staff and she had problems getting her evening medications timely. On 04/13/26 at 3:41 P.M., an observation revealed Certified Nursing Assistant (CNA) #613 enter Resident #61's room with a mechanical lift device and no other aide was observed entering or exiting the room. On 04/13/26 at 3:46 P.M., an observation of Resident #61's room revealed CNA #613 was operating the mechanical lift device alone to lower Resident #61 into bed. There were no other staff members present in the room at this time. On 04/13/26 at 3:48 P.M., an interview with Regional Registered Nurse (RN) #649 confirmed CNA #613 was in Resident #61's room with the mechanical lift device and there were no other staff in the room. On 04/13/26 at 3:50 P.M., an interview with CNA #613 confirmed she transferred Resident #61 from the wheelchair to the bed using a mechanical lift device. CNA #613 claimed another CNA (#620) was assisting with the transfer but left to go back to the Assisted Living hall. On 04/13/26 at 3:50 P.M., an interview with Resident #85 stated call lights took a while to be answered. On 04/13/26 at 3:57 P.M., an interview with CNA #620 said she did not help CNA #613 transfer Resident #61 because she had to go back to the Assisted Living unit. CNA #620 further stated CNA #613 was the only aide assigned to Resident #61's hall. On 04/14/26 at 8:01 A.M., an interview with Resident #26 stated staff operated mechanical lifts with only staff member to transfer her. On 04/14/26 at 9:54 A.M., an interview with Resident #61 stated staff always transferred her with just one person operating the lift because there was only ever one aide assigned to the hall. On 04/14/26 at 10:25 A.M., an interview with Resident #1 stated he had staffing concerns. On 04/14/26 at 11:21 A.M., an interview with Resident #40 stated it took over 30 minutes to answer her call light on 04/13/26 because she was on isolation for COVID-19. On 04/16/26 at 9:03 A.M., an observation revealed Resident #17's call light was activated. At 9:04 A.M., Medical Records Coordinator #503 entered Resident #17's room, Resident #17 said she needed changed, and Medical Records Coordinator #503 deactivated Resident #17's call light at that time. At 9:12 A.M., Resident #17 activated her call light again. At 9:16 A.M., Medical Records Coordinator #503 entered Resident #17's room, Resident #17 said she still needed to be changed, and Medical Records Coordinator #503 deactivated Resident #17's call light at that time. No other staff were observed entering Resident #17's room from 9:16 A.M. to 9:34 A.M. On 04/16/26 at 9:34 A.M., an interview with Resident #17 confirmed nobody had come to change her yet. On 04/16/26 at 9:34 A.M., an interview with Certified Medication Aide (CMA) #529 stated she was unaware Resident #17 needed changed. On 04/16/26 at 9:37 A.M., observation revealed CMA #529 and Certified Nursing Assistant (CNA) #544 entered Resident #17's room to perform incontinence care, approximately 34 minutes after Resident #17 initially requested assistance. On 04/16/26 at 9:45 A.M., an interview with Regional Registered Nurse (RN) #649 stated it was not typically policy to deactivate the call light without addressing the need. She further stated if someone who was unable to provide the requested care answered the call light, they could turn the call light off and go get someone who could provide the care. During the Resident Council meeting on 04/20/26 at 1:01 P.M. with Residents #40, #43, #66, and #90 revealed Residents #40, #66, and #90 all stated call light response time by staff was always a long wait. They felt the facility put too much on the staff to handle and to large an assignment. Resident #40 said when she had Covid-19 recently she felt like nobody wanted to take the time to put on a gown and come into her room to answer her call light. This deficiency represents non-compliance investigated under Complaint Numbers 2690512 and 2637021.

Based on record review and interview, the facility failed to ensure the physician or nurse practitioner (NP) was notified promptly of Resident #104's change in condition, failed to ensure Residents #7 and #52's wound care were completed as ordered and Resident #98's peripherally inserted central catheter (PICC) was removed timely as ordered. This finding affected one (Resident #104) of three residents reviewed for a change in condition, two (Residents #7 and #52) of three residents reviewed for general skin conditions, and one (Resident #98) of one resident reviewed for PICC lines. The facility census was 89.Findings include:1. Review of Resident #104's medical record revealed the resident was admitted on [DATE] with diagnoses including Alzheimer's disease with late onset, dementia in other diseases classified elsewhere and need for assistance with personal care.Review of Resident #104's hospital discharge documentation dated 08/12/24 revealed the resident's code status was Do Not Resuscitate (DNR) Do Not Intubate (DNI).Review of Resident #104's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment.Review of Resident #104's Nurse Practitioner (NP) progress note dated 05/07/25 revealed the resident was assessed regarding a recent hospice referral. The family refused to sign the hospice consent.Review of Resident #104's Palliative Care note dated 05/27/25 revealed the resident was being seen today for palliative care visit.Review of Resident #104's NP progress note dated 06/09/25 revealed the staff requested an encounter for weakness and difficulty transferring. The resident was awake, alert and in no acute distress. The resident was calm, cooperating and appeared comfortable. The resident was chronically ill appearing lying back in a broda chair.Review of Resident #104's progress note dated authored by Registered Nurse (RN) #657 dated 06/15/25 at 11:56 P.M. revealed resident noted oxygen saturation of 85 % very sleepy and would respond to name then back to sleep oxygen placed on two liters of oxygen via nasal cannula and a note was left in the physician book.Review of Resident #104's vital signs documented in the electronic health record (EHR) confirmed the resident's oxygen level was 85% on room air, the blood pressure was 100/50, the respirations were 22 breaths per minute, and the temperature was 97 degrees Fahrenheit.Review of Resident #104's progress note dated 06/16/25 at 11:21 A.M. revealed NP #658 was in to assess the resident with a new order to send the resident to the emergency room (ER) for altered mental status and hypoxia. An Attempt to notify the representative without success. Report called to the ER. Review of Resident #104's NP Progress note dated 06/16/25 revealed the staff requested an encounter for a change in condition and hypoxia. The resident resides in a long-term care facility and staff reported the resident had been unable to feed self, very restless, minimal response. The prior night the oxygen level was 85% and two liters of supplemental oxygen were placed. The resident's lips were purple and aroused with repeated stimuli. The resident did not follow commands.Review of Resident #104's progress note dated 06/16/25 at 5:59 P.M. authored by RN #659 revealed she spoke with the ER, and the resident was admitted to the intensive care unit (ICU) for a urinary tract infection (UTI) and altered mental status.Review of Resident #104's Hospital Inpatient Patient Summary report dated 06/19/25 at 2:45 P.M. revealed the admission reason was hyper UTI, confusion and natremia.Review of Resident #104's progress note dated 06/19/25 at 6:39 P.M. revealed the resident was readmitted from the hospital.Review of Resident #104's progress note dated 06/20/25 at 7:29 P.M. revealed the nurse practitioner signed the DNR Comfort Care (DNR CC) form.Interview on 04/14/26 at 2:00 P.M. with NP #658 confirmed she had assessed Resident #104 in the middle of the morning on 06/16/26 and the resident needed to go to the hospital. NP #658 confirmed RN #657 should have called for the resident's change in condition, and she was not aware of the change in condition until the next day. Interview on 04/15/26 at 10:12 A.M. with Regional RN #649 confirmed the nurse should have called the NP for Resident #104's change in condition.Interview on 04/15/26 at 11:32 A.M. with Regional RN #649 confirmed no one notified her of the change in condition not addressed.Review of the Guidelines for Provider Notification form updated 06/2023 confirmed immediate notification for the provider included change in condition/mental status, fall with injury requiring further evaluation and treatment, weight changes, abnormal X-ray and PT/INR results. 2. Review of Resident #52's hospital history and physical dated 03/17/26 revealed a left great toe wound was present with no purulence or bloody discharge. Review of Resident #52's Infectious Disease (ID) Consult Notes dated 03/26/26 at 4:44 P.M. digitally signed by Physician #651 revealed the resident had a left great toe gangrenous change. The X-Ray of the left foot revealed extensive vascular calcifications and no acute findings. Review of Resident #52's medical record revealed the resident was admitted on [DATE] (readmitted on [DATE] following a fall) with diagnoses including pneumonia, gangrene of the left great toe and unsteadiness on the feet. Review of Resident #52's progress note dated 03/27/26 at 9:30 P.M. (recorded as a late entry on 03/28/26 at 7:15 A.M.) revealed the resident was admitted from the hospital following a placement of three heart stents. A head-to-toe skin assessment was completed with a skin tear on the right forearm and a recent left big toe removal. Review of Resident #52's History and Physical form dated 03/30/26 authored by the Medical Director (MD) revealed ID recommended workup of the left foot due to concern of possible toe ulceration following recent left great toe removal. The Cat (CT) Scan did not demonstrate osteomyelitis, only swelling. ID recommended four weeks of antibiotics with outpatient follow-up. Review of Resident #52's Diabetic Ulcer Care Plan revealed an intervention dated 03/30/26 to perform current treatment as ordered and observe for effectiveness. Review of Resident #52's Wound Observation History form dated 03/30/26 at 1:44 P.M. revealed the resident had a left great toe wound which measured 2.9 centimeters (cm) length by 3.8 cm width by 0.4 cm depth with moderate exudate with full thickness through the dermis and down to the subcutaneous tissue and muscle with granulation tissue. The surrounding skin was dark purple or rusty discoloration with edema. Review of Resident #52's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #52's physician orders revealed an order dated 04/01/26 (discontinued 04/09/26) to cleanse the left great toe with normal saline, pat dry, apply calcium alginate and silicone super absorbent dressing and change daily; and an order dated 04/09/26 to cleanse the left great toe with normal saline, pat dry, apply xeroform and silicone super absorbent dressing once daily. Review of Resident #52's medication administration records (MARS) and treatment administration records (TARS) from 03/27/26 to 04/15/26 revealed no evidence the left great toe wound treatments were completed on 04/04/26, 04/07/26, and 04/08/26. Review of Resident #52's Wound Observation History dated 04/06/26 at 2:23 P.M. revealed the resident had a left great toe wound which measured 4 cm length by 8.5 cm width and the depth could not be measured. The tissue type was necrotic with thin watery exudate and 10% epithelialization tissue and 70% eschar. The area had an increase and a recommendation referral to vascular along with an antibiotic order and new treatment order. The resident and the resident's spouse were notified. Interview on 04/16/26 at 7:52 A.M. with Regional RN #649 confirmed Resident #52's medical record did not have evidence of wound care to the resident's left great toe on 04/04/26, 04/07/26 or 04/08/26. Interview on 04/16/26 at 11:42 A.M. with the MD revealed Resident #52 did not require treatments to the left great toe upon admission from 03/27/26 to 03/31/26 and treatments were initiated on 04/01/26. The MD confirmed Resident #52's left great toe declined due to the resident's disease process. Telephone interview on 04/16/26 at 2:45 P.M. with Resident #52's wife who revealed she felt care and services were not provided timely for the resident's left toe wound. 3. Review of Resident #7's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including cutaneous abscess of the left lower limb, muscle weakness and major depressive disorder. Review of Resident #7's Surgical Wound Care Plan revealed an intervention dated 02/06/26 to perform current treatment as ordered and observe for effectiveness. Review of Resident #7's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #7's physician orders revealed an order dated 03/13/26 (discontinued 04/14/26) to cleanse the left lower extremity with normal saline, pat dry, apply silver alginate and cover with an abdominal dressing and secure with paper tape every other day and as needed; and an order dated 04/14/26 to cleanse the left lower extremity with normal saline, pat dry, apply silver alginate and cover with an abdominal dressing and secure with paper tape once daily and as needed (from 7:00 A.M. to 3:00 P.M.). Review of Resident #7's MARS and TARS from 03/01/26 to 04/20/26 revealed no evidence wound care to the left lower extremity was completed on 03/27/26, 03/31/26, and 04/14/26 (documented as morning shift nurse did not complete). Review of Resident #7's physician orders revealed an order dated 03/13/26 (discontinued 04/09/26) to cleanse the left upper thigh with normal saline, pat dry, apply silver alginate and cover with an abdominal dressing and secure with paper tape once every other day and as needed; and order dated 04/09/26 to cleanse the left upper thigh with normal saline, pat dry, apply silver alginate, cover with an abdominal dressing and secure with paper tape once daily and as needed (from 7:00 A.M. to 3:00 P.M.). Review of Resident #7's MARS and TARS from 03/01/26 to 04/20/26 revealed no evidence wound care to the left upper thigh was completed on 03/27/26, 03/31/26 and 04/16/26 (documented as morning shift nurse did not complete). Interview on 04/20/26 at 8:40 A.M. with Regional RN #649 confirmed the above findings. Interview on 04/21/26 at 11:30 A.M. with Resident #7 revealed the resident could not state if the wound care to the left upper thigh or left lower leg was completed as ordered. Review of the Clean Technique Wound Care policy updated 05/01/25 revealed it was the facility's policy to provide wound care to residents using professional standards of practice. 4. Review of the medical record for Resident #98 revealed an admission date of 01/19/26 and discharge date of 02/10/26. Diagnoses included metabolic encephalopathy, chronic diastolic heart failure, peripheral vascular disease, and end stage renal disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #98 had mild cognitive impairment and required extensive assistance for all activities of daily living. Review of the progress note dated 01/21/26 revealed Resident #98 in on intravenous antibiotics via PICC line, tolerating well, and safety measures are maintained. Review of the comprehensive care plan dated 01/23/26 revealed no care plan related to the PICC line. Review of the progress note dated 01/23/26 revealed the nurse spoke with the physician regarding the removal of the PICC line for Resident #98 due to her receiving antibiotics during dialysis treatment. The physician gave an order to remove the PICC line. Resident #98 was notified. Review of the progress note dated 01/24/26 revealed vascular access team in the facility to remove Resident #98's PICC line per order. No attempts were made to remove the PICC line due to it's proximity to the existing dialysis catheter and no documentation from the inserting hospital about the status of the PICC line. The vascular access team recommended the facility reach out to the inserting facility to remove. Resident #98 would need an appointment scheduled. Resident #98 was notified. Review of the orders for Resident #98 revealed an order dated 01/27/26 revealed an order to schedule an appointment for PICC line removal. No other PICC line orders were observed. Review of the progress note dated 02/03/26 revealed the nurse received a call back from the hospital requesting that they fax the order again to remove Resident #98's PICC line. The order was refaxed and they were awaiting a call back. Review of the progress note dated 02/05/26 revealed Resident #98 was requesting to go to the hospital for becoming hypoglycemic during dialysis. Review of the progress note dated 02/05/26 revealed Resident #98 returned from the hospital emergency room and her PICC line was removed there. Interview on 04/20/26 at 10:22 A.M. with Regional Nurse #649 confirmed the order to pull Resident #98's PICC line was placed on 01/23/26. The nurse assessed the PICC line on 01/24/26 and saw a suture intact and notified the facility's access center. They accessed the line on 01/24/26 and could not determine if the line was tunneled and they were concerned due to how close it was to the dialysis access, so they recommended the facility reach out to the inserting facility and schedule a removal. The PICC line was inserted in the interventional radiology department at the local hospital. No documentation was placed regarding reaching out to that facility until 02/03/26. She confirmed there was no documentation of PICC line care. This deficiency represents non-compliance investigated under Complaint Numbers 2799624, 2795522 and 261336.

Based on record review and interview, the facility failed to obtain Residents #3, #84, #101 and #104's weights as ordered to ensure proper nutrition status. This finding affected four residents (Residents #3, #84, #101 and #104) of six residents reviewed for nutrition. The facility census was 89.Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of [DATE]. Diagnoses included chronic cholecystitis, cystostomy status, and chronic diastolic heart failure. Review of orders revealed no order listed for weights. Review of the care plan dated [DATE] revealed Resident #3 was at risk for altered nutrition related to impaired skin integrity and medical diagnoses. Interventions included provide supplements as ordered and diet as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had moderate cognitive impairment. Resident #3 required extensive assistance for all activities of daily living. Review of the weights for Resident #3 revealed she weighed 286.6 pounds on [DATE], 288.7 pounds on [DATE], 286.8 pounds on [DATE], 159.5 pounds on [DATE], and 227.2 pounds on [DATE]. Review of the dietician progress note dated [DATE] revealed Resident #3's current body weight of 159.5 pounds appears to be in error. The current body weight is inconsistent with previous weights. Review of the dietician progress note dated [DATE] revealed Resident #3 had a significant weight loss. Meal intakes have been good. Resident #3 was ordered a supplement for wound healing twice a day. Resident #3's medications were reviewed. Resident #3 was ordered Lasix (diuretic) and weight loss may be attributed to fluid loss. No further supplements recommended at this time and she will continue to monitor. Interview on [DATE] at 1:38 P.M. with Dietician #650 confirmed she saw the weight for Resident #3 in March and requested a reweight be completed. Dietician #650 confirmed the staff never got another weight. She also confirmed that Resident #3 had another weight completed on [DATE] that showed 222 pounds which would mean she had an over 100-pound weight loss and then a 60-pound weight gain. She reported that staff are not good at obtaining weight and she is in the building two to three days per week. She reported she did leave a note in the chart that Resident #3 had weight loss due to fluid shifts while on a diuretic and confirmed that she would be checking weekly weights on Resident #3 going forward but she did not document the weekly weight checks and did not place an order for it. Dietician #650 reported she only listed Resident #3 on the weekly weight list that is posted at all nursing stations. Interview on [DATE] at 1:55 P.M. with Certified Nursing Assistant (CNA) #569 confirmed Resident #3 gets weights checks with the mechanical lift scale. She reported the nurses inform them daily of weights are needed to be obtained and then they report the weight to the nurse. Interview on [DATE] at 1:58 P.M. with Licensed Practical Nurse (LPN) #517 reported she does inform the aides daily of what weights are needed. She reported the weights either appear on the medication administration record as a requirement or there is a list at the nurse's station with weights that need obtained. Observation of the nurse's station for Resident #3 revealed no list of weights available. LPN #517 confirmed the list was not available at the nurse's station. Review of the facility policy weight/reweigh, updated [DATE] revealed a resident's weight will be monitored to evaluate the resident's nutrition status, within the parameters of the resident's overall medical condition. A member of the dietary staff will notify the nursing staff when a re-weight on a resident is indicated. 2. Resident #84 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, traumatic brain injury, legal blindness, overactive bladder, psychosis, visual hallucinations, delusional disorder, anxiety disorder, epilepsy, chronic pain, and major depressive disorder. Review of the physician's orders for Resident #84 revealed on [DATE] and order was written to consult dietary for concerns of weight loss and to consult a gastroenterologist for a colonoscopy. The resident's diet order was for a regular diet, regular texture, with thin liquids. No nutritional supplements were ordered. Review of Resident #84's nursing progress notes revealed on [DATE] at 2:17 P.M. Registered Dietician (RD) #650 documented the resident had a significant weight loss at the 180 day marker with March weights. Weight loss was appropriate due to her Body Mass Index (BMI) of 25.3 being overweight for her height. RD #650 noted the resident's meal intakes were varied and the resident's oral intake would be monitored and if there was a need for nutritional supplements if weight loss continues. Review of Resident #84's nursing progress notes revealed on [DATE] at 2:05 P.M. RD #650 noted an order for her to speak to the resident due to weight loss. RD #650 previously addressed weight loss on [DATE] and the resident stated she is happy with her weight at this time and refuses nutritional supplements. RD #650 will continued to monitor for weight loss and needed interventions as resident is agreeable. Review of Resident #84's nursing progress notes revealed on [DATE] at 9:08 A.M. RD #650 documented the resident's reweight was 138.7 pounds. RD #650 will continued to monitor and encourage kilocalories (kcal) supplements if the resident was agreeable. Resident #84 does not want kcal supplements at this time and is happy with her current body weight. RD #650 will continue to monitor weekly weights. Review of Resident #84's weights revealed resident was admitted on [DATE] and the first weight obtained was on [DATE] at 168 pounds. The resident's weight on [DATE] was 138.7 pounds indicating a significant weight loss of 17.4%. No weights were obtained in [DATE] or [DATE]. Review of Resident #84's comprehensive quarterly Minimum Data Set (MDS) 3.0, dated [DATE], revealed the resident was cognitively intact, the resident's height was 61 inches and her weight was 143 pounds. Answers to the questions of whether there was a weight loss of 5% or more in the last month or 10% or more in the last six months was answered no. Review of Resident #84's care plan for nutrition, last reviewed on [DATE], revealed the resident was at risk for altered nutrition related to a BMI of 32.9 indicating class I obesity. Monitor appetite and weight as resident is a new admit. On [DATE] the resident's BMI was 30.3 again indicating class I obesity. No significant weight loss at this time. On [DATE] the resident's BMI was 27.1 which is overweight for the resident's height. The resident had no significant weight loss however her weight has decreased and the weight loss is appropriate due to her BMI. The goals were to receive adequate nutrition and have no significant weight loss. Supplements were to be provided per physician's orders. RD #650 was to be notified if a significant weight loss of 5% was observed. The care plan was not revised after significant weight loss was identified. Interview with Resident #84's mother on [DATE] at 2:59 P.M. revealed she was concerned about her daughter's weight especially since she has had chronic diarrhea since admission but nothing has been done about it. Interview with RD #650 on [DATE] at 10:40 A.M. revealed Resident #84's weight loss was a positive thing. Her BMI remains a bit high and the resident refuses supplements at this time. The resident is on weekly weights. The weights were reviewed for Resident #84 as well as the physician's orders. Weekly weights were not obtained and the physician's orders revealed no order for weekly weights. RD #650 said she is unable to do anything about the facility obtaining weights. She puts a list out weekly on the nursing units as to who needs weights but she is unable to get the requested weights or reweights. When questioned why there was not a physician's order for weekly weights RD #650 stated she is not able to write orders. RD #650 confirmed she did not update Medical Director (MD) #653 or Nurse Practitioner (NP) #658 regarding Resident #84's significant weight loss. RD #650 said usually NP #658 notifies her when a resident has significant weight loss. RD #650 confirmed she has not updated the nutrition care plan to reflect the resident's significant weight loss. Interview with Regional Registered Nurse (RRN) #649 on [DATE] at 11:15 A.M. confirmed obtaining weights for the residents was a problem. They had identified the problem just prior to the start of the survey process and are implemented a plan to correct the problem. Review of the facility's Weight/Reweigh Policy, last revised [DATE], revealed residents weights will be monitored to evaluate the resident's nutrition status. A resident's weight will be obtained weekly for a minimum of four weeks for the following situations: new admissions, readmissions, pressure injuries, significant unplanned monthly weight loss of 5% or greater, 10% or greater in six months, or as determined by the skin and weight assessment team. Nursing will be notified of residents requiring weekly weights. Monthly weights will be obtained by nursing for all residents in the facility unless the physician determines it is contraindicated. All weights will be documented in the electronic health record. 3. Review of Resident #104's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease with late onset, dementia in other diseases and impulsiveness. Review of Resident #104's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #104's progress note dated [DATE] at 11:02 A.M. revealed the resident received house supplements once daily to support nutrition. Meal intakes were varied and no weight history to review at 30, 90 or 180 days; however, weight had been stable the past couple of months. Review of Resident #104's medical record revealed the weights on [DATE] was 124.6; [DATE] was 124.8; [DATE] was 114.9; [DATE] was 114.9; [DATE] was 120.6; [DATE] was 120.3 and [DATE] was 114.3. The resident expired on [DATE]. The medical record did not have evidence of monthly weights on 04/2025, 05/2025 or 08/2025. Interview on [DATE] at 9:02 A.M. with Registered Nurse (RN) Regional #649 confirmed Resident #104 was not provided monthly weights as indicated. Review of the Weight/Reweigh Policy updated [DATE] revealed a monthly weight will be obtained by the nursing staff for all residents in the facility unless the physician determines it was contraindicated. 4. Resident #101 was admitted to the facility on [DATE] and was discharged home on [DATE]. The admitting diagnoses included acute and chronic respiratory failure with hypoxia, Influenza A, high blood pressure, heart disease, atrial fibrillation, pulmonary fibrosis, asthma, a pacemaker, depression, pneumonia, congestive heart failure, and oxygen dependent. Review of the physician's orders for Resident #101 revealed on [DATE] an order was written for the resident to received four ounces of house supplement with meals. On [DATE] and order was written to obtain weekly weights for four weeks. On [DATE] two ounces of liquid protein was ordered three times a day to assist with wound healing. On [DATE] a packet of Juven was ordered daily also for wound healing. Review of the nursing progress notes for Resident #101 revealed on [DATE] at 10:30 A.M. RD #650 completed an initial nutrition assessment. The skin assessment said to see the nursing wound grids. The resident's height was listed as 72 inches and the weight was listed as 163.8 pounds. The resident's BMI was listed as within normal range. Resident #101 reported no issues upon admission. Meal intakes had varied since admission. Nursing reported no edema upon admission. The resident receives Vitamin B12 and Iron to support nutrition. The resident was ordered four ounces of house supplement with all meals, two ounces of liquid protein three times a day and one packet of Juven twice a day for wound healing. RD #650 said she would monitor appetite and weight as the resident is a new admit. Review of Resident #101's weights revealed no weights were obtained at any time throughout the resident's stay in the facility. Resident #101 had a nutrition care plan initiated, on [DATE], which indicated the resident was at risk for altered nutrition related to an order of a cardiac diet, regular texture, and thin liquids. The care plan recommended a regular diet, thin liquids, and no added salt. The goal was for the resident to receive adequate nutrition to meet estimated nutrition needs as evidenced by no significant weight change and no skin breakdown. Interventions were to monitor weekly weights for four weeks then monthly if stable. Review of Resident #101's comprehensive MDS admission assessment dated [DATE] revealed the resident was cognitively intact, had two pressure ulcers present upon admission, had a height of 72 inches and a weight of 164 pounds. The resident had no known weight loss or gain. Interview with RD #650 on [DATE] at 10:40 A.M. revealed she provided a list of weights to be obtained by nursing but it often was not completed. She was unaware no weights were obtained throughout Resident #101's stay and the care plan should have reflected the resident was admitted with wounds and already had skin breakdown. Interview with Regional Registered Nurse (RRN) #649 on [DATE] at 11:15 A.M. confirmed obtaining weights for the residents was a problem. They had identified the problem just prior to the start of the survey process and were implementing a plan to correct the problem. Review of the facility's Weight/Reweigh Policy, last revised [DATE], revealed residents weights will be monitored to evaluate the resident's nutrition status. A resident's weight will be obtained weekly for a minimum of four weeks for the following situations: new admissions, readmissions, pressure injuries, significant unplanned monthly weight loss of 5% or greater, 10% or greater in six months, or as determined by the skin and weight assessment team. Nursing will be notified of residents requiring weekly weights. Monthly weights will be obtained by nursing for all residents in the facility unless the physician determines it is contraindicated. All weights will be documented in the electronic health record.

Based on observation and interview, the facility failed to ensure medications were secured appropriately. This finding affected two of the three medication carts reviewed and had the potential to affect nine cognitively impaired and independently mobile residents (Residents #10, #18,#24, #70, #71, #72, #83, #90, #106) who reside in the skilled nursing facility. The facility census was 89.Findings include: 1. On 04/16/26 at 11:27 A.M., an observation revealed a white oblong capsule in a chair in common area between 100 hall and 400 hall. On 04/16/26 at 11:37 A.M., an observation with Regional Registered Nurse (RN) #649, Administrator, and Assistant Director of Nursing (ADON) #501 verified there was a loose medication capsule in the chair in the common area. Regional RN #649 obtained a glove and retrieved the capsule from the chair and stated the capsule had CREON printed on it. Regional RN #649, Administrator, and ADON #501 all said they had no idea who the Creon capsule was meant for or how long it had been in that chair. 2. Observation on 04/20/26 at 9:42 A.M. with Licensed Practical Nurse (LPN) #517 of the 400-hall medication cart revealed one loose white pill lying on the bottom of the second drawer of the medication cart. Interview on 04/20/26 at 9:45 A.M. with LPN #517 confirmed the above findings. 3. Observation on 04/20/26 at 9:55 A.M. with Registered Nurse (RN) #646 of the 300-Long medication cart revealed one loose green pill located on the bottom of the second drawer of the medication administration cart. Interview on 04/20/26 at 10:00 A.M. with RN #646 confirmed the above findings. Review of the Medication Storage in the Facility policy dated 05/2020 revealed medications were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on record review and interview, the facility failed to maintain complete and accurate documentation in the medical record for all residents. This affected five residents (#2, #8, #26, #57, and #86) and had the potential to affect all 89 residents in the facility. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 03/29/25 with diagnoses including congestive heart failure, type two diabetes mellitus, hypertension, and end stage renal disease. Review of the physician's orders for Resident #26 revealed there were no active dietary orders in place. The previous dietary order for a renal diet gluten free was discontinued on 04/01/26. Review of the nutritional assessment dated [DATE] revealed Resident #26 needed a diet order added to the electronic medical record. Review of the dietary progress note dated 04/11/26 at 11:13 A.M. revealed Resident #26 did not have a diet order in the electronic medical record and the previous diet was renal diet gluten free with regular texture and thin liquids. On 04/17/26 at 9:18 A.M., an interview with Regional Registered Nurse (RN) #649 verified Resident #26 did not have a physician's order for dietary restrictions. Regional RN #649 further clarified that the facility was changing the wording of their renal diets and when Resident #26's was discontinued, they must of missed reactivating it with the new wording. 2. Review of the medical record for Resident #2 revealed they were admitted to the facility on [DATE] with diagnoses that included stroke, hemiplegia (paralysis on one side of the body), hemiplegia (weakness on one side of the body), need for assistance with personal care, hypertension, psychotic disorder with delusions, and atrial fibrillation (an abnormal heart rhythm). Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively impaired, did not reject care, was dependent on staff for activities of daily living, was frequently incontinent of urine, was always incontinent of bowel, and utilized a feeding tube. Review of the care plan revealed Resident #2 had cardiac impairment related to atrial fibrillation, high blood pressure, and stroke dated 03/03/26 with a goal to be free from cardiac complications. Interventions included administering medications as ordered, observing elevated vital signs, and obtaining vital signs as ordered and as needed. Resident #2 had alteration in comfort related to reduced mobility dated 03/03/26 with a goal to verbalize comfort with interventions that included administering pain medications as needed, observing for effectiveness, and observing for breakthrough pain. Review of the physician orders revealed the following: vital signs every shift dated 02/20/26; Diltiazem (a medication to treat high blood pressure) 90 milligrams (mg) every six hours by gastric tube dated 02/24/26 and assess pain every shift dated 02/20/26. Review of the MAR from 03/01/26 to 03/31/26 revealed the following: absence of vital sign documentation for night shit on 03/12/26; the absence of vital sign documentation for day shift on 03/19/26; the absence of vital sign documentation for day shift and evening shift on 03/21/26; the absence of vital sign documentation for evenings and night shift on 03/22/26 with a comment that noted previous shift; the absence of vital sign documentation on evening and night shift on 03/23/26; the absence of vital sign documentation on 03/31/26 with a dash as a comment; the absence of a pain assessment on evening shift 03/18/26, the absence of a pain assessment on day shift 03/21/26; and the absence of a pain assessment on evening and night shift on 03/23/26. Blood pressure was not documented prior to all doses of diltiazem administration on 03/01/26, 03/02/26, 03/03/26, 03/04/26, 03/05/26, 03/06/36, 03/07/26, 03/08/26, 03/09/26, 03/10/26, 03/11/26, 03/12/26, 03/13/26, 03/14/26, 03/15/25, 03/16/26, 03/17/26, and 03/18/26. Review of the MAR from 04/01/26 to 04/15/26 revealed the following: pain was not assessed on 04/08/26 for evening shift, pain was not assessed on 04/09/26 for night shit, the absence of vital sign documentation for dayshift on 04/07/26, the absence of vital sign documentation on evening shift for 04/08/26, the absence of vital sign documentation on night shift for 04/09/26, and the absence of vital sign documentation on evening shift for 04/10/26. An interview on 04/15/26 at 10:20 A.M. with Regional Registered Nurse (RN) # 649 verified the above findings. Review of the facility policy titled Change in the Residents Condition or Status, dated 05/01/25 revealed the nurse would monitor and notify the medical team when there was a change in condition and the nurse would record information in the medical record. Review of the facility policy titled Pain Assessment and Management, dated 05/01/25 revealed the facility would assess, evaluate, and treat pain. 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] and was discharged on 04/08/26, diagnoses included pancreatic cancer, liver cancer, spinal cancer, dementia, stroke, repeated falls, and heart disease. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #8 was cognitively intact, did not reject care, required moderate to maximal assistance for activities of daily living, received medication for pain, had constant pain, had a history of falling, received antianxiety medications, received opioids, and received anti-seizure medication. Review of the care plan revealed Resident #8 had pain related to metastatic cancer dated 01/28/26 with a goal to verbalize comfort. Interventions included administering pain medications, observing effectiveness, and observing breakthrough pain. Review of the physician orders revealed an order to assess pain every shift dated 01/14/26. Review of the MAR from 03/01/26 to 03/31/26 revealed the absence of pain assessment documentation on 03/05/26 night shift, 03/11/26 day shift, 03/14/26 night shift, 03/16/26 night shift, 03/19/26 night shift, 03/21/26 evening shift, 03/22/26 night shift, 03/26/26 evening shift, 03/27/26 night shift, and 03/29/26 evening shift. Review of the MAR from 04/01/26 to 04/08/26 revealed the absence of pain assessment on 04/02/26 night shift. An interview on 04/21/26 at 12:45 P.M. with Regional RN #649 verified the above findings. Review of the facility policy titled Change in the Residents Condition or Status, dated 05/01/25 revealed the nurse would monitor and notify the medical team when there was a change in condition and the nurse would record information in the medical record. Review of the facility policy titled Pain Assessment and Management, dated 05/01/25 revealed the facility would assess, evaluate, and treat pain. 4. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses that included kidney infection, heart disease, abnormalities of gait and mobility, malnutrition, and low back pain. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #57 was cognitively intact, was incontinent of bowel and bladder, had a pressure reduction device for her bed, and was dependent on staff for toileting, bathing, and transferring. Review of the care plan revealed Resident #57 was at risk of skin breakdown due to impaired mobility and a history of impaired skin integrity dated 08/08/25 with a goal she would not develop skin breakdown. Interventions included observing for signs of skin breakdown and using an air mattress. Review of the physician orders revealed an order for a low air loss mattress and to check placement and function every shift dated 12/18/25 and an order to wash skin folds with mild soap and water, pat dry, and apply antifungal cream three times a day dated 03/16/26. Review of the MAR from 03/01/26 to 03/31/26 revealed the absence of documentation that the low air loss mattress was checked for placement and function from 03/02/26 night shift through all shifts on 03/31/26. Review of the MAR from 04/01/26 to 04/15/26 revealed the absence of any documentation the low air loss mattress was checked for function. Review of the MAR from 04/01/26 to 04/15/26 revealed the absence of documentation skin fold care was performed on 04/04/26 evening shift, 04/04/26 night shift, 04/05/26 evening shift, 04/09/26 night shift, and 04/10/26 evening shift. An interview on 04/13/26 at 10:11 A.M. with Resident #86 revealed he did not have concerns with symptom monitoring or nursing care. An observation on 04/13/26 at 12:12 P.M. revealed Resident #57's bed had a low air loss mattress that Resident #57 was laying on. An interview on 04/15/26 at 3:31 P.M. with Regional RN #649 verified the above findings. An interview on 04/21/26 at 11:13 A.M. with Licensed Practical Nurse (LPN) #517 revealed air mattresses were checked for function and would be documented in the treatment section of the MAR. Review of the facility policy titled Change in the Residents Condition or Status, dated 05/01/25 revealed the nurse would monitor and notify the medical team when there was a change in condition and the nurse would record information in the medical record. 5. Review of the medical record for Resident #86 revealed they were admitted to the facility on [DATE] with re-entry on 06/28/24 with diagnoses that included respiratory failure, chronic obstructive pulmonary disease (lung disease), peripheral vascular disease, arthritis, heart disease, chronic pain, and reduced mobility. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #86 was cognitively intact, had verbal behaviors, rejected care, required set up assistance to supervision for most activities of daily living, and had shortness of breath with exertion. Review of the care plan revealed Resident #86 had cardiac impairment related to heart disease and congestive heart failure dated 07/12/23. Interventions included observing for swelling to lower extremities, observing for shortness of breath, observing for chest pain, and monitor for elevated blood pressure, pulse, or respiration. Review of the physician orders revealed an order to monitor for signs of worsening heart failure dated 06/29/26. Review of the MAR from 03/01/26 to 03/31/26 revealed the absence of heart failure monitoring documentation on 03/02/26 night shift and on 03/09/26 evening shift. Review of the MAR from 04/01/26 to 04/15/26 revealed the absence of heart failure monitoring documentation on 04/04/26 evening shift and night shift, and 04/05/26 evening shift, 04/09/26 night shift. Review of the progress notes from 03/02/26 to 04/15/26 revealed the absence of documentation that Resident #86 refused heart failure monitoring. An interview on 04/13/26 at 10:11 A.M. with Resident #86 revealed he did not have concerns with symptom monitoring or nursing care. An interview on 04/21/26 at 8:50 A.M. with Regional RN #649 verified the above findings. Review of the facility policy titled Change in the Residents Condition or Status, dated 05/01/25 revealed the nurse would monitor and notify the medical team when there was a change in condition and the nurse would record information in the medical record. This deficiency represents non-compliance investigated under Complaint Number 2637021.

Based on observation, interview, and record review the facility failed to ensure Resident #54's dignity was maintained at all times. This affected one resident (Resident #54) of three residents reviewed for dignity. The facility census was 86.Review of the medical record for Resident #54 revealed an admission date of 07/03/25 with diagnoses included hypertension, atrial fibrillation, and legal blindness. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. Resident #54 required extensive assistance for all activities of daily living. Review of the physician's order dated 07/17/25 revealed Resident #54 was dependent for shaving and required shaving weekly. Review of the care plan dated 01/19/26 revealed Resident #54 was unable to perform activities of daily living. Interventions included to perform nail and hair care weekly with showers and to assist with and or shave facial hairs. Review of the facility shower schedule revealed Resident #54 was scheduled for showers every Monday and Thursday. Review of the shower sheets for Resident #54 from 03/12/26 to 04/13/26 revealed she received a shower or a bed bath twice a week as scheduled. No documentation was found related to facial hair. Observation on 04/13/26 at 1:00 P.M. revealed Resident #54 lying in bed sleeping with long full facial hair. Interview on 04/15/2026 145 P.M. with Resident #54 revealed she wanted staff to take care of her facial hair but reported they had not taken care of them in a while. Observation during the interview revealed that Resident #54 still had a face full of facial hair. Interview on 04/15/26 at 2:00 P.M. with Certified Nursing Assistant (CNA) #635 and Registered Nurse (RN) Supervisor #610 reported Resident #54 gets showers on Monday and Thursday afternoons, and they take care of her facial hair then. CNA #635 and RN Supervisor #610 confirmed Resident #54 has not had her facial hair cared for in a while due to the length of the hair. Interview on 04/16/26 at 2:45 P.M. with CNA #587 confirmed that Resident #54 gets shaved ever Monday with her bath or shower. She confirmed she did not shave Resident #54 during her shower on 04/13/26. Review of the facility policy shaving a resident, updated 05/01/25, revealed it is the facility's policy to promote resident hygiene by assisting a resident with removal of facial hair as needed. This deficiency represents non-compliance investigated under Complaint Numbers 2793933 and 2690512.

Based on interview and record review the facility failed to notify Resident #98's representative of a change in condition. This affected one (Resident #98) of three residents reviewed for notification of change in condition. The facility census was 86.Findings include:Review of the medical record for Resident #98 revealed an admission date of 01/19/26 and a discharge date of 02/10/26 with diagnoses including metabolic encephalopathy, acute and chronic respiratory failure with hypoxia, osteoporosis, and end stage renal disease.Review of the face sheet for Resident #98 revealed she was listed as the primary contact and her mother was also listed as a primary contact.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #98 had moderate cognitive impairment. Resident #98 required extensive assistance for all activities of daily living.Review of the care plan dated 01/31/26 revealed Resident #98 had a risk for pathological injuries/falls and pain related to osteoporosis. Interventions included to keep personal items within reach and to keep the call light within reach at all times.Review of the nursing progress note dated 02/04/26 at 7:37 P.M. revealed Resident #98 was requesting to go to the hospital due to right shoulder pain. Resident #98 reported her shoulder had been hurting since the day prior and was refusing Tylenol as needed for pain. The nurse practitioner was notified and an x-ray of her right shoulder was ordered and ibuprofen for pain. Resident #98 initially refused to have the x-ray completed in the facility and the ibuprofen but then reported she would agree to the treatment and if it still hurt the next day she would go. There was no evidence Resident #98's representative was notified of the pain to shoulder, x-ray, and request for hospitalization. Review of the nursing progress note dated 02/05/26 at 9:14 A.M. revealed while Resident #98 was at the dialysis center, dialysis sent her to the hospital for evaluation due to hypoglycemia. There was no evidence Resident #98's representative was notified the resident was sent to the hospital.Interview on 04/20/26 at 10:22 A.M. with Regional Nurse #649 reported Resident #98's mother was not notified of the change in condition for Resident #98 because Resident #98 was alert and oriented and listed as primary contact.This deficiency represents non-compliance investigated under Complaint Number 2795522.

Based on interview and record review the facility failed to care plan a peripherally inserted central catheter (PICC) line for Resident #98. This affected one resident (Resident #98) of six residents reviewed for care plans. The facility census was 86. Review of the medical record for Resident #98 revealed an admission date of 01/19/26 and discharge date of 02/10/26 with diagnoses included metabolic encephalopathy, chronic diastolic heart failure, peripheral vascular disease, and end stage renal disease. Review of the orders for Resident #98 revealed an order dated 01/27/26 revealed an order to schedule an appointment for PICC line removal. No other PICC line orders were observed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #98 had mild cognitive impairment and required extensive assistance for all activities of daily living. Review of the comprehensive care plan dated 01/23/26 revealed no documentation related to the PICC line. Interview on 04/20/26 at 10:22 A.M. with Regional Nurse #649 confirmed there was no care plan developed for Resident #98's PICC line or documentation of care. This deficiency represents non-compliance investigated under Complaint Numbers 2727070, 2795522, and 2690512.

Based on record review and interview, the facility failed to ensure care plans were revised for weight loss. This affected two residents (Residents #84 and #101) of six residents reviewed for nutrition. The facility census was 89. Findings Include:1. Resident #84 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage, traumatic brain injury, legal blindness, overactive bladder, psychosis, visual hallucinations, delusional disorder, anxiety disorder, epilepsy, chronic pain, and major depressive disorder. Review of Resident #84's nursing progress notes revealed on 04/04/26 at 2:17 P.M. Registered Dietician (RD) #650 documented the resident had a significant weight loss at the 180 day marker with March weights. Weight loss was appropriate due to her Body Mass Index (BMI) of 25.3 being overweight for her height. RD #650 noted the resident's meal intakes were varied and the resident's oral intake would be monitored and if there was a need for nutritional supplements if weight loss continues. Review of Resident #84's nursing progress notes revealed on 04/14/26 at 2:05 P.M. RD #650 noted an order for her to speak to the resident due to weight loss. RD #650 previously addressed weight loss on 04/04/26 and the resident stated she is happy with her weight at this time and refuses nutritional supplements. RD #650 will continued to monitor for weight loss and needed interventions as resident is agreeable. Review of Resident #84's nursing progress notes revealed on 04/15/26 at 9:08 A.M. RD #650 documented the resident's reweight was 138.7 pounds. RD #650 will continued to monitor and encourage kilocalories (kcal) supplements if the resident was agreeable. Resident #84 does not want kcal supplements at this time and is happy with her current body weight. RD #650 will continue to monitor weekly weights. Review of Resident #84's weights revealed resident was admitted on [DATE] and the first weight obtained was on 10/03/25 at 168 pounds. The resident's weight on 04/16/26 was 138.7 pounds indicating a significant weight loss of 17.4%. No weights were obtained in December 2025 or January 2026. Review of Resident #84's comprehensive quarterly Minimum Data Set (MDS) 3.0, dated 01/27/26, revealed the resident was cognitively intact, the resident's height was 61 inches and her weight was 143 pounds. Answers to the questions of whether there was a weight loss of 5% or more in the last month or 10% or more in the last six months was answered no. Review of Resident #84's care plan for nutrition, last reviewed on 02/04/26, revealed the resident was at risk for altered nutrition related to a BMI of 32.9 indicating class I obesity. Monitor appetite and weight as resident is a new admit. On 11/17/25 the resident's BMI was 30.3 again indicating class I obesity. No significant weight loss at this time. On 02/04/26 the resident's BMI was 27.1 which is overweight for the resident's height. The resident had no significant weight loss however her weight has decreased and the weight loss is appropriate due to her BMI.The goals were to receive adequate nutrition and have no significant weight loss. Supplements were to be provided per physician's orders. RD #650 was to be notified if a significant weight loss of 5% was observed. The care plan was not revised after significant weight loss was identified. Interview with RD #650 on 04/21/26 at 10:40 A.M. revealed Resident #84's weight loss was a positive thing. Her BMI remains a bit high and the resident refuses supplements at this time. The resident is on weekly weights. The weights were reviewed for Resident #84 as well as the physician's orders. Weekly weights were not obtained and the physician's orders revealed no order for weekly weights. RD #650 said she is unable to do anything about the facility obtaining weights. She puts a list out weekly on the nursing units as to who needs weights but she is unable to get the requested weights or reweights. When questioned why there was not a physician's order for weekly weights RD #650 stated she is not able to write orders. RD #650 said usually NP #658 notifies her when a resident has significant weight loss. RD #650 confirmed she had not updated the nutrition care plan to reflect the resident's significant weight loss. 2. Resident #101 was admitted to the facility on [DATE] and was discharged home on [DATE]. The admitting diagnoses included acute and chronic respiratory failure with hypoxia, Influenza A, high blood pressure, heart disease, atrial fibrillation, pulmonary fibrosis, asthma, a pacemaker, depression, pneumonia, congestive heart failure, and oxygen dependent. Review of the physician's orders for Resident #101 revealed on 01/27/26 an order was written for the resident to received four ounces of house supplement with meals. On 01/28/26 and order was written to obtain weekly weights for four weeks. On 01/29/26 two ounces of liquid protein was ordered three times a day to assist with wound healing. On 01/30/26 a packet of Juven was ordered daily also for wound healing. Review of the nursing progress notes for Resident #101 revealed on 01/28/26 at 10:30 A.M. RD #650 completed an initial nutrition assessment. The skin assessment said to see the nursing wound grids. The resident's height was listed as 72 inches and the weight was listed as 163.8 pounds. The resident's BMI was listed as within normal range. Resident #101 reported no issues upon admission. Meal intakes had varied since admission. Nursing reported no edema upon admission. The resident receives Vitamin B12 and Iron to support nutrition. The resident was ordered four ounces of house supplement with all meals, two ounces of liquid protein three times a day and one packet of Juven twice a day for wound healing. RD #650 said she would monitor appetite and weight as the resident is a new admit. Review of Resident #101's weights revealed no weights were obtained at any time throughout the resident's stay in the facility. Review of Resident #101's comprehensive MDS admission assessment revealed the resident was cognitively intact, had two pressure ulcers present upon admission, had a height of 72 inches and a weight of 164 pounds. The resident had no known weight loss or gain. Resident #101 had a nutrition care plan initiated, on 01/28/26, which indicated the resident was at risk for altered nutrition related to an order of a cardiac diet, regular texture, and thin liquids. The care plan recommended a regular diet, thin liquids, and no added salt. The goal was for the resident to receive adequate nutrition to meet estimated nutrition needs as evidenced by no significant weight change and no skin breakdown. Interventions were to monitor weekly weights for four weeks then monthly if stable. Interview with RD #650 on 04/21/26 at 10:40 A.M. revealed she provided a list of weights to be obtained by nursing but it often was not completed. She was unaware no weights were obtained throughout Resident #101's stay and the care plan should have reflected the resident was admitted with wounds and already had skin breakdown. This deficiency represents noncompliance for Complaint Numbers 2727070 and 2690512.

Based on observation, record review, and interview, the facility failed timely assist Resident #17 with activities of daily living (ADLs). This affected one resident (Resident #17) out of 13 reviewed for ADL care. The facility census was 89. Findings include: Review of the medical record for Resident #17 revealed an admission date of 11/05/20 with diagnoses including chronic respiratory failure, bipolar disorder, herpes viral infection, and dementia. Review of the care plan dated 11/21/20 revealed Resident #17 had an impaired ability to perform or participate in daily activities of daily living (ADL) care related to diabetes mellitus, neuropathy, weakness, debility, chronic respiratory failure, anemia, morbid obesity, arthritis, back pain, and shortness of breath on exertion and when lying flat. Interventions included provide assistance with all ADL care and mobility as needed and anticipate resident needs as able implemented 11/21/20, and mechanical lift with assistance of two staff for transfers implemented 06/05/24, Review of the care plan dated 03/14/21 revealed Resident #17 was incontinent of bladder and at risk for altered dignity, skin breakdown, and urinary tract infections. Interventions included provide incontinence care as needed implemented 06/10/24. Review of the care plan dated 03/14/21 revealed Resident #17 was incontinent of bowel and at risk for altered dignity, skin breakdown, diarrhea, and constipation. Interventions included provide incontinence care as needed implemented 03/14/21. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had moderately impaired cognition with a brief interview for mental status (BIMS) score of 10 out of 15. The assessment indicated Resident #17 was frequently incontinent of bladder and bowel, and was dependent for toileting hygiene. On 04/16/26 at 9:03 A.M., an observation revealed Resident #17's call light was activated. At 9:04 A.M., Medical Records Coordinator #503 entered Resident #17's room, Resident #17 said she needed changed, and Medical Records Coordinator #503 deactivated Resident #17's call light at that time. At 9:12 A.M., Resident #17 activated her call light again. At 9:16 A.M., Medical Records Coordinator #503 entered Resident #17's room, Resident #17 said she still needed to be changed, and Medical Records Coordinator #503 deactivated Resident #17's call light at that time. No other staff were observed entering Resident #17's room from 9:16 A.M. to 9:34 A.M. On 04/16/26 at 9:34 A.M., an interview with Resident #17 confirmed nobody had come to change her yet. On 04/16/26 at 9:34 A.M., an interview with Certified Medication Aide (CMA) #529 stated she was unaware Resident #17 needed changed. On 04/16/26 at 9:37 A.M., observation revealed CMA #529 and Certified Nursing Assistant (CNA) #544 entered Resident #17's room to perform incontinence care, approximately 34 minutes after Resident #17 initially requested assistance. On 04/16/26 at 9:45 A.M., an interview with Regional Registered Nurse (RN) #649 stated it was not typically policy to deactivate the call light without addressing the need. She further stated if someone who was unable to provide the requested care answered the call light, they could turn the call light off and go get someone who could provide the care. Review of the facility policy titled Call Light – Answering, dated 05/01/25, revealed call lights would be answered timely to meet resident needs. The procedure for staff included answering the call light as soon as possible, knocking on the door and introducing themselves, turning the call light off, listening to the resident's request, providing the service requested or informing the resident that their request needs to be fulfilled by the nurse, and following up on their request promptly. This deficiency represents non-compliance investigated under Complaint Numbers 2637021 and 2616336.

Based on record review and interview, the facility failed to ensure Residents #3, #66 and #67's pressure ulcer wound care was completed as ordered and per best practice guidelines. This finding affected three (Residents #3, #66 and #67) of six residents reviewed for pressure ulcers. The facility census was 89.Findings include: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic cholecystitis, congestive heart failure, high blood pressure, renal insufficiency, diabetes, protein malnutrition, anxiety disorder, depression, atrial fibrillation, and chronic obstructive pulmonary disorder. Review of Resident #3's physician's orders revealed on 12/12/25 and order was written for Expedite (a liquid protein supplement) 30 milliliters (ml) twice a day for wounds. An order written on 03/09/26 to clean sacrum with wound cleanser as needed and on a weekly basis. No other wound healing supplements were ordered. Review of the comprehensive quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #3, dated 01/19/26, revealed the resident was cognitively intact, was always incontinent of bowel and bladder, and had a Stage 4 pressure injury (a severe, full-thickness wound extending to exposed muscle, tendon, or bone) which was present upon admission. Review of the Medication Administration Record (MAR) for April 2026 for Resident #3 revealed no as needed wound cleansing was provided by the facility. Review of the wound notes for Resident #3 by Wound Nurse Practitioner (WNP) #652 revealed the resident had a Stage 4 pressure ulcer to the sacrum with wound onset dated approximately 05/20/25. Review of the wound evaluation dated 04/13/26 revealed the wound progress was considered to be stagnate. WNP #652 chose to use a TV-8 Tiger Tail trial for that reason. No information was provided by the facility regarding what a Tiger Tail trial consisted of. Due to difficulty keeping the dressing intact WNP #652 utilized gentian violet (a liquid applied to cuts, scrapes, and burns to prevent infection), skin prep (a wipe used to increase adhesiveness of a dressing), and stomahesive (a paste and powder designed to protect skin and improve adhesion by filling uneven skin surfaces and absorbing moisture) to keep the dressing in place. The dressing was to be changed weekly by WNP #652. Review of the wound notes from 03/23/26 through 04/13/26 revealed the wound was stagnate but was noted by WNP #652 to be improved and healing each week. Observation on 04/20/26 at 7:39 A.M. with WNP #652 of Resident #3's stage four sacrum pressure ulcer wound care revealed the resident did not have a dressing in place at the time of the observation. WNP #652 assessed Resident #3's stage four sacrum pressure wound which measured 1.6 centimeters (cm) in length by 0.5 cm in width and 0.3 cm depth. Interview on 04/20/26 at 7:41 A.M. with WNP #652 confirmed Resident #3's sacrum pressure ulcer wound care was completed weekly on a Monday. When questioned, she revealed the dressing usually did not last all week due to showers etc. and there were orders to replace the dressing. WNP #652 confirmed she was unsure how long the dressing had been off the resident's sacrum pressure ulcer wound and the staff usually leave the resident's wound care for her to complete once weekly since the resident was on a clinical wound trial. Interview on 04/20/26 at 7:52 A.M. with Resident #3 revealed she had a shower on 04/14/26. Interview with WNP #652 on 04/20/26 at 11:46 A.M. revealed Resident #3's dressing should be in place for seven days. Each week she removes the dressing and takes it off and applies a new one. The resident is currently on week nine of a skin substitute called [NAME] (Cellular, Acellular, and Matrix-like Products ([NAME]) used to treat chronic, hard to heal wounds by promoting tissue regeneration and remodeling. The wound looked good today. The resident does not need a dressing as the wound is not that deep. WNP #652 said the resident's dressing did come off this week however when she had a shower. WNP #652 said until today she had not written an order for what the staff should do if the dressing comes off before her visit. She wrote an order today to cleanse the wound with wound cleanser and apply a foam dressing. WNP #652 confirmed staff did not notify her the dressing had come off and she did not know when it came off. Review of the facility's Pressure Injuries: Assessment, Prevention & Treatment policy, last revised 05/01/25, revealed it was the facility's policy to identify residents at risk for developing pressure injuries and provide care for existing pressure injuries. Any resident with wounds will be referred to the dietician. Vitamins, mineral and protein supplements should be used in accordance with physician orders. 2. Review of Resident #66's medical record revealed the resident was admitted on [DATE] with diagnoses including paraplegia, pressure ulcer of sacral region stage 4 and generalized anxiety disorder. Review of Resident #66's Pressure Ulcer Injury Care Plan revealed an intervention dated 06/20/23 to perform current treatment as ordered and observe treatment for effectiveness. Review of Resident #66's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #66's physician orders revealed an order dated 02/16/26 (discontinued 03/10/26) to cleanse the sacrum with normal saline, pat dry, apply a small cut to size piece of hydrofera blue, and cover with a composite dressing every Monday, Wednesday and Friday; an order dated 03/10/26 (discontinued 03/31/26) to cleanse the sacrum with normal saline, pat dry, apply hydroconductive dressing, silicone super absorbent dressing daily; an order dated 03/31/26 (discontinued 04/09/26) to cleanse the sacrum with normal saline, pat dry, apply collagen, silicone super absorbent dressing daily; an order dated 04/09/26 to cleanse the sacrum with normal saline, pat dry, apply collagen, silicone super absorbent dressing daily. Review of Resident #66's Observation History form dated 04/20/26 at 3:50 P.M. revealed the resident had a Stage 4 sacrum pressure ulcer which measured 0.4 centimeters (cm) length by 1.1 cm width by 0.2 cm depth. Review of Resident #66's medication administration records (MARS) and treatment administration records (TARS) from 03/01/26 to 04/16/26 revealed no evidence treatments were completed on 03/13/26, 03/27/26 and 04/04/26. Interview on 04/15/26 at 7:41 A.M. with Regional Registered Nurse (RN) #649 confirmed Resident #66's wound care treatments were not completed as ordered. 3. Review of Resident #67's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic kidney disease stage 4, diabetes and hypothyroidism. Review of Resident #67's Pressure Ulcer/Injury Care Plan revealed an intervention dated 03/30/26 to perform current treatment as ordered and observe treatment for effectiveness. Review of Resident #67's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #67's physician orders revealed an order dated 03/31/26 to cleanse the left upper buttock with normal saline, pat dry, apply medihoney and calcium alginate, cover with a dry dressing and change daily. Review of Resident #67's Observation History form dated 04/13/26 at 4:30 P.M. revealed the resident had an unstageable (with slough and/or eschar) left upper, inner buttock pressure wound which measured 3.3 cm length by 2.6 cm width and the depth could not be measured. Review of Resident #67's MARS and TARS from 04/01/26 to 04/14/26 revealed no evidence wound care was completed on 04/01/26, 04/04/26, 04/06/26, 04/07/26, 04/09/26, 04/10/26, 04/12/26 and 04/13/26. Interview on 04/15/26 at 9:10 A.M. with Regional RN #649 confirmed the above findings. Review of the Pressure Injuries: Assessment, Prevention and Treatment policy updated 05/01/25 revealed it was the facility's 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. This deficiency represents non-compliance investigated under Complaint Number 2727070.

Based on observation, record review, interview, and review of facility policy, the facility failed to provide safe transfer assistance utilizing a mechanical lift device for Resident #61. This affected one resident (#61) out of seven reviewed for accident hazards. The facility census was 89. Findings include: Review of the medical record for Resident #61 revealed an admission date of 10/07/24 with diagnoses including end stage renal disease, abnormalities of gait and mobility, reduced mobility, rheumatoid arthritis, acquired absence of left leg below knee, repeated falls, and history of transient ischemic attack and cerebral infarction. Review of the care plan dated 10/08/24 revealed Resident #61 had impaired ability to perform or participate in activities of daily living (ADL) care related to left below knee amputation, diabetes mellitus, tremors, use of assistive devices, dialysis, impaired range of motion of the left lower extremity, and medical co-morbidities. Interventions included provide assistance with ADL care and mobility as needed and anticipate resident needs as able implemented 10/08/24. Review of the five day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment indicated Resident #61 was dependent for chair/bed-to-chair transfers. Review of the physician's orders for Resident #61 identified orders for bed to chair transfers to be completed with a mechanical lift with assistance of two staff effective 01/27/26. On 04/13/26 at 3:41 P.M., an observation revealed Certified Nursing Assistant (CNA) #613 enter Resident #61's room with a mechanical lift device and no other aide was observed entering or exiting the room. On 04/13/26 at 3:46 P.M., an observation of Resident #61's room revealed CNA #613 was operating the mechanical lift device alone to lower Resident #61 into bed. There were no other staff members present in the room at this time. On 04/13/26 at 3:48 P.M., an interview with Regional Registered Nurse (RN) #649 confirmed CNA #613 was in Resident #61's room with the mechanical lift device and there were no other staff in the room. On 04/13/26 at 3:50 P.M., an interview with CNA #613 confirmed she transferred Resident #61 from the wheelchair to the bed using a mechanical lift device. CNA #613 claimed another CNA (#620) was assisting with the transfer but left to go back to the Assisted Living hall. On 04/13/26 at 3:57 P.M., an interview with CNA #620 said she did not help CNA #613 transfer Resident #61 because she had to go back to the Assisted Living unit. CNA #620 further stated CNA #613 was the only aide assigned to Resident #61's hall. On 04/14/26 at 8:01 A.M., an interview with Resident #26 stated staff operated mechanical lifts with only staff member to transfer her. On 04/14/26 at 9:54 A.M., an interview with Resident #61 stated staff always transferred her with just one person operating the lift because there was only ever one aide assigned to the hall. Review of the facility policy titled Hoyer Lift, dated 05/01/25, revealed two staff members must be present when using the lift device. This deficiency represents non-compliance investigated under Complaint Numbers 2742677 and 2690512.

Based on observation, record review, interview, and review of facility policy, the facility failed to ensure Resident #27's respiratory needs were ordered and the cleaning and storage of oxygen services were in place. This affected two residents (#27 and #89) out of four reviewed for respiratory care. The facility census was 89. Findings include: 1. Review of the medical record for Resident #27 revealed an admission date of 01/05/26 with diagnoses including congestive heart failure, asthma, thrombocytopenia, end stage renal disease, history of pulmonary embolism, and obstructive sleep apnea. Review of the care plan, revised 01/05/26, revealed Resident #27 had the potential for alteration in respiratory function related to congestive heart failure, asthma, shortness of breath while lying flat or during exertion, anxiety, and obesity. Interventions included administer oxygen as ordered implemented 01/05/26. Review of the five day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment indicated Resident #27 did not receive oxygen therapy. Review of the physician's orders for Resident #27 revealed there were no active orders for oxygen use. On 04/13/2026 at 1:25 P.M., an observation of Resident #27 revealed she was wearing a nasal cannula with oxygen running and the oxygen tubing was dated 03/24/26. On 04/13/2026 at 1:40 P.M., an observation and interview with Certified Medication Aide (CMA) #529 verified the oxygen tubing was dated 03/24/26 and stated she believed it was supposed to be changed weekly. On 04/13/2026 at 2:37 P.M., an interview with Regional Registered Nurse (RN) #649 verified Resident #27 had no orders for oxygen use. On 04/13/2026 at 2:53 P.M., an interview with Regional RN #649 verified oxygen tubing was to be changed weekly. Review of the facility's policy titled Oxygen Administration, dated 05/01/25, revealed oxygen equipment including tubing, mask, cannula, and humidifier should be replaced weekly and as needed. 2. Review of the medical record for Resident #89 revealed an admission date of 04/02/26. Diagnoses included traumatic hemorrhage of the cerebrum, acute respiratory failure with hypoxia, and dysphagia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #89 had intact cognition. Resident #89 required extensive assistance for all activities. Review of the physician's orders for Resident #89 revealed an order dated 04/03/26 for 3 liters of oxygen with 28% humidified aerosol trach collar at bedtime and as needed. Review of the care plan dated 04/15/26 revealed Resident #89 has a potential for alteration in respiratory function related to respiratory failure and tracheostomy placement. Interventions included administering respiratory treatments as ordered and encourage fluids. Interview and observation on 04/14/26 at 11:19 A.M. revealed Resident #89 was receiving oxygen at 6L with trach mask and humidified water attached, with no date noted on tubing, water, or trach mask as to when it was changed last. Interview during the observation with Licensed Practical Nurse (LPN) #517 confirmed the oxygen set up was not dated at all.

Based on record review and interview, the facility failed to ensure residents on dialysis received ongoing assessment and monitoring to ensure health status and reduce complication of dialysis care. This finding affected three (Residents #26, #67, and #85) of five residents reviewed for dialysis. The facility census was 89.Findings include:1. Review of the medical record for Resident #26 revealed an admission date of 03/29/25 with diagnoses including congestive heart failure, type two diabetes mellitus, hypertension, and end stage renal disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had no cognitive impairment and received dialysis treatments. Review of the physician's orders for Resident #26 identified orders for dialysis every Monday, Wednesday and Friday at 5:30 A.M. effective 04/06/26, complete the pre-dialysis observation and vital signs on dialysis days at 4:30 A.M. effective 04/06/26, and completed the post-dialysis observation and vital signs on dialysis days at 12:30 P.M. effective 04/06/26. Review of the pre- and post-dialysis assessments for Resident #26 from January 2026 through April 2026 revealed the following: On 01/02/26, the pre-dialysis assessment was missing the weight. On 01/05/26, the pre-dialysis assessment was missing the weight, and the post-dialysis assessment was missing the pulse, temperature, respirations, and pulse ox. On 01/07/26, the pre-dialysis assessment was missing the weight. On 01/09/26, the pre-dialysis assessment was missing the pulse, temperature, respirations, pulse ox, and weight. On 01/12/26, the pre-dialysis assessment was missing the weight, and the post-dialysis assessment was missing the pulse, temperature, respirations, and pulse ox. On 01/15/26, there was no pre-dialysis assessment or post-dialysis assessment in the medical record. The dialysis communication form sent from the dialysis center indicated Resident #26 received dialysis treatment on 01/15/26. On 01/16/26, the pre-dialysis assessment was missing the weight and there was no post-dialysis assessment in the medical record. The dialysis communication form sent from the dialysis center indicated Resident #26 received dialysis treatment on 01/16/26. On 01/19/26, the pre-dialysis assessment was missing the weight, and the post-dialysis assessment was missing the pulse, temperature, respirations, and pulse ox. On 01/21/26, the pre-dialysis assessment was missing the pulse, temperature, respirations, and pulse ox, and there was no post-dialysis assessment in the medical record. The dialysis communication form sent from the dialysis center indicated Resident #26 received dialysis treatment on 01/21/26. On 01/23/26, the pre-dialysis assessment was missing the weight. On 01/26/26, the pre-dialysis assessment was missing the weight, and the post-dialysis assessment was missing the pulse, temperature, respirations, and pulse ox. On 01/28/26, the pre-dialysis assessment was missing the weight, and the post-dialysis assessment was missing the pulse, temperature, respirations, and pulse ox. On 01/30/26, the pre-dialysis assessment was missing the weight, and the post-dialysis assessment was missing the blood pressure, pulse, temperature, respirations, and pulse ox. On 02/02/26, the pre-dialysis assessment was missing the weight. On 02/04/26, the pre-dialysis assessment was missing the pulse, temperature, respirations, pulse ox, and weight. On 02/06/26, the pre-dialysis assessment was missing the temperature, respirations, pulse ox, and weight. On 02/09/26, the pre-dialysis assessment was missing the temperature, respirations, pulse ox, and weight. On 02/11/26, the pre-dialysis assessment was missing the temperature, respirations, pulse ox, and weight. On 02/13/26, the pre-dialysis assessment was missing the weight. On 02/16/26, the pre-dialysis assessment was missing the weight. On 02/18/26, the pre-dialysis assessment was missing the weight, and there was no post-dialysis assessment in the medical record. The dialysis communication form sent from the dialysis center indicated Resident #26 received dialysis treatment on 02/18/26. On 02/23/26, there was no pre-dialysis assessment in the medical record. The dialysis communication form sent from the dialysis center indicated Resident #26 received dialysis treatment on 02/23/26. On 02/25/26, there was no pre-dialysis assessment in the medical record. The dialysis communication form sent from the dialysis center indicated Resident #26 received dialysis treatment on 02/25/26. On 02/27/26, the pre-dialysis assessment was missing the weight. On 03/02/26, there was no pre-dialysis assessment in the medical record. The dialysis communication form sent from the dialysis center indicated Resident #26 received dialysis treatment on 03/02/26. On 03/04/26, the pre-dialysis assessment was missing the blood pressure and weight, and there was no post-dialysis assessment in the medical record. The dialysis communication form sent from the dialysis center indicated Resident #26 received dialysis treatment on 03/04/26. On 03/06/26, the pre-dialysis assessment was missing the weight, and the post-dialysis assessment was missing the pulse, temperature, respirations, and pulse ox. On 03/09/26, the pre-dialysis assessment was missing the weight, and the post-dialysis assessment was missing the pulse, temperature, respirations, and pulse ox. On 03/11/26, the pre-dialysis assessment was missing the blood pressure, pulse, temperature, pulse ox, and weight, and the post-dialysis assessment was missing the pulse, temperature, respirations, and pulse ox. On 03/13/26, the pre-dialysis assessment was missing the weight. On 03/14/26, there was no pre-dialysis assessment or post-dialysis assessment in the medical record. The dialysis communication form sent from the dialysis center indicated Resident #26 received dialysis treatment on 03/14/26. On 03/16/26, the pre-dialysis assessment was missing the weight. On 03/18/26, the pre-dialysis assessment was missing the respirations, pulse ox, and weight, and the post-dialysis assessment was missing the pulse, temperature, respirations, and pulse ox. On 03/20/26, the pre-dialysis assessment was missing the weight. On 03/23/26, the pre-dialysis assessment was missing the temperature, respirations, pulse ox, and weight. On 03/25/26, the pre-dialysis assessment was missing the weight, and the post-dialysis assessment was missing the pulse, temperature, respirations, and pulse ox. On 03/27/26, the pre-dialysis assessment was missing the weight, and there was no post-dialysis assessment in the medical record. The dialysis communication form sent from the dialysis center indicated Resident #26 received dialysis treatment on 03/27/26. On 03/30/26, there was no pre-dialysis assessment in the medical record. The dialysis communication form sent from the dialysis center indicated Resident #26 received dialysis treatment on 03/30/26. On 04/06/26, there was no pre-dialysis assessment or post-dialysis assessment in the medical record. The dialysis communication form sent from the dialysis center indicated Resident #26 received dialysis treatment on 04/06/26. On 04/08/26, the pre-dialysis assessment was missing the weight, and there was no post-dialysis assessment in the medical record. The dialysis communication form sent from the dialysis center indicated Resident #26 received dialysis treatment on 04/08/26. On 04/10/26, there was no pre-dialysis assessment or post-dialysis assessment in the medical record. The dialysis communication form sent from the dialysis center indicated Resident #26 received dialysis treatment on 04/10/26. On 04/17/26 at 1:15 P.M., an interview with Regional Registered Nurse (RN) #649 verified dialysis assessments were not completed as ordered. Regional RN #649 further stated the facility got cited on every survey for dialysis assessments because they had such a large population of residents receiving dialysis treatments. Review of the facility policy titled Dialysis Policy, dated 05/01/25, revealed residents were to receive interdisciplinary monitoring to ensure safety and the facility was to complete pre and post-dialysis assessments. 2. Review of the medical record for Resident #85 revealed they were admitted to the facility on [DATE] with diagnoses that included stroke, hemiplegia (paralysis of one side of the body), hemiparesis (weakness on one side of the body), end stage renal disease (ESRD), need for assistance with personal care, muscle weakness, and reduced mobility. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #85 was cognitively impaired, had behaviors not directed towards others, did not reject care, required maximal assistance for most activities of daily living, was dependent for transferring, and required dialysis. Review of the care plan revealed Resident #85 had an alteration in renal function related to ESRD and dialysis dated 01/27/26 with a goal to not have dialysis related complications and the facility and dialysis center were to coordinate care. Interventions included monitoring the dialysis access site, observe for signs and symptoms of fluid retention which included shortness of breath and high blood pressure, obtain vital signs as ordered, and the facility was to communicate any concerns to the dialysis center. Review of the physician orders revealed orders for dialysis every Monday, Wednesday, and Friday dated 01/26/26; pre-dialysis observation and vital signs were to be completed on dialysis days dated 03/23/26; and post-dialysis observation and vital signs were to be completed on dialysis days dated 01/26/26. Review of the dialysis communication sheets from 03/02/26 to 04/15/26 revealed Resident #85 received dialysis 03/02/26, 03/04/26, 03/06/26, 03/09/26, 03/11/26, 03/14/26, 03/16/26, 03/18/26, 03/20/26, 03/23/26, 03/25/26, 03/27/26, 03/30/26, 04/03/26, 04/06/26, 04/08/26, 04/10/26, and 04/13/26. Review of the pre and post-dialysis assessments from 03/02/26 to 04/13/26 revealed the following: the post-dialysis assessment on 03/02/26 was absent of all vital sign documentation except blood pressure; the post-dialysis assessment on 03/04/26 was absent of all vital sign documentation except blood pressure; the post-dialysis assessment on 03/06/26 was absent of all vital sign documentation except blood pressure; the pre-dialysis assessment on 03/11/26 was absent of all vital sign documentation except blood pressure; the post-dialysis assessment on 03/11/26 was absent of all vital sign documentation except blood pressure; on 03/13/26 a post-dialysis assessment was not completed; the post-dialysis assessment on 03/25/26 was absent of all vital sign documentation except blood pressure; on 03/27/26 a pre-dialysis assessment was not completed; the post-dialysis assessment on 04/03/26 was absent of all vital sign documentation except for blood pressure; the post-dialysis assessment on 04/06/26 was absent of all vital sign documentation except blood pressure; on 04/08/26 a post-dialysis assessment was not completed; on 04/10/26 a pre-dialysis assessment was not completed; on 04/10/26 the post-dialysis assessment was absent of vital sign documentation and a note to see the Medication Administration Record (MAR) for vital signs; and the post-dialysis assessment on 04/13/26 was absent of all vital sign documentation except blood pressure. Review of the progress notes from 03/02/26 to 04/15/26 revealed the absence of documentation related to incomplete dialysis assessments, missing dialysis assessments, or resident refusal of assessments or vital signs. Review of the MAR from 03/02/26 to 03/31/26 revealed all post-dialysis observations were documented as completed. Review of the MAR from 04/01/26 to 04/14/26 revealed all post-dialysis assessments were documented as completed. An interview on 04/15/26 at 10:12 A.M. with Regional Registered Nurse (RN) #649 verified the above findings. Review of the dialysis contract dated 10/19/18 revealed the facility was to provide the dialysis center with any information related to a change in condition, any information that would facilitate coordination of care, and the facility was responsible to ensure the resident was medically stable for transportation to the dialysis center. Review of the facility policy titled Dialysis Policy, dated 05/01/25 revealed residents were to receive interdisciplinary monitoring to ensure safety and the facility was to complete pre and post-dialysis assessments. 3. Review of Resident #67's medical record revealed the resident had chronic kidney disease stage 4, diabetes and hypothyroidism. Review of Resident #67's Alteration in Renal Function Care Plan dated 03/26/26 revealed the resident was on hemodialysis. Review of Resident #67's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #67's physician orders revealed an order dated 03/27/26 for dialysis every Tuesday, Thursday and Saturday with a chair time of 10:15 A.M.; an order dated 03/27/26 to complete post-dialysis observation on dialysis days on Tuesday, Thursday and Saturday; and an order dated 03/27/26 to complete pre-dialysis observation and vital signs on dialysis days once a day on Tuesday, Thursday and Saturday; and an order dated 03/26/26 for daily weights once a day. Review of the hemodialysis assessments confirmed a pre-assessment was completed on 04/02/26 at 3:11 P.M.; post assessment on 04/02/26 at 3:12 P.M.; pre assessment on 04/04/26 at 9:06 A.M.; no post assessment for 04/04/26; pre assessment on 04/07/26 at 2:37 P.M.; post assessment on 04/07/26 at 2:38 P.M.; pre assessment on 04/09/26 at 2:36 P.M.; post assessment on 04/09/26 at 2:40 P.M.; pre assessment on 04/14/26 at 3:03 P.M.; and post assessment on 04/14/26 at 3:04 P.M. Review of Resident #67's dialysis assessments revealed no evidence that a post hemodialysis assessment was completed on 04/04/26. Review of Resident #67's medical record from 04/01/26 to 04/14/26 revealed no evidence daily weights were completed on 04/01/26, 04/03/26, 04/04/26, 04/08/26, 04/10/26, 04/11/26, 04/12/26 and 04/13/26. Interview on 04/15/26 at 9:15 A.M. with Regional Registered Nurse (RN) #649 confirmed the above findings. Review of the Dialysis Policy updated 05/01/25 revealed it was the policy of the facility that all residents utilize renal dialysis receive comprehensive interdisciplinary monitoring to ensure resident safety and support of dialysis services. This deficiency represents non-compliance investigated under Complaint Number 2637021.

Based on observation, record review and interview, the facility failed to ensure Resident #12 was free from significant medication error. This finding affected one (Resident #12) of six residents observed for medication administration. The facility census was 89.Findings include: Review of Resident #12's medical record revealed the resident was admitted on [DATE] with diagnoses including muscle weakness, need for assistance with personal care and chronic kidney disease stage 4.Review of Resident #12's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] the resident exhibited intact cognition.Review of Resident #12's physician orders revealed an order dated 04/11/26 for Buspirone 10 milligrams (mg) three times a day (due at 7:00 A.M. to 11:00 A.M., 1:00 P.M. to 2:30 P.M. and 6:30 P.M. to 10:30 P.M.; Ferrous Sulfate 325 mg twice daily with meals (due from 7:00 A.M. to 11:00 A.M. and 6:30 P.M. to 10:30 P.M.; Humalog KwikPen insulin 12 units subcutaneous with breakfast once a day at 7:00 A.M.; Lactulose solution 10 grams/15 ml twice a day (9:00 A.M. to 9:30 A.M. and 5:00 P.M. to 5:30 P.M.), Metoprolol Succinate tablet 150 mg (hold for systolic blood pressure less than 90 or heartrate less than 55) twice daily (from 7:00 A.M. to 11:00 A.M. and 6:30 P.M. to 10:30 P.M.); Xifaxan 550 mg twice daily (due 7:00 A.M. to 11:00 A.M. and 6:30 P.M. to 10:30 P.M.), and an order dated 04/14/26 for dialysis every Monday, Wednesday and Friday at 12:30 P.M. The physician orders indicated the blood sugars were to be obtained for breakfast and dinner meals.Review of Resident #12's medication administration records (MARS) and treatment administration records (TARS) on 04/13/26 revealed no evidence a blood sugar was obtained for the breakfast or dinner meals.Review of Resident #12's Nurse Practitioner (NP) Progress note dated 04/07/26 revealed to send blood sugars to endocrinology.Observation on 04/13/26 at 9:26 A.M. revealed Resident #12 was just coming back from dialysis. The resident was observed on a transportation cart in the resident's room. Interview with Resident #12 at the time of the observation revealed she was waiting on staff to transfer her from the cart to bed using a Hoyer mechanical lift.Observation on 04/13/26 at 10:30 A.M. with Licensed Practical Nurse (LPN) #553 revealed the nurse was administering medications to residents on the 100-hall. LPN #553 confirmed Resident #12 returned to the facility around 9:30 A.M. and had breakfast at that time but she had been unable to administer the resident's medications when due because she fell behind.Interview on 04/13/26 at 11:22 A.M. with Resident #12 revealed there were not enough staff, and her medications were consistently administered late. Resident #12 confirmed she had not received her morning medications on this date. Resident #12 confirmed she had her breakfast meal, and she did not receive her insulin as ordered.Interview on 04/13/26 at 12:15 P.M. with Regional Registered Nurse (RN) #649 confirmed LPN #553 had not administered Resident #12's scheduled medications including her insulin in a timely manner. Regional RN #649 confirmed she talked to the NP and adjusted the resident's medications due to the resident's medications not administered timely including the resident's insulin medication.Interview on 04/13/26 at 1:33 A.M. with Regional RN #649 confirmed Resident #12's blood sugars were to be obtained prior to the breakfast and dinner meals (no lunch meal). Regional RN #649 also confirmed Resident #12's blood sugar was not obtained per the MARS and TARS on 04/13/26 for the breakfast or dinner meal.Review of the Medication Administration Policy dated 05/2020 revealed medications were administered as prescribed in accordance with good nursing principles and practices and only by people legally authorized to do so.This deficiency represents non-compliance investigated under Complaint Numbers 2793933 and 2690512.

Based on record review and interview, the facility failed to obtain laboratory samples and results as ordered. This affected one resident (#85) out of six reviewed for unnecessary medications. The facility census was 89. Findings include: Review of the medical record for Resident #85 revealed an admission date of 01/23/26 with diagnoses including end stage renal disease, seizures, and history of cerebral infarction. Review of the physician's orders for Resident #85 identified orders for Levetiracetam (Keppra) 500 milligrams (mg) per 5 milliliters (ml) to give 500 mg twice daily effective 01/29/26. Review of the pharmacy recommendation dated 02/03/26 revealed a recommendation was made for a supplemental dose of Levetiracetam after each dialysis session. Nurse Practitioner (NP) #658 reviewed the recommendation on 02/26/26 and ordered to obtain a Levetiracetam level on the next lab day. Review of the laboratory documentation revealed NP #658 ordered for the bloodwork to be drawn on 02/27/26 and the lab did not collect the specimen because Resident #85 was at dialysis, which the dialysis center was attached to the facility. On 04/21/26 at 8:45 A.M., an interview with Regional Registered Nurse (RN) #649 verified the Levetiracetam labs that were ordered were never obtained for Resident #85.

Based on observation, record review, interview, and review of facility policy, the facility failed to ensure staff followed infection control protocols for residents on contact isolation and droplet isolation. This affected three residents (#12, #17, and #40) out of five reviewed for infection control. The facility census was 89. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 08/23/25 with diagnoses including history of urinary tract infections, type two diabetes mellitus, end stage renal disease, congestive heart failure, and need for assistance with personal care. Review of the physician's orders for Resident #12 identified orders for contact transmission based precautions effective 04/11/26. Review of the progress note dated 04/11/26 at 3:20 P.M. revealed Resident #12 had returned from the hospital this day and was on contact isolation precautions due to a urinary tract infection with the presence of Extended-Spectrum Beta-Lactamase (ESBL), which are enzymes produced by bacteria that are resistant to many standard antibiotics. Review of the care plan dated 03/18/26 revealed Resident #12 had recurrent urinary tract infections. Interventions included staff to maintain transmission based precautions as ordered. On 04/13/26 at 11:31 A.M., an observation revealed Nurse Aide in Training #537 entered Resident #12's room without donning any personal protective equipment (PPE). There was a sign posted by the door indicating contact isolation precautions were in place and everyone must wear a gown and gloves when entering the room. On 04/13/26 at 11:34 A.M., an interview with Nurse Aide in Training #537 verified she did not don any PPE prior to entering Resident #12's room. She stated she did not see the sign for contact isolation. Nurse Aide in Training #537 stated Resident #12 needed changed and she changed the resident wearing only gloves. 2. Review of the medical record for Resident #17 revealed an admission date of 11/05/20 with diagnoses including chronic respiratory failure, bipolar disorder, herpes viral infection, and dementia. Review of the physician's orders for Resident #17 identified orders for contact transmission based precautions effective 04/10/26. Review of the care plan dated 04/13/26 revealed Resident #17 was utilizing antiviral medication related to herpes viral infection and was on contact isolation precautions. Interventions included staff to maintain transmission based precautions as ordered. On 04/13/26 at 11:45 A.M., an observation revealed Physical Therapy Assistant (PTA) #656 entered Resident #17's room without donning any personal protective equipment (PPE). There was a sign posted by the door indicating contact isolation precautions were in place and everyone must wear a gown and gloves when entering the room. After entering the room, PTA #656 applied a glove to her right hand and deactivated the call light. An interview at the time of observation with PTA #656 confirmed she did not apply the proper PPE prior to entering the room. PTA #656 stated she did not touch Resident #17 while in the room and she just turned the call light off. PTA #656 confirmed there were no stipulations for contact precautions indicating PPE did not have to be worn in the room if staff were not touching the resident. On 04/13/26 at 11:49 A.M., an interview with Regional Registered Nurse (RN) #649 confirmed she heard PTA #656 say she did not don PPE because she was only turning the call light off and not touching the resident. 3. Resident #40 was admitted to the facility on [DATE] with diagnoses including end stage renal disease dependent on renal dialysis, diabetes, and asthma. Review of the physician's orders for Resident #40 revealed on 04/06/26 the resident was started on Mucinex ER 600 milligrams (mg) every 12 hours for congestion for seven days, Benzonatate 100 mg three times a day for cough for seven days, a Medrol dose pack for help with the resident's asthma, obtain a chest x-ray, and an albuterol inhaler two puffs every six hours for wheezing. Review of the nursing progress notes for Resident #40 revealed on 04/06/26 complained of not feeling well, had a cough, and felt like she was not able to get enough oxygen. The resident tested positive for Covid-19 and was placed on airborne precautions to prevent the further spread of Covid-19. Review of Resident #40's care plans revealed the resident has potential for alteration in respiratory function related to testing positive for Covid-19 on 04/06/26. The care plan was revised to reflect this on 04/15/26. Observation and interview on 04/13/26 from 11:06 A.M. through 11:32 A.M. revealed Resident #40 was on airborne precautions for Covid with personal protective equipment (PPE) located outside the resident's closed door. At 11:06 A.M. Resident #40 activated her call light. The call light remained on at 11:11 A.M. Facility staff were observed going up and down hall past the resident's room while the light was on including Regional Registered Nurses (RRN) #648 and #649. The Assistant Director of Nursing also went up and down the hall without stopping. Resident #40's call light remained on at 11:17 A.M., 11:21 A.M., 11:25 A.M., and 11:30 A.M. At 11:32 A.M. this surveyor asked RRN #649 why the resident's call light had not been responded to since 11:06 A.M. RRN #649 replied she was just going to check on the resident now. RRN #648 then told RRN #649 he would go in and check on the resident, put on a gown, mask, and gloves and entered the room. Eye protection was not in use. Interview with RRN #648 at 11:41 A.M. confirmed eye protection should be worn. This deficiency represents noncompliance investigated under Complaint Number 2800089.

Based on medical record review, review of hospital documentation, policy review, and interview, the facility failed to ensure ongoing assessments and monitoring were completed for Resident #10's right ring finger skin impairment. This finding affected one (Resident #10) of three residents reviewed for skin impairments.Actual harm occurred on 07/02/25 when Resident #10, who was assessed upon admission with a right ring finger bruise and/or scab, was admitted to the hospital with the diagnosis of a necrotic finger resulting in the partial amputation of his right ring finger.Findings Include:Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE] with diagnoses including necrotizing fasciitis, cutaneous abscess of the groin and end stage renal disease.Review of Resident #10's progress note dated 06/12/25 at 6:50 P.M. (recorded as a late entry on 06/13/25 at 01:19 A.M.) authored by Registered Nurse (RN) #812 revealed the resident was admitted to the facility via an ambulance service on a cot and sheet lifted onto the bed. The resident was alert and oriented to person, place, time and situation and the resident denied pain or discomfort. The resident stated he was blind in the left eye and poor vision in the right eye. The resident was on dialysis Monday, Wednesday and Friday and was diabetic. He had a right inner thigh wound, two abrasions to the left knee, a scabbed area to the right outer ankle, ulcerated area on the right great toe, scab on the second and third right digits, scabs and bruising to the left great toe and left third digit, various scabs and bruises to the right and left fingers, and an abdominal dressing to the left lower quadrant.Review of Resident #10's Illustration of Documentation and Measurements of Skin Areas form (admission skin assessment) authored by RN #812 dated 06/12/25 revealed the resident had a bruised nail bed on the right ring finger, scabs on the second digit of the left hand, a wound to the left thigh, a wound to the right thigh, abrasions to the left leg, scabbed areas to the left ankle, bruising to the third right toe, scabbed areas to the right great toe, and scabbed areas to the left great toe, first toe and fourth toe.Review of Resident #10's Pressure Ulcer/Injury care plans revealed an intervention dated 06/13/25 to observe/report any signs and symptoms of skin irritation such as lack of sensation, tingling or burning feeling, verbal/nonverbal signs of pain, discoloration, edema, excoriation, and erythema and to report to the physician as needed.Review of Resident #10's Nursing Skin Tool dated 06/13/25 revealed no new areas and no changes to the existing wounds. The skin impairment to the right ring finger was not identified on the form.Review of Resident #10's Nursing Assistant Bathing/Skin Tool dated 06/14/25 revealed the resident had a complete bed bath. Old bruising and healing scrapes on the toes were noted on the form. The skin impairment to the right ring finger was not identified on the form.Review of Resident #10's Physician History and Physical dated 06/16/25 authored by Physician #913 (the Medical Director) revealed the [AGE] year-old-male was admitted to the skilled facility following hospitalization from 06/02/25 to 06/12/25 for sepsis secondary to a groin abscess with possible necrotizing fasciitis. The resident went for multiple aggressive debridement's concerning of necrotizing fasciitis. The resident was evaluated by wound care and a wound vacuum (vac) was reapplied. The resident's skin was normal with a normal temperature and left arm fistula. The skin impairment to the right ring finger was not identified on the form.Review of Resident #10's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #10's Nursing Skin Tool dated 06/20/25 revealed no changes to the previous areas and no new areas. The skin impairment to the right ring finger was not identified on the form.Review of Resident #10's Physician Note form dated 06/20/25 authored by Therapy Physician #914 revealed an initial consultation to evaluate skilled therapy services. The resident was admitted to the hospital with a three-day history of fever, weakness, and severe peritoneal pain with a fall. The resident was found to have necrotizing fasciitis of the left groin and underwent surgical debridement on 06/02/25 and again on 06/05/25. The resident's skin was thin with bruising, a fistula in the right arm with a good pulse and thrill. The skin impairment to the right ring finger was not identified on the form.Review of Resident #10's physician progress note dated 06/26/25 authored by Covering Physician #915 revealed the resident's skin had a normal temperature and a left arm fistula with no abnormal bruising.Review of Resident #10's Nursing Skin Tool dated 06/27/25 revealed no changes and no new areas noted. The skin impairment to the right ring finger was not identified on the form.Review of Resident #10's Nursing Assistant Bathing/Skin Tool dated 07/01/25 revealed the resident received a shower. Written documentation on the form indicated no new concerns were identified. The skin impairment to the right ring finger was not identified on the form.Review of Resident #10's progress note dated 07/01/25 at 2:47 P.M. revealed Resident #10 had a colonoscopy scheduled for 07/02/25 at 6:45 A.M.Review of Resident #10's hospital admission paperwork dated 07/02/25 revealed the resident was recently hospitalized from [DATE] to 06/12/25 for management of a groin abscess and the concern for necrotizing fasciitis, he was discharged to a skilled nursing facility with a wound vac. The resident presented to the emergency room (ER) today with a concern for a right fourth digit necrosis and lower extremity wounds. The resident's finger had reportedly been turning black and associated with pain with any kind of movement for the past few days. He also had several ulcerated lesions on his toes bilaterally and was supposed to be scheduled for a follow-up with podiatry, but had not been seen yet. The x-ray of the hand demonstrated lucency under the nailbed of the fourth digit likely related to an infection.Review of hospital emergency room documentation dated 07/02/25 at 4:29 P.M. revealed Resident #10's right ring finger nailbed and tip of the finger appeared black. Photos were included in the documentation which showed the tip of the right ring finger appeared black with flaking, peeling skin at the tip, with a small uneven portion of the tip of the finger missing underneath the fingernail. The hospital documentation noted on 07/02/25, the resident had a revision amputation of the right fourth finger by orthopedic surgery. Per orthopedic surgery, the distal phalanx bone was felt to be of good strength, but a large portion of the phalanx was debrided due to the level of skin necrosis.Review of Resident #10's Operative Report dated 07/03/25 at 11:28 A.M. revealed the resident presented with necrosis of the right ring finger which had worsening surrounding erythema and pain. The resident was offered formal irrigation and debridement in the operating room with revision amputation to achieve adequate soft tissue closure. The distal phalanx bone was felt to be of good strength atypical of osteomyelitis but due to the level of skin necrosis, a large portion of the phalanx was debrided and sent for specimen.Review of the hospital Nephrology Service note dated 07/03/25 at 1:57 P.M. revealed Resident #10, who received dialysis was admitted with right ring finger necrosis with worsening pain and redness. He was status post revision amputation of the finger earlier in the morning.Interview on 07/10/25 at 4:55 A.M. with RN #804 indicated staff sometimes did not do what they were supposed to do in terms of wound care, but she would not specify. RN #804 revealed (on 07/02/25) Resident #10 had gone for a colonoscopy and the hospital staff had identified the resident had a necrotic finger. The resident was then admitted to the hospital. Interview on 07/10/25 at 6:28 A.M. with Licensed Practical Nurse (LPN) Wound Nurse (WN) #809 revealed Resident #10 had a bruised, dark finger. She denied the resident had a surgical consultation for the finger and denied knowledge of the area looking necrotic. Interview on 07/10/25 at 7:40 A.M. with the Director of Nursing (DON) revealed Resident #10's right finger was bruised but stated the staff did not notice necrotic tissue.Telephone interview on 07/10/25 at 7:54 A.M. with RN #812 revealed Resident #10 was admitted to the facility with an open area to the left groin and some areas on the left and right feet as well as left and right hands. She stated she could not remember exactly what the wounds looked like, including the areas on the resident's hands.Interview on 07/10/25 at 9:44 A.M. with Dialysis RN #910 revealed she had provided care to Resident #10 on several occasions and did not observe necrosis on the resident's fingers.Interview on 07/10/25 at 9:52 A.M. with Certified Occupational Therapy Assistant (COTA) #911 revealed Resident #10 had some blackness and scaling on his right ring finger but she could not tell if it was a bruise or not. She stated that it was not within her scope of practice to assess the area. COTA #911 did not disclose if she notified any nursing staff regarding the resident's black scaly right ring finger. Interview on 07/10/25 at 9:55 A.M. with LPN #912 revealed Resident #10's right ring finger looked dark but denied knowledge of it being weeping or open. LPN #912 indicated the ring finger did not look necrotic to her knowledge.Interview on 07/10/25 at 11:25 A.M. with Physician #913 revealed he assessed Resident #10 on 06/16/25 and did not identify concerns with the resident's right ring finger or necrosis. Physician #913 also stated Physician #914 assessed the resident on 06/20/25 and Physician #915 assessed the resident on 06/26/25 and no one had identified any type of necrotic areas on the resident's hands during those visits. The resident was transported to the hospital related to the condition of his finger on 07/02/25 (six days after last being seen by a physician).Interview on 07/10/25 at 1:08 P.M. with RN Regional #909 revealed nursing staff were to complete a whole-body assessment once weekly. The Rn revealed facility staff did not document bruises on the form unless there was a change in the bruise. If the bruise worsened, it would be reassessed and reported to the physician for further orders. RN Regional #909 confirmed the documentation for Resident #10 did not have evidence the right ring finger was assessed for improving or worsening of the skin impairment.Telephone interview on 07/14/25 at 11:48 A.M. with Resident #10's family member revealed the resident's right finger started turning dark in May 2025. The family member stated the resident had been admitted to the hospital on two separate occasions and the hospital was monitoring the finger. Resident #10's family member revealed the resident had reported pain to the nursing staff during his stay (date not provided) and was told the right ring finger was just bruised. She indicated when the resident was sent to the hospital for the colonoscopy (on 07/02/25) it was determined the right ring finger was necrotic and the resident had to have surgery to remove the necrosis. Review of the undated Wound Care policy revealed it was the facility policy to provide guidelines for the care of wounds to promote healing.This deficiency represents non-compliance investigated under Complaint Number OH00167473 (1367059).

Based on closed medical record review, hospital record review and staff interview the facility failed to implement a comprehensive and individualized pressure ulcer prevention program for Resident #95 to prevent the development and worsening of pressure ulcers. Actual harm occurred on [DATE] when Resident #95 was admitted to the facility, at risk for pressure ulcer development and with evidence of pressure ulcers present and was not provided adequate assessment/monitoring of skin, wound care or effective and individualized pressure ulcer preventative measures. On [DATE] the resident was assessed by the wound nurse practitioner to have developed new and worsening pressure ulcers including an unstageable pressure ulcer to the coccyx, a deep tissue injury (DTI) to the left heel, DTI ulcers to the left metatarsals and lateral malleolus, a DTI to the right heel and a DTI to the right lateral calf. This affected one resident (Resident #95) of three residents reviewed for pressure ulcers. The facility census was 94. Findings include: Review of Resident #95's closed medical record revealed an admitted [DATE] with admission diagnoses that included cardiac arrest, diabetes mellitus, peripheral vascular disease, peripheral artery disease and congestive heart failure. Further review of the medical record including prior hospitalization notes and emergency services (EMS) transport notes revealed Resident #95 was admitted to the hospital on [DATE] following cardiac arrest requiring advanced cardiac life support services (ACLS) including cardio-pulmonary resuscitation (CPR). Resident #95 was admitted to the hospital from [DATE] until transfer to a skilled nursing facility on [DATE]. During the resident's hospital stay, a wound consultation note, dated [DATE] identified wounds to the resident's buttocks. On [DATE] four deep tissue injury (DTI) (purple or maroon localized area of discolored intact skin) ulcerations were noted to the resident's left middle back measuring 5.0 centimeters (cm) by 6.5 cm, left buttock measuring 7.0 cm by 5.7 cm, right buttock measuring 0.3 cm by 0.8 cm and sacrum measuring 1.0 cm by 0.5 cm. Review of the facility paper admission packet paperwork, dated [DATE] but not signed by a nurse revealed an informal skin assessment tool which identified skin issues to the resident's coccyx measuring 5.5 cm by 3.7 cm with 0.2 cm depth, left middle back with no measurement noted, left hand, right forearm and left neck. There was no evidence of any wound description or identification of wound staging completed upon admission. Upon admission to the facility a nursing progress note, dated [DATE] at 3:30 P.M. indicated the resident had multiple skin issues noted. No additional information was provided. Review of the electronic health record (EHR) revealed no evidence of a wound assessment completed at the time of admission on [DATE]. Review of Resident #95 skin breakdown assessment tool dated [DATE] indicated the resident was at high risk for development of skin breakdown and had current areas of skin breakdown. Review of the Admission care plan dated [DATE] revealed wounds were present on admission, see wound notes. Interventions: encourage to turn/reposition every two hours, check skin daily with care and bathing weekly, report changes to the nurse/nurse practitioner/physician, obtain and place pressure redistribution devices as indicated, record wound measurements weekly, inform the nurse practitioner/physician of any changes in skin condition, monitor for pain, educate on disease management as needed. Further review of Resident #95's medical record revealed following admission to the facility there was no evidence of wound care orders or preventative interventions being implemented to assist in wound healing and further skin breakdown except skin prep (protects skin from friction) to bilateral heels every shift, ordered [DATE]. Review of Resident #95's admission history and physical on [DATE] completed by the facility Medical Director revealed Resident #95 had significant pressure ulcers of the sacrum and recommended to follow up with wound care team, dressings and rotation. However, there was no evidence of orders for wound care or preventative measures. Review of Resident #95's Minimum Data Set (MDS) 3.0 admission assessment with a reference date of [DATE] revealed the resident required extensive assistance to total dependence for all activities of daily living (ADL) including bed mobility, transfers, dressing, hygiene, toileting and bathing. The resident was identified as being at risk for pressure ulcer development. The MDS identified Resident #95 had no current unhealed pressure ulcers. Review of the weekly wound assessments revealed no evidence of wound assessments upon admission until [DATE] when Resident #95 was evaluated by the facility wound nurse practitioner consultant and additional pressure wounds were identified. Review of the Treatment Administration Records (TAR) for Resident #95 revealed no evidence of any wound care from admission until [DATE] after the resident was seen by the wound care nurse. Review of a wound nurse consultant evaluation on [DATE] revealed the following areas of skin breakdown were identified for Resident #95: an unstageable (slough or eschar, known but unstageable due to coverage of wound bed by slough or eschar) pressure ulcer to the coccyx/sacrum measuring 15.0 cm by 19.0 cm, a left heel DTI measuring 9.5 cm by 13.5 cm, a left lateral foot DTI measuring 1.5 cm by 2.0 cm, a left fifth lateral metatarsal DTI measuring 1.3 cm by 2.0 cm, a left lateral malleolus DTI measuring 3.0 cm by 2.2 cm, a left first metatarsal head DTI measuring 1.8 cm by 2.2 cm, a left great metatarsal DTI measuring 0.5 cm by 1.5 cm, a right heel DTI measuring 5.5 cm by 8.0 cm and an ulcer to the right lateral calf assessed to be a DTI measuring 6.5 cm by 5.5 cm. New orders were given for a low air loss mattress to the bed, protein supplements twice a day and oxy ears (padding for oxygen tubing at the ears) for prevention. Nursing was to wash the unstageable pressure ulcer to the sacrum/coccyx with wound cleanser and apply Triad (adheres to wet [NAME] and can be used on broken skin in the presence of incontinence or maceration of the peri-wound) three times a day and as needed. The remaining ulcers nursing was to apply skin prep, ABD (non-woven dressing that is thick and absorbent) and wrap with kerlix (gauze wrap) daily. Review of the facility wound assessments also completed on [DATE] revealed no evidence of a comprehensive wound assessment for the pressure ulcer to the left heel as identified by wound nurse practitioner consultant. Further review of the physician orders revealed the addition of low air loss mattress dated [DATE], ProSource (protein supplement) 30 milliliters twice a day written [DATE], and only to be up in chair for therapy dated [DATE]. Review of the wound nurse consultant evaluation on [DATE] revealed the resident was assessed to have the following pressure ulcers: a new pressure ulcer wound to the left calf that was assessed to be unstageable measuring 15.0 cm by 3.5 cm, a coccyx/sacrum unstageable pressure ulcer measuring 15.0 cm by 19.0 cm, a left heel DTI measuring 6.7 cm by 12.0 cm, a left lateral foot DTI measuring 1.3 cm by 1.9 cm, a left fifth metatarsal DTI measuring 0.9 cm by 1.7 cm, a left lateral malleolus pressure ulcer measuring 3.0 cm by 2.2 cm, a left first metatarsal head DTI measuring 1.8 cm by 1.9 cm, a left great metatarsal DTI measuring 0.5 cm by 1.5 cm, a right heel DTI measuring 5.5 cm by 6.0 cm, and a right lateral calf unstageable measuring 11.0 cm by 6.6 cm. Review of the facility wound assessments also completed on [DATE] revealed no evidence a wound assessment was completed for the ulcers to the coccyx/sacrum, left heel or left calf wounds and there was no description or staging for the ulcers to the left lateral foot, left lateral malleolus and left fifth metatarsal. Review of the progress note dated [DATE] at 2:08 P.M. revealed the patient has been confused, shaky and is running a fever of 101.8 (degrees Fahrenheit). The Nurse Practitioner (NP) was notified, and she ordered Tylenol 650 (milligrams) every six hours as needed. I administered the Tylenol at 2:05 P.M. to the patient. The patient was unpleasant not wanting to take the Tylenol. The patient ended up taking the Tylenol. He is resting in bed with his CPAP on and his wife at the bedside. Review of the progress note dated [DATE] at 8:24 P.M. revealed this nurse went to assess the resident at the beginning of her shift. Vitals blood pressure ,d+[DATE], temp 99.3 oral, pulse 126 respirations 26 and pulse ox (oxygen level) 90 (%) on four liters (of oxygen) via nasal cannula (normal ,d+[DATE]%). Resident was exhibiting signs of rapid breathing, was very lethargic. Nurse Practitioner notified and explained the situation to her. Ordered a STAT (immediate) chest x-ray. Nurse Practitioner ordered to send resident to the hospital if oxygen level of 90 (%) not achieved. Resident's wife wanted resident sent to the hospital. Resident sent to (hospital name) for further evaluation. Review of the progress note dated [DATE] at 9:52 P.M. revealed update from (hospital name). Resident admitted with sepsis, urinary tract infection (UTI), ulcer and confusion. Review of the hospital records revealed a consult note dated [DATE] (unknown department) revealed the resident was an uncontrolled diabetic, obese. History of vascular reconstruction and amputation of one toe. Large pressure ulcer on the sacral area which extends from the sacral (area) to both buttocks as a large butterfly type ulcer, black necrotic very hard leather like, still adherent to the underlying tissues and is not separated. Measures 12 (cm) by 15 (cm) in size. No additional notes were in the hospital record. Further review of the hospital record revealed the resident remained hospitalized from [DATE]-[DATE] when he transferred to a skilled care facility and then to another long-term care facility on [DATE]. Interview with Registered Nurse (RN) #105 on [DATE] at 2:30 P.M. verified there were no wound care orders implemented following admission ([DATE]) until [DATE], no evidence of preventive skin interventions being implemented following admission for the resident, who was identified to have skin impairment on admission and additional risk for the development and/or worsening of current pressure wounds, an error on the MDS coding related to staff documenting the resident had no current pressure ulcers (the resident did have pressure wounds/ulcers at the time of the assessment) and errors in facility wound assessments completed on [DATE] and [DATE]. During a follow up interview with RN #105 on [DATE] at 9:30 A.M. the RN verified upon admission Resident #95 did not have a formal wound assessment completed in the EHR to identify current skin issues including wound staging, description and measurement. RN #105 indicated the admission nurse was to complete the paper admission skin assessment, then forward a copy of the admission skin assessment to the facility wound nurse for completion of the formal wound assessment. Attempts were made to reach Resident #95's spouse; however, the attempts were unsuccessful. This deficiency represents non-compliance investigated under Complaint Number OH00148601.

Based on record review and interview the facility failed to ensure one resident's (Resident #1) Type II Diabetes was monitored by clarifying admission orders [REDACTED]. This affected one resident (Resident #1) of three sampled residents. Findings include: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] following a hospitalization with a [DIAGNOSES REDACTED]. Record review revealed no Minimum Data Set 3.0 entry assessment completed as the resident was discharged from the facility to the hospital on [DATE]. Review of Resident #1's hospital discharge record dated 01/10/18 revealed Resident #1 had previously been admitted to the hospital for [MEDICAL CONDITION] disorder, medication non-compliance, metabolic [MEDICAL CONDITION], non ST elevation MI type II, systolic and diastolic [MEDICAL CONDITION], Diabetes Mellitus Type II, hypertension and [MEDICAL CONDITION]. Resident #1 received sliding scale insulin for elevated blood sugars as high as 352 mg/Dl while in the hospital. Review of Specified Resident #1's hospital discharge medications, dated 01/10/18 revealed the resident was to receive the following medications: [REDACTED] [MEDICATION NAME] 5 milligrams (mg) once a day take 30 minutes before meal. (Preferably before breakfast) (Diabetic medication) [MEDICATION NAME] 200 mg ([MEDICAL CONDITION] medication) [MEDICATION NAME] 750 mg tabs two twice a day ([MEDICAL CONDITION] medication) Eliquis 5 mg twice a day (anticoagulant) Aspirin 325 mg every day with meal Atorvastatin 40 mg once a day (cholesterol lowering medication) Carvedilol 3.125 mg twice a day (blood pressure beta blocker) [MEDICATION NAME] 20 mg every day. Insulin [MEDICATION NAME] (Humalog) (Insulin [MEDICATION NAME]) Humalog 100 units/ml subcutaneous 2-10 units four times a day. Sliding scale for insulin levels: 150- 199- give 2 units 200-249- give 4 units 250-299- give 6 units 300-349- give 8 units 350-399- give 10 units Call physician if over 300 However, review of Resident #1's facility copy of the resident's hospital discharge record, dated 01/10/18 and provided by the Regional Nurse and Director of Nursing, revealed the resident was discharged on [DATE] with the following medication orders [REDACTED] Aspirin 325 mg every day Atorvastatin 40 mg once a day Carvedilol 3.125 mg twice a day [MEDICATION NAME] 750 mg two tablets twice a day. Eliquis 5 mg twice a day [MEDICATION NAME] 20 mg once a day [MEDICATION NAME] 200 mg Review of Resident #1's admission plan of care dated 01/10/18 at 2:31 P.M. completed by Assistant Director of Nursing (ADON) #210 revealed the resident had alternation in blood glucose metabolism related to diabetes. Resident #1's goal was to be free from signs and symptoms of hypo and [MEDICAL CONDITION]. Resident #1 had Type II Diabetes interventions including blood glucose monitoring per order, medication per order and glucose blood level checks per (N) nursing. The plan of care included to monitor for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] signs and symptoms and report to the physician or nurse practitioner if noted. No blood glucose monitoring was conducted for Resident #1 while at the facility between 01/10/18 and 01/13/18. Record review revealed the resident was transferred to the emergency roiagnom on [DATE]. Review of Resident #1's nursing progress note, dated 01/13/18 at 12:04 P.M. revealed the resident was alert but the nurse could not assess orientation. Resident #1 did not follow commands or answer questions. Nurse Practitioner (NP) #185 was contacted for an order to send Resident #1 to the hospital emergency room . Family was at bedside and was aware. 911 was called and Resident #1 was transported to the hospital emergency room . Review of Resident #1's hospital record, dated 01/13/18 revealed the resident was brought to the Emergency Department (ED) by Emergency Medical Services (EMS) from the facility for lethargy and change in mental status. Per unidentified nursing staff at facility, patient was in her normal state of health yesterday sitting up, eating and communicating appropriately with nursing staff. Nurse did say that she had been getting increasingly weak and needed assistance to help her in and out of her chair. The nursing staff did not notice any change in her health status, no cough, fever, chill, diarrhea, chest pain, abdominal pain or dysuria. The staff at the facility mentioned that she (resident) was not getting any medication for her diabetes as they were not aware that she was diabetic. There was also some concern that she may have aspirated in the nursing home. EMS reported her glucose to be about 800. On arrival to the ED, vitals showed temperature of 35.2 Celsius, heart rate 85, respirations 20, and hypotensive with a blood pressure of 92/56. Lab revealed a critical high blood glucose level of 1023 (normal 70 to 126). Review of Resident #1's hospital emergency room summary dated 01/13/18 revealed the resident would be admitted with acute metabolic [MEDICAL CONDITION], altered mental status likely secondary to hyperosmolar hyperglycemic state (complication of diabetes mellitus in which high blood sugar results in high osmolarity without significant ketoacidosis. Symptoms include signs of dehydration, weakness, legs cramps, trouble seeing, and an altered level of consciousness). Resident #1 was admitted to the medical intensive care unit for further management. The hospital record documented [MEDICAL CONDITION]ly precipitated from lack of receiving her insulin treatment at the nursing home. Aggressive hydration with normal saline at 100 cc/hr. Insulin drip and diabetic ketoacidosis protocol. Bedside blood glucose monitoring every one hour and when necessary. During an interview on 03/23/18 at 10:30 A.M., Regional Nurse (RN) #175 indicated the [MEDICATION NAME] (oral hyperglycemic agent) and insulin (subcutaneous hyperglycemic agent) were not part of the orders received by the facility at the time of the resident's admission. However, the hospital discharge records documented Resident #1 had received insulin in the hospital for elevated blood sugars. Although documented in the hospital discharge record, the facility failed to contact the physician or nurse practitioner for additional guidance for Resident #1's Type II Diabetes. An interview was conducted with the Director of Nursing (DON) and Regional Registered Nurse (RN) #175 on 03/23/18 at 10:30 A.M. and both stated the hospital did send a multiple page hospital discharge summary to the facility and then stated the hospital only sent them a two page copy of the hospital discharge record with Resident #1's list of ordered medication. Regional Nurse #175 stated the facility did not call to get orders clarified because the hospital never sends all the papers and the hospital would not have sent the papers. Resident #1 had an admission care plan for diabetes management which indicated the resident was to have blood glucose levels as ordered by the physician. Regional Nurse #175 stated this plan of care was added to everyone's admission care, but if there was no order to do blood sugars then staff did not do them. Regional Nurse #175 stated there were no insulin or blood sugar checks ordered for Resident #1 on the order sheet they received. Regional Nurse #175 indicated neither the resident's physician or medical director was contacted for orders to assess or treat Resident #1's Diabetes. Regional Nurse #175 verified no follow up calls were made by staff to verify if the hospital orders were correct. Although, the facility's hospital records did document Resident #1 had received insulin for elevated blood sugars while in the hospital, no facility nurse followed up with the physician or the nurse practitioner to determine if the resident still required the use of the insulin or oral hyperglycemic medication. An interview with Assistant Director of Nursing (ADON) #210 on 03/27/18 at 9:30 A.M., with Regional Nurse (RN) #175 and the DON present revealed ADON #210 stated she was the nurse who admitted Resident #1 to the facility. ADON #210 verified she did not call the physician to verify the resident's orders from the hospital to ensure the orders were correct. ADON #210 stated she completed a physical assessment and everything was good. The resident was alert and oriented and told ADON #210 she was diabetic. ADON #210 stated the orders she had from the hospital revealed the resident was not on oral hyperglycemic medication or insulin. ADON #210 stated the resident could not recall if she was on diabetic medication and the ADON did not pursue it further. ADON #210 stated she flagged the admission plan of care to include monitoring blood glucose as ordered. ADON #210 stated no glucose blood sugars were obtained as a baseline, because there was no order to do so. ADON #210 stated she flagged the glucose monitoring on every diabetic resident admitted to the facility. Although the facility's hospital discharge record documented the resident received insulin in the hospital, ADON #210 was unaware the resident was on insulin in the hospital for glucose blood sugars of 352 mg/DL. ADON #210 confirmed she was aware the resident was diabetic. This deficiency substantiates Complaint Number OH 702.

Based on observation, interview, and record review, the facility failed to ensure pressure sensitive bed alarms were functioning properly to aid in the prevention of falls. This affected four of five residents reviewed for falls (Residents #45, #49, #110, and #111). The facility identified 35 residents with alarming devices to assist with fall prevention. The facility census was 109. Actual harm occurred to Resident #111 when the resident's pressure sensitive bed alarm did not function and she got up unassisted and fell near the bathroom door fracturing her right hip. Findings include: 1. Review of the closed record revealed Resident #111 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing assessment dated [DATE] indicated the resident was admitted from home with long-term and short-term memory deficits, was able to hear in special situations only, had moderately impaired vision, and a history of falls. Resident #111 had no hearing aids or glasses and used a board to communicate. She was at high risk for falls. Review of the care plan for falls dated 05/17/16 indicated Resident #111 was at risk for falls/injury related to poor vision and history of falls. Interventions included bed alarm implemented on admission, communication board, encourage resident to use call light for transfer/ambulation assistance, and educate her as able about limitations and safety concerns. Review of a progress note documented by Licensed Practical Nurse (LPN) #134 on 05/19/16 at 4:54 A.M. revealed at 3:50 A.M. staff heard a crash and a call for help. Resident #111 was found on the floor. LPN #134 assessed the resident to have right hip pain and right foot rotation. LPN #134 notified the registered nurse. Resident #111 was sent to the hospital. Review of the facility's Event Report (undated) for the fall on 05/19/16 at 3:50 A.M. revealed staff responded to the crash and Resident #111 yelling. The report indicated the bed alarm was in place. It did not indicate whether the alarm was sounding. Review of witness statements and interviews revealed the staff caring for Resident #111 the morning of 5/19/16 were State tested Nursing Assistant (STNA) #135 and LPN #134. Review of STNA #135's witness statement dated 05/19/16 revealed she heard Resident #111 yelling for help after a big crash. The STNA found the resident sitting on the floor in the doorway of the bathroom. STNA #135 notified the nurse. Review of the facility investigation documentation revealed the Director of Nursing (DON) interviewed STNA #135 and LPN #134. STNA #135's interview on 05/23/16 indicated she was in Resident #111's room around midnight and 2:00 A.M. on 05/19/16. The resident was sleeping soundly each time. LPN #134's interview on 05/23/16 revealed he checked Resident #111's alarm after the fall. He pulled down the linens and sat on the bed to verify the alarm was functioning. It was functioning. He had not been in the resident's room that night prior to the fall. There was no documented evidence to support the alarm was checked each shift to ensure it was functioning correctly. There was no documented evidence of when the batteries in the alarm were last changed. During an interview on 06/03/16 at 3:52 A.M., STNAs #131 and #133 indicated there were two types of alarms for the pressure sensitive bed pads, a black colored one and a gray one. The black-colored alarms had a light that blinked on and off to let staff know they were functioning. The gray-colored alarms had to be manually checked to ensure they were on. STNAs #131 and #133 stated all alarms were checked each shift to ensure they worked and batteries changed on the 15th of the month. During an interview on 06/03/16 at 4:08 A.M., LPN #134 revealed Resident #111 fell and broke her right hip. She got up out of bed and fell . Her bed alarm did not sound. He checked the alarm immediately after the fall by placing his hand on the pad. The alarm was functioning and sounded. LPN #134 indicated he did not know why it failed to sound when Resident #134 got out of bed on 05/19/16. During an interview on 06/03/16 at at 5:52 A.M., STNA #135 indicated Resident #111 was hard of hearing. The resident was continent of bowel and bladder and frequently got up during the night to go to the bathroom. The resident sometimes used the call light and sometimes did not. When she heard the resident's bed alarm, STNA #135 knew the resident was up and would go in to assist her. The morning Resident #111 fell , she heard the bathroom door slam against the door jamb then heard the resident yell for help. STNA #135 found the resident sitting on the floor in the doorway of the bathroom. The pressure sensitive bed alarm was not sounding. During an interview on 06/03/16 at 1:17 P.M., the DON confirmed Resident #111's pressure sensitive bed alarm did not function the morning of 05/19/16 prior to the fall. She checked the alarm upon arriving the morning on 05/19/16. At that time, the alarm was functioning. 2. Review of the medical record revealed Resident #45 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly assessment dated [DATE] revealed Resident #45 was moderately cognitively impaired and needed extensive assistance of two staff with transfers. Review of the Resident Care Conference dated 04/20/16 indicated the resident was at high risk for falls. Interventions in place for falls included bed against wall, bed alarm, chair alarm, and anti-roll backs to wheelchair. The fall care plan initiated 12/13/15 included chair and bed alarms to alert staff to unassisted rising and check placement and function every shift. On 06/03/16 from 4:16 A.M. to 4:45 A.M., a tour was completed of 100 Unit accompanied by STNA #138 and/or STNA #139. Resident #45's pressure sensitive bed alarm was not functioning. After attempts to get the alarm to function, the STNA asked her coworker to get a new battery. During an interview on 06/03/16 at 4:20 A.M., STNA #139 confirmed the alarm was not working. She indicated the batteries were changed on the 15th of the month. The STNA was unable to state how frequently the alarms were checked to ensure they worked. 3. Review of the medical record revealed Resident #110 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan for falls initiated 09/10/13 revealed fall interventions for non-skid strips to floor in front of toilet and bed alarm. Review of the Resident Care Conference revealed Resident #110 was at high risk for falls. On 06/03/16 from 4:16 A.M. to 4:45 A.M., a tour was completed of 100 Unit accompanied by STNA #138 and/or STNA #139. Resident #110's pressure sensitive bed alarm was not functioning. At 4:26 A.M., STNA #138 confirmed Resident #110's alarm was not functioning. 4. Review of the record revealed Resident #49 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident Care Conference dated 03/31/16 indicated the resident was at high risk for falls. Review of the care plan for falls initiated 05/01/14 revealed Resident #49 was at risk for falls/injury related to behavior, confusion, history of falls, and impaired gait stability. Interventions included staff check on every one hour through the night, additional non-skid strips in bathroom, non-skid strips to floor beside bed, bed and chair alarms, check placement and functioning of alarms every shift. On 06/03/16 from 4:16 A.M. to 4:45 A.M., a tour was completed of 100 Unit accompanied by STNA #138 and/or STNA #139. Resident #49's pressure sensitive bed alarm was not functioning. At 4:27 A.M., STNA #138 confirmed the alarm was not turned on. This deficiency substantiated Complaint Number OH 644.