Every finding on record at Arbors at Gallipolis

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, review of the Self-Reported Incident (SRI) and investigation, review of video recording, review of a police report, review of an employee file, witness interview, resident and staff interviews, and policy review, the facility failed to ensure residents were free from emotional abuse by facility staff. Actual psychosocial harm occurred on or prior to 03/24/26 for Resident #41 when Certified Nursing Aide (CNA) #777 video recorded Resident #71 while the resident was sleeping without the resident's knowledge or consent. CNA #777 added a written statement to the video that reflected severe anger conveyed through threatening and aggressive wording and posted the recording on a social media platform. Applying the reasonable person concept to the incident would result in the person feeling humiliated, demeaned and exploited. This affected one (Resident #41) of three residents reviewed for abuse. The facility census was 86. Findings include: Review of the medical record for Resident #41 revealed an admission date of 12/26/22. Diagnoses included anxiety, depression, and dementia. Review of the Minimum Data Set (MDS) assessments dated 02/11/26 and 07/01/26 revealed Resident #41 had severe cognitive impairment.Review of the facility's SRI revealed on 06/10/26, the facility was made aware that Resident #41 was video recorded by a former employee (CNA #777). CNA #777 was telephoned and stated he did not remember recording Resident #41 while employed at the facility. CNA #777's last day worked at the facility was 03/25/26. The Administrator was provided with the video recording and confirmed the allegation did occur. The allegation of abuse was substantiated. Review of the seven second video recording revealed Resident #41 was laying asleep in bed softly breathing. CNA #777 added a written statement to the video that reflected severe anger conveyed through threatening and aggressive wording and posted the recording on a social media platform. A caption on the video stated that he wanted to shove his foot down [their] expletive throat 'bro'. The video then flashes to a face identified by the facility as CNA #777. Resident #41 was fully clothed throughout the entire video. There was no date on the recording, nor any evidence provided to show what date it was recorded or posted on a social media platform. Review of the police incident report dated 06/15/26 revealed they received a complaint involving a former employee (CNA #777) who allegedly took a photograph/video of a clothed female (Resident #41) while she was sleeping at the facility. It stated that dispatch was advised [CNA #777] allegedly sent the image and made comments about harming [Resident #41]. During an interview on 07/09/26 at 9:05 A.M., Resident #41 did not have recollection of the event due to severely impaired cognition.During an interview on 07/09/26 at 11:10 A.M., Witness #1 revealed he was the former partner of CNA #777. Witness #1 confirmed CNA #77 had sent this video to him and he was appalled when he watched it. Witness #1 stated he notified the facility on 06/10/26, and he understood they started the investigation immediately. During an interview on 07/09/26 at 10:27 A.M., the Administrator confirmed she was notified on 06/10/26 in regard to an allegation of abuse involving Resident #41. The Administrator stated she viewed the video and verified the individuals as being Resident #41 and CNA #777. The Administrator verified that a reasonable person would consider this video as a form of psychosocial abuse. The Administrator stated she was deeply disturbed by the video footage. Review of CNA #777's employee file revealed he was hired on 05/02/23 and quit without notice on 03/24/26.Review of the facility policy titled Abuse, Neglect and Exploitation dated July 2020, revealed mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident.Review of the facility policy titled Social Media dated April 2017 revealed employees are not to use social media to post, upload, send or otherwise share or disclose a photograph or video of any resident without prior written permission of the resident or the resident's authorized agent as required by applicable law. This includes photos or videos where the resident is easily identifiable, whether in the photo or video itself or through a caption.The deficient practice was corrected on 06/15/26 when the facility implemented the following corrective actions: On 03/25/26, CNA #777 was no longer employed by the facility. On 06/12/26 at 8:00 A.M., Resident #41's responsible party and physician were both notified of the allegation and the video recording. On 06/12/26, Social Services Director #430 completed a psychosocial and PHQ9 assessment (a standardized validated depression screening tool) on Resident #41 with no negative psychosocial effect noted. Follow-up psychosocial assessments were also completed on 06/15/26 and 06/16/26 with no negative psychosocial effect noted. On 06/12/26, all staff were interviewed by the Director of Nursing/designee regarding any knowledge of any residents being video recorded by a staff member and or a video of a resident by staff member being posted on a social media platform with no negative findings. On 06/12/26, Social Services Director #430 interviewed all residents with a Brief Interview of Mental Status score (BIMS) score of 12 or above (BIMS score of 13 to 15 revealed the resident's cognition was intact) with no reports of cellular phones being used to record residents. On 06/12/26, skin and psychosocial assessments for residents with a BIMS less than 12 were completed by the Director of Nursing/designee with no negative findings. On 06/15/26 at 8:30 A.M., review of Resident #41's medical record was reviewed for the media release agreement by the Director of Nursing and the Administrator with no release agreement on file for this resident. On 06/15/26, the local police department (LPD) were notified, and a report was filed on 06/15/26. By 06/15/26, all staff were educated by the Staff Development Coordinator (SDC #150)/designee on the abuse and social media policies. On 06/15/26, an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was completed with the interdisciplinary management team to review the facility's correction action plan. Beginning 06/15/26, the Administrator/designee completed rounds the facility five times per week on various shifts per week to ensure staff do not have cellular phones in resident care areas. SDC #150/designee will complete a questionnaire with five staff members weekly for four weeks related to cell phone usage and abuse. The results of the audits were reviewed weekly in an ad hoc QAPI meeting for any needed revisions by the QAPI committee.This deficiency represents non-compliance investigated under Complaint Number 3040999 and 3035795.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, review of a self-reported incident (SRI), review of facility investigative documentation, review of facility video footage, personnel file review, policy review, and interview the facility failed to protect Resident #70's right to be free from abuse by Certified Nursing Assistants (CNAs) #210, #220 and #225. Actual harm occurred on 04/11/26 when Resident #2, who was cognitively impaired and diagnosed with dementia, was physically and psychosocially abused by CNAs #210, #220, and #225. The three CNAs forced the resident into a chair, held his arms down to keep him seated, and were overheard by other residents teasing and laughing at him. A reasonable person in the resident's position would have experienced fear, distress, humiliation, and a loss of dignity as a result of this treatment. Following the incident, Resident #2 was noted to have bruising and a skin tear to his arms (of unknown origin), increased agitation, which was exacerbated by the staff involved, and he was subsequently ordered and administered the anticonvulsant medication Depakote for two days following the incident for behavioral management. This affected one resident (#2) of the five residents reviewed for abuse.Findings include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, unspecified psychosis, depression, seizure disorder, cognitive communication deficit, unsteadiness on feet, and muscle weakness. Review of Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adequate hearing and clear speech. The assessment revealed the resident was sometimes able to make himself understood and was sometimes able to understand others. The resident's cognition was severely impaired. Physical and verbal behaviors directed at others occurred one to three days during the seven-day assessment period. Other behaviors not directed at others occurred four to six days during the seven-day assessment period. The assessment revealed the resident was not known to reject care but was known to display wandering behavior. No mobility devices were used for his mobility. The resident was assessed to require supervision or touching assistance with sit-to-stand transfers and ambulation.Review of a self-reported incident tracking number 273236, submitted by the facility to the State Agency, revealed an allegation of physical abuse. The initial source of the allegation was identified as an unusual circumstance. Resident #2 was identified as the involved resident and the alleged perpetrator was identified as being facility staff. Resident #2 could not provide any meaningful information when interviewed related to his diagnoses of vascular dementia and cognitive communication deficit. A brief description of the allegation revealed the facility's Administrator was made aware of an allegation of physical abuse by CNAs holding Resident #2's arms down. The CNAs were suspended pending the investigation findings. A narrative summary of the incident revealed the occurrence was on 04/11/26 at 9:30 P.M. at the nurses' station. Residents #17 and #83 were listed as being witnesses to the alleged incident. Staff witnesses were CNA #210, CNA #220, and CNA #225. Witness statements obtained from the staff involved revealed they claimed they were holding the resident's arms due to him being combative towards staff. Resident #2 had an increase in behaviors occurring on 04/11/26. The facility's Administrator filed an official report with the local police department on 04/13/26. The three CNA's involved in the physical abuse allegation involving Resident #2 were terminated from their employment with the facility on 04/20/26, as the facility substantiated the incident of physical abuse had occurred. Review of Resident #2's progress note dated 04/11/26 at 9:30 P.M. and written by Registered Nurse (RN) #200 documented during a medication administration pass, the nurse heard yelling and arguing coming from a female resident's room (Resident #29). Upon the nurse entering the room, she found Resident #2 standing by the female resident's bed where she had been sleeping. Both residents were engaged in a physical altercation where they were hitting and smacking each other. Resident #2 was yelling at the female resident (Resident #29) to get out of his bed. The note revealed the nurse attempted to separate the residents and diffuse the situation. A CNA (unidentified) took Resident #2 up to the nurses' station, where it was documented the resident continued to be physically abusive and verbally aggressive toward staff. Assessments of both residents were performed with no injuries noted at the time. The physician was made aware of the incident and new orders were received for the medications Haldol and Depakote. Resident #2's son was also notified of the altercation and consented to the medication administration that had just been ordered. Resident #2 was later taken to his bed where he eventually fell asleep, so the ordered medication (Haldol) was not given. However, the order for the change in his daily medication (added Depakote) was entered into the computer. The note included the unit manager, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were all notified. Review of the April 2026 Medication Administration Record (MAR) revealed the resident received the ordered Depakote on 04/12/26 and 04/13/26 before it was discontinued by the physician. Review of the facility's investigation file documented there was alleged abuse of a resident status post resident to resident altercation involving Resident #2 and Resident #29. Staff were holding the arms of a resident (Resident #2), walking (Resident #2) down the hallway, and appeared to sit the resident down on a chair forcefully. The CNAs further held the resident's arms down, holding him in the chair. The resident could not provide information or a description of the incident due to his impaired cognition when interviewed by staff.Included in the facility investigation was information from Resident #83 (who was alert and oriented/cognitively intact) obtained by SSD #245 on 04/13/26. Resident #83 stated two girls held an older guy (Resident #2) down in a chair at the nurse's station. All he wanted was to go to his room, while they were holding both of his arms, teasing him. The older guy was not even fighting, and she was not sure what their issue was. Resident #83 told SSD #245 that what she observed was abuse for sure. Included in the facility investigation was information obtained from Resident #17 (who was alert and oriented/cognitively intact) by SSD #245 on 04/13/26. Resident #17 revealed he had observed an incident on 04/11/26. Resident #17 told SSD #245 that two girls (unidentified) held Resident #2 down in a chair and would not let him up. They were laughing and teasing him while holding him down and all the resident wanted to do was walk and get away from everyone. A verbal statement obtained by the Administrator from CNA #260 on 04/13/26 revealed an aide came to the second floor and said they needed help with an altercation between two residents. When they went up there, everyone was standing, trying to figure out things. Resident #2 started to walk, pacing in the dining room. The girls were all up in Resident #2's face, trying to get him to calm down. She (the CNA) did not like how they handled it. When asked if that resident was your family member, would you consider that abuse, the CNA replied yes. A verbal statement obtained by the Administrator from CNA #275 on 04/13/26 revealed her and two other employees were all outside smoking, when the trainee told them someone was on the floor. CNA #210 and CNA #220 were taking Resident #2 up front. She went to get LPN #250 because she was the supervisor. Resident #2 was sitting in the chair and CNA #210 and CNA #220 were holding his arms down. Review of Resident #2's progress note documented he was seen by his attending physician on 04/14/26, as a follow up visit. It was reported to the physician Resident #2 was having an increase in a series of behaviors, with agitation and aggressive behaviors with psychotic issues present. Resident #2 started on Depakote in response to the incident (on 04/11/26). The note included it was found the resident was being treated inappropriately and behaviors were instigated by staff. The physician discontinued the Depakote that had been ordered as the resident had been having increased behaviors before restarting his Seroquel, which had shown marked improvement of his symptoms. Resident #2 was found to be pleasant and cooperative during the visit with the physician on this date. Review of the personnel files for CNA #210, CNA #220, and CNA #225 revealed all three CNAs were terminated from working at the facility on 04/20/26. The reason for termination was violating the rights of the residents, including abuse and for failing to report to their supervisor. During an interview on 04/27/26 at 12:40 P.M., Physician #400 stated he had been told by the facility that Resident #2 was having severe behaviors and was not easily redirected. He was also told the resident was a threat to other residents that prompted him to initiate new medication for the resident. However, he stated Resident #2 was responding to how the staff were intervening with his behaviors. He described the resident as being in a protective type of mode. He was told one of the CNAs grabbed the resident. The new medication had since been stopped and Resident #2 was doing fine without it. Physician #400 revealed staff should have tried to redirect Resident #2 without force, placing the resident in a calm environment and removing him from the provoking area, or getting him away from the situation would also be helpful. If the resident that was being combative was not harmful to himself or others, staff could just walk away and give the resident his space. They could also try to offer them food or drinks to try to alter the behavior. He stated trying to hold down a cognitively impaired resident who was being combative would elicit a retaliatory response from the resident. On 04/27/26 at 1:30 P.M. the video footage of the abuse incident was reviewed with the Administrator. On 04/11/26 at 9:32 P.M., CNA #210 and CNA #220 had Resident #2 by both his arms directing him down the hall towards the nurse's station. He was coming from the long hall on the third floor. The Administrator identified the employee grabbing the resident's right arm as CNA #210 and the employee grabbing the resident's left arm as CNA #220. A third aide, identified as CNA #225, approached around the time the two aides and the resident reached the area by the nurses' station. CNA #210 and #220 initially sat Resident #2 down into the chair. It appeared the staff were exchanging words with Resident #2 but there was no audio on the footage. Resident #2 became agitated a short time after he was initially placed in the chair and he stood up and started heading in the direction of the two CNAs. CNA #225 came back into view of the camera and assisted the two aides with getting the resident back down into the chair. CNA #210 and CNA #220 grabbed the resident by the arms and CNA #225 grabbed the back of Resident #2's sweatpants, pulling them up and back as the resident was forcefully placed in a seated position in the chair. CNA #210 and CNA #220 held Resident #2's arms down, pushing them down against the arm rest of the stationary chair, so he could not get up. CNA #220 was straddling the resident's left leg. CNA #225 left briefly while the two CNAs continued to hold the resident's arms down onto the arm rest of the chair. Their hands were over his wrists and lower forearms in a palm down position with their hands closed. CNA #225 took the place of CNA #210, holding the resident's right arm down onto the arm rest of the chair. She held his arm in the same manner before releasing his arm and holding his hand in her right hand as she supported the weight of his arm in her left hand, when another resident and her visiting family approached and came into view of the camera at 9:35 P.M. Multiple other unidentified staff entered the area along with the nurse assigned to the third floor. There were four staff members who had come up the stairs from the second floor to assist the staff with Resident #2's behaviors. At one point during the video, there were nine staff members, two other residents, and three family members standing in the area in close proximity to Resident #2. Resident #2's right arm was released at 9:36 P.M. CNA #275 replaced CNA #220 with holding the resident's left arm. She was gentler with the resident as she was just holding his hand. The incident concluded at 9:39 P.M. when Resident #2 stood up and started to walk back the long hall. Resident #2 walked around the nurses' station to the dining area before he was allowed to go back down the hall, where the staff helped him get into his bed. During an interview on 04/27/26 at 3:55 P.M., Resident #83 stated she witnessed the incident on 04/11/26 involving Resident #2 but was not able to identify the staff involved. She stated she came out to the nurses' station area from her hall with some of her family members who were leaving after a visit. She observed the staff holding Resident #2 down, when he was sitting in a chair across from the nurses' station. The resident reported the staff would not allow him to get up out of the chair. She stated staff were laughing at him, telling him they were not going to deal with it that night, and told him, try it again and see what happens and we're holding you down, that means you don't move stupid. During an interview on 04/28/26 at 10:05 A.M., Resident #17 stated he witnessed part of the incident that occurred on 04/11/26 involving Resident #2 and the staff. He recalled the staff were trying to keep Resident #2 sitting down, as he believed it was to keep the resident from falling. The resident stated the staff kept pushing him (Resident #2) down into the chair and would not allow him to get up.During an interview on 04/28/26 at 10:32 A.M., Resident #2's responsible party stated he was contacted by the facility staff on 04/11/26 and informed Resident #2 was wandering and looking into other residents' rooms. He was also told the resident went into one room and tried to get into bed with a female resident that ended up in an altercation. He was informed about a sedative they were wanting to give the resident that evening. He then received a second call on 04/13/26 from the facility's social worker, who went into more detail as to what took place on 04/11/26. He recalled being told the staff were unprofessional in what they did. He was also told the facility management staff looked at video footage and staff were unprofessional about how they handled it. No one told him Resident #2 was abused. He said the director stated she requested to see the film and was disgusted by what she saw. He was told the resident was brought to the nurses' station forcibly and those involved seemed aggravated. During the interview Resident #2's responsible party revealed the facility had contacted the police department regarding the incident. During an interview on 04/28/26 at 1:44 P.M., Regional Director of Clinical Operations #500 and the DON revealed they were reviewing video to follow up on an incident involving a resident-to-resident altercation. It was during this review (on 04/13/26) they saw on the video that abuse had potentially occurred with Resident #2, by staff, during the aftermath of that incident with the other resident. They suspended the CNA staff involved immediately, pending an investigation. They confirmed their investigation did substantiate physical abuse had occurred and the three CNA staff involved in the incident were terminated. Review of the facility Abuse policy revised 01/10/24 revealed it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which could include staff to resident abuse. Willful was defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse included, but was not limited to hitting, slapping, punching, biting, and kicking. It also included controlling behavior through corporal punishment. The deficient practice was corrected on 04/20/26 when the facility implemented the following corrective actions: On 04/13/26 at 10:00 A.M., the facility self-identified that a potential physical abuse incident had occurred (involving Resident #2), when reviewing a video recording at the third floor nurses' station to follow up on a report of a resident-to-resident altercation. An immediate investigation into the possible abuse was initiated. On 04/13/26 at 10:10 A.M., the facility nurse practitioner was made aware of the allegation of abuse and discontinued an order for Depakote and a Haldol injection that were previously ordered for Resident #2 on 04/11/26. The Haldol IM injection had not been given.On 04/13/26 at 10:15 A.M., a facility floor nurse assessed Resident #2's skin from head to toe and found a skin tear and a small bruise on the resident. At the time of the incident, the facility was unable to determine the origin of the bruise and skin tear. On 04/13/26 at 10:30 A.M. all staff were assigned re-education/ in-service training on Preventing Resident Abuse that was to be completed by 04/15/26. The training was assigned to all staff's in-service training to be completed in SNF Clinic (computer software program used for training purposes).On 04/13/26 (between 10:30 A.M. and 6:00 P.M.), whole house skin sweeps were completed on all residents with cognitive impairment with no signs or symptoms of abuse noted. All alert and oriented residents were interviewed regarding abuse, with two complaints related to Resident #2's incident. Witness statements were obtained from those residents and from staff involved.On 04/13/26 at 11:00 A.M., PHQ9 and psychosocial assessments were completed on Resident #2. On 04/13/26 at 12:00 P.M., employee questionnaires were initiated for all staff to ensure competency weekly for four weeks and would run plan through the facility Quality Assessment and Performance Improvement (QAPI) committee monthly for two months with the Medical Director's involvement. On 04/13/26 at 1:00 P.M., the alleged perpetrators (CAN #210, #220 and #225) were suspended and statements regarding the incidents were obtained. On 04/13/26 at 5:00 P.M., Resident #2's representative was notified regarding the allegation of physical abuse. On 04/13/26 at 5:30 P.M., incident of alleged abuse was reported to local law enforcement. Local law enforcement to come out on 04/14/26 and took an official report from the Administrator. On 04/13/26 at 6:30 P.M., an Ad Hoc (not scheduled) Quality Assurance, Performance Improvement meeting with the Medical Director, DON, and Administrator was completed to ensure facility compliance with abuse policy and timely reporting of abuse with Quality Plan to ensure all staff were educated on the abuse policy and timely reporting. On 04/14/26 at 8:00 A.M., the Psychiatric Nurse Practitioner (NP) evaluated Resident #2. On 04/14/26 at 2:30 P.M., the (medical) physician evaluated Resident #2. On 04/14/26 at 3:00 P.M., the facility filed an official report with local police department. On 04/20/26 CNA #210, CNA #220, and CNA #225 were terminated due to substantiated abuse. This deficiency represents non-compliance investigated under Incident Number 299063.

Based on record review, policy review and interview the facility failed to ensure Resident #2, who had a diagnosis of dementia with behaviors received adequate, necessary and effective interventions as per his care plan to de-escalate a behavioral episode and to prevent increased agitation for the resident. This affected one resident (#2) of five residents reviewed for abuse. Findings include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia, unspecified psychosis, depression, seizure disorder, cognitive communication deficit, unsteadiness on feet, and muscle weakness. Record review revealed a plan of care dated 03/13/26 for behaviors related to dementia, psychosis, depression, and insomnia as evidenced by restlessness, anxiousness/ nervousness, physical aggression, hallucinations, delusions, exit seeking, history of verbal aggression, and wandering. Interventions included administer medications as ordered and observe for effectiveness and side effects, approach resident in a calm manner to avoid frustration and behavior escalation, if resident becomes agitated and shows signs of escalation -re-approach later, attempt to redirect resident when exhibiting behaviors, re-approach when resident has de-escalated, communicate care to resident before starting task, give non-judgmental support, keep resident safe during episodes of behaviors, attempt to redirect, observe and document episodes of inappropriate behaviors, notify physician when behaviors persist and did not de-escalate, offer psychologist/ psychiatrist services as needed, offer resident choices whenever possible in order to promote a feeling of self-worth and control over the environment and care delivery, encourage participation from resident to make own decisions, and offer and provide activities of interest to keep resident engaged in positive interactions. Review of Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had adequate hearing and clear speech. The resident was sometimes able to make himself understood and was sometimes able to understand others. The assessment revealed the resident's cognition was severely impaired. Review of Resident #2's progress notes dated 04/11/26 at 9:30 P.M. and written by Registered Nurse (RN) #200 documented during a medication administration pass, the nurse heard yelling and arguing coming from a female resident's room (Resident #29). Upon the nurse entering the room, she found Resident #2 standing by the female resident's bed where she had been sleeping. Both residents were engaged in a physical altercation where they were hitting and smacking each other. Resident #2 was yelling at the female resident (Resident #29) to get out of his bed. The note included the nurse attempted to separate the residents and diffuse the situation. A CNA (unidentified) took Resident #2 up to the nurses' station, where he continued to be physically abusive and verbally aggressive toward staff. The physician was made aware of the incident and new orders were received for Haldol and Depakote. Resident #2's son was also notified of the altercation and consented to the medication administration that had just been ordered. Resident #2 was later taken to his bed where he eventually fell asleep, so the ordered medication (Haldol) was not given. However, the order for the change in his daily medication (added Depakote) was entered into the computer. The unit manager, Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were all notified. Review of the nursing progress note revealed no additional information related to how the nurse or staff attempted to diffuse the situation and/or any additional non-pharmacological interventions provided to Resident #2 following and/or as a result of this incident. Review of the April 2026 Medication Administration Record (MAR) revealed the resident received the ordered Depakote on 04/12/26 and 04/13/26 before it was discontinued by the physician. Review of Resident #2's progress note documented he was seen by his attending physician on 04/14/26, as a follow up visit. It was reported to the physician Resident #2 was having an increase in a series of behaviors, with agitation and aggressive behaviors with psychotic issues present. Resident #2 started on Depakote in response to the incident (on 04/11/26). The note included it was found the resident was being treated inappropriately and behaviors were instigated by staff. The physician discontinued the Depakote that had been ordered, as the resident had been having increased behaviors before restarting his Seroquel (resumed prior to this incident), which had shown marked improvement of his symptoms. Resident #2 was found to be pleasant and cooperative during the visit with the physician on this date. During an interview on 04/27/26 at 12:40 P.M., Physician #400 stated he had been told by the facility that Resident #2 was having severe behaviors and was not easily redirected. He was also told the resident was a threat to other residents that prompted him to initiate new medication for the resident. However, he stated Resident #2 was responding to how the staff were intervening with his behaviors. He described the resident as being in a protective type of mode. He was told one of the CNAs grabbed the resident. The new medication had since been stopped and Resident #2 was doing fine without it. Physician #400 revealed staff should have tried to redirect Resident #2 without force, placing the resident in a calm environment and removing him from the provoking area, or getting him away from the situation would also be helpful. If the resident that was being combative was not harmful to himself or others, staff could just walk away and give the resident his space. They could also try to offer them food or drinks to try to alter the behavior. He stated trying to hold down a cognitively impaired resident who was being combative would elicit a retaliatory response from the resident. During an interview on 04/28/26 at 12:45 P.M., CNA #225 stated she was working on the short hall of the third floor on 04/11/26 and was outside when an orientee came out and informed them that they needed help. She recalled being told Resident #2 pulled another resident out of bed and they were fighting. By the time she got there, CNAs #210 and #220 were already removing Resident #2 from the room. Resident #2 was taken to the nurses' station area and sat down into a chair. After the resident had been sitting down in the chair to get him to calm down, he stood up and became argumentative. She then helped the other two CNAs sit the resident back down into the chair. During the interview the CNA reported she had received some training on dealing with residents with dementia and behaviors but felt they needed more resident specific behavior training so they knew what to do for each different resident they had. She stated staff had asked for additional training but the management staff just told them to offer someone food or snacks when they were having behaviors. During an interview on 04/28/26 at 12:59 P.M., CNA #220 stated she was working the night of 04/11/26, when the incident occurred involving Resident #2. She recalled running down the hall that evening to respond to the nurse yelling for help. She and CNA #210 took Resident #2 up front, as the resident had been hitting another resident. She stated they arm to armed him, explaining it as wrapping their arms around the resident's arms (on both sides of the resident). She stated they helped him into the chair across from the nurses' station. He sat there for a few minutes, but when staff were talking to one another, he jumped up and started to go at CNA #210. They grabbed a hold of the resident and arm to armed him back into the chair. The CNA revealed during the incident the resident screamed a little bit. During an interview on 04/28/26 at 2:07 P.M., CNA #210 stated she and CNA #220 were in the dining room when they heard screaming. They ran down the hall and saw Resident #2 had a hold of the nurse. The nurse was trying to get him out of the room and the resident was screaming and kicking her. They were trying to take him gently at first by asking him to come with them. He refused, so they asked the nurse what she wanted them to do. The nurse told them she did not know but just take him out of there. They arm to armed him taking their arm and putting them under his. During the interview, the CNA revealed staff from the second floor came up, but she did not feel they were needed. She was not sure who called for them but did not feel they helped matters. She felt the additional staff present just made things worse and got the resident more agitated and it was probably overwhelming for the resident to have them all around him. In addition, during the interview the CNA revealed she did not feel staff were properly trained to deal with residents with aggressive behaviors. They received annual training, but it was over the computer and there was nothing hands on. They were not taught how to deal with aggressive or violent behaviors. Review of the facility policy on Behavior Management Program revised 10/27/23 revealed residents exhibiting behaviors negatively affecting self or other residents or with new behaviors negatively affecting self or other residents would be reviewed by the Behavior Management team which may include but was not limited to the Activity Director, Social Services Director, nurse manager, physician, contracted behavioral health partner's prescriber (PA, psychiatrist, or NP), psychologist, and any other parties that the facility members deemed appropriate. The team would explore the root cause of behaviors/ mood. The team would identify target behaviors and an individualized plan of care. The team would use non-pharmacological interventions, when applicable, to minimize the need for medication, permit the use of the lowest possible dose, or allow medications to be discontinued.This deficiency represents non-compliance investigated under Incident Number 299063.

Based on observation, record review, facility policy review and interview, the facility failed to implement adequate and effective interventions to promote healing and prevent the deterioration of a left below the knee surgical site with staples for Resident #48 at the time of the resident's admission. This affected one resident (#48) reviewed for surgical wounds and for pressure wounds. Actual harm occurred on 03/25/25 when Resident #48, who was assessed to have hemiplegia affecting his left side with the need for (staff) assistance to turn and reposition in bed, did not have interventions in place to alleviate pressure and promote optimal healing of the resident's left below the knee surgical site resulting in a decline and worsening of the wound. Findings include: Review of the medical record for Resident #48 revealed an admitted [DATE] with diagnoses including acquired absence of left leg below knee, need for assistance with personal care, weakness, cerebral infarction, atherosclerosis of native arteries of extremities with gangrene, left leg, hemiplegia, affecting left non-dominant side, dementia, and chronic obstructive pulmonary disease. Review of Resident #48's admission skin assessment dated [DATE] revealed the resident had a left below the knee amputation with 35 surgical staples measuring 7.82 centimeters (cm) by by 2.87 cm. Review of Resident #48's nursing admission evaluation dated 03/20/25 revealed the resident required at least one person assistance with bed mobility. Review of the plan of care dated 03/20/25 for Resident #48 revealed the resident had impaired skin integrity related to recent surgery; mobility status as evidenced by: surgical wound to left leg with no intervention to elevate the left stump. Further review of the resident's plan of care revealed an activity of daily living self-care performance deficit related to acquired left below the knee amputation and hemiplegia affecting left dominant side with an intervention of bed mobility requiring a one person assist. Review of Resident #48's Braden Scale for Predicting Pressure Sore Risk dated 03/20/25 revealed a score of 17.0 on a scale of 6 (high risk) to 23 (no risk) which indicated the resident was at risk for skin breakdown. Review of the active physician orders for Resident #48 dated 03/20/25 revealed to encourage to turn and reposition frequently when in bed to prevent skin breakdown. Further review of the active physician orders for Resident #48 revealed no order to elevate the left below the knee amputation stump. Review of the medical record for Resident #48 from 03/20/25 through 03/24/25 revealed no documented evidence of elevation of the left stump, the resident being turned every two hours, the resident refusing to be turned or that the resident favored his left side. Review of an Interdisciplinary team (IDT) functional assessment for Resident #48 dated 03/24/25 revealed the resident still required substantial/maximal (staff) assistance with bed mobility. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 which suggested moderate cognitive impairment. The resident was assessed to require substantial/maximal assistance with shower/bathe self, bed mobility and total dependence on staff for toilet hygiene and transfers. This resident was also assessed to be at risk for developing pressure ulcers, had an unstageable deep tissue injury not on admission and a surgical wound. Review of Resident #48's left below the knee amputation surgical wound assessment dated [DATE] revealed the site measured at 6.64 cm by 10.20 cm and was noted to have declined. Review of the active physician's order for Resident #48 dated 03/25/25 revealed to encourage the resident to float left stump. Observation on 04/14/25 at 10:38 A.M. of Resident #48 revealed the resident was on his left side in bed with his left stump not floated/elevated. Observation on 04/14/25 at 12:41 P.M. of Resident #48 revealed the resident was on his left side in bed with his left stump not floated/elevated. Interview on 04/14/25 at 12:51 P.M. with Licensed Practical Nurse (LPN) #104 revealed Resident #48 never refused care and required (staff) assistance to be turned in bed. Observation on 04/15/25 at 10:26 A.M. revealed Resident #48 was in bed on his left side. Observation on 04/15/25 at 1:23 P.M. revealed Resident #48 was in bed on his left side. Observation on 04/15/25 at 1:28 P.M. with Certified Nurse Assistant (CNA) #205 verified Resident #48 was positioned on his left side. Interview on 04/16/25 at 9:25 A.M. with Registered Nurse (RN) #196 revealed Resident #48 never refused care and required (staff) assistance to be turned in bed. Interview on 04/16/25 at 9:27 A.M. with CNA #173 revealed Resident #48 never refused care and did favor his left side. The CNA did not recall propping (floating/elevating) the resident's left stump since he had been admitted to the facility. Interview on 04/16/25 at 9:29 A.M. with Resident #48 revealed he needed help when moving in bed because his left side was so weak. The resident stated he sometimes had a pillow under his legs but not always. The resident also revealed he did not refuse to allow staff to turn him in bed when staff ask and help him turn. At this time, the resident was observed on his left side with his left stump not floated/elevated. Observation on 04/16/25 at 9:31 A.M. with RN #196 verified Resident #48 did not have his left stump floated/elevated and the resident was on his left side with no interventions in place to assist with off-loading the pressure to his left side and/or to promote the healing of the surgical wound. Interview on 04/16/25 at 1:29 P.M. with the Director of Nursing (DON) revealed if a resident, who required (staff) assistance, refused to be turned and repositioned or was refusing to off-load/float an extremity, it was to be documented, and the physician was to be notified. Observation on 04/16/25 at 2:01 P.M. revealed Resident #48 was on his left side. Interview on 04/16/25 at 2:19 P.M. with the DON revealed Resident #48 had refused a few times to turn and reposition since being admitted to the facility. During the interview, the DON revealed the resident favored his left side and no interventions had been implemented to help off-load pressure such as pillows or a wedge. The DON also verified no orders or documentation to float/elevate the left stump were in place at the time of admission. Orders were not implemented until 03/25/25 when the resident's left below the knee amputation surgical site worsened. The DON verified orders/interventions should have been in place for the left stump to be floated at the time of admission. Interview on 04/16/25 at 2:29 P.M. with Certified Nurse Practitioner #170 revealed he was never informed of Resident #48 refusing to turn and reposition in bed or that the resident preferred his left side. Observation on 04/17/25 at 9:11 A.M. of Resident #48 revealed the resident was on his left side with no interventions to help off-load pressure/promote healing and the resident's left stump not being floated. At the time of the observation, interview with the resident revealed he does prefer to be positioned on his left side better but did not recall the staff placing pillows or a wedge so that he could lay on his left side with less pressure. Observation on 04/17/25 at 11:25 A.M. with CNA #168 verified Resident #48 was positioned on his left side with no interventions in place to off-load pressure and the resident's left stump not floated/elevated. Review of the facility policy titled Pressure Ulcer/Skin Breakdown-Clinical Protocol revised 03/20/2024 revealed the plan of care for prevention and/or treatment would include a turning schedule/off-loading.

Based on observation and interviews, the facility failed to ensure opened multi-dose Tuberculin Purified Protein (TB) vials were dated when opened. This had the potential to affect all 81 residents residing in the facility. Findings Include: On 04/17/25 10:15 A.M., observation of the third floor medication room refrigerator revealed an opened vial of Tuberculin Purified Protein one milliliter (ml) was undated to when the first dose was obtained. Registered Nurse (RN) #196 verified the vial of TB solution was not dated when opened at the time of the observation. On 04/17/25 at 10:22 A.M., observation of the second floor medication room refrigerator revealed an opened vial of Tuberculin Purified Protein one milliliter (ml) was undated to when the first dose was obtained. Licensed Practical Nurse (LPN) #157 verified the TB solution was not dated when opened at the time of the observation.

Based on record review, observation, interview, and policy review the facility failed to implement interventions to promote skin integrity for a resident ordered to wear a knee brace. This affected one resident (#48) of one resident reviewed for skin integrity. Findings Include: Review of the medical record for Resident #48, revealed an admitted [DATE] (from the hospital). Diagnoses included but were not limited to acquired absence of left leg below knee, need for assistance with personal care, weakness, cerebral infarction, atherosclerosis of native arteries of extremities with gangrene, left leg, hemiplegia, affecting left nondominant side, dementia, and chronic obstructive pulmonary disease. Review of the hospital discharge paperwork dated 03/20/25 for Resident #48 revealed a left knee immobilizer to be on at all times. Review of the plan of care dated 03/20/25 for Resident #48 revealed the resident had impaired skin integrity related to recent surgery; mobility status as evidenced by: assist resident with turning and repositioning as needed. Further review of this resident's plan of care revealed activity of daily living self-care performance deficit related to acquired left below the knee amputation and hemiplegia affecting left dominant side with the intervention of bed mobility requiring a one person assist. Review of Resident #48's nursing admission evaluation dated 03/20/25 revealed the resident to need at least one person assistance with bed mobility. Review of Resident #48's Braden Scale for Predicting Pressure Sore Risk dated 03/20/25 revealed a score of 17.0 on a scale of 6 (high risk) to 23 (no risk) which indicated the resident was at risk for skin breakdown. Review of the physician's order dated 03/20/25 at 9:37 P.M. revealed a brace to the left below the knee amputation to be on at all times every day and night shift. Further review of this resident's physicians order dated 03/20/25 revealed to encourage to turn and reposition frequently when in bed to prevent skin breakdown. Review of Resident #48's daily skilled assessments dated 03/20/25 through 03/24/25 revealed skin assessments were completed. Review of the medical record for Resident #48 from 03/20/25 through 03/24/25 revealed no documentation of refusing to be turned every two hours and that this resident favored his left side. Review of the physical therapy notes dated 03/24/25 for Resident #48 revealed alerted nurse of skin breakdown observed from knee immobilizer, nursing assessed. Review of Resident #48's medical record revealed an assessment and treatment order for skin break down noted by physical therapy on 03/24/25. Review of Resident #48's wound assessment dated [DATE] revealed an in-house facility acquired deep tissue injury (DTI) (persistent non-blanchable deep red, maroon or purple discoloration intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to the front left thigh that measured 1.60 CM (centimeters) by 7.21 CM. Review of the active physician's orders dated 03/25/25 for Resident #48 revealed to skin prep area to front of left thigh every day and night. Review of the medical record for Resident #48 from 03/25/25 through 04/01/25 revealed minimal documentation of the resident refusing to be turned every two hours and no documentation that this resident favored his left side. Review of Resident #48's wound assessment dated [DATE] revealed an in-house facility acquired unstageable slough/eschar area to the left popliteal fossa that measured 2.68 CM by 1.91 CM by 0.1. Observation on 04/14/25 at 10:38 A.M. of Resident #48 revealed the resident to be on his left side in bed. Observation on 04/14/25 at 12:41 P.M. of Resident #48 revealed the resident to be on his left side in bed. Interview on 04/14/25 at 12:51 P.M. with Licensed Practical Nurse (LPN) #104 revealed Resident #48 never refuses care and does need assistance to be turned in bed. Observation on 04/15/25 at 10:26 A.M. revealed Resident #48 in bed on his left side. Observation on 04/15/25 at 1:23 P.M. revealed Resident #48 in bed on his left side. Observation on 04/15/25 at 1:28 P.M. with Certified Nurse Assistant (CNA) #205 verified Resident #48 to be on his left side. Interview on 04/16/25 at 9:25 A.M. with Registered Nurse (RN) #196 revealed Resident #48 never refuses care, needs assistance to be turned in bed. Interview on 04/16/25 at 9:27 A.M. with CNA #173 revealed Resident #48 never refuses care and does favor his left side. Interview on 04/16/25 at 1:29 P.M. with the Director of Nursing (DON) revealed if a resident refuses to be turned and repositioned that need assistance and if a resident is refusing to float an extremity, it is to be documented, and the physician is to be notified. Observation on 04/16/25 at 9:31 A.M. with RN #196 verified Resident #48 to be on his left side. Interview on 04/17/25 at 9:31 A.M. with Physical Therapist #171 revealed Resident #48 was in therapy on Monday which was 03/24/25 and she removed his brace and noticed the skin area to his left thigh and alerted the nursing staff to assess it. Interview on 04/17/25 at 9:33 A.M. with Licensed Practical Nurse (LPN) #104 verified Resident #48's DTI to the front left thigh was discovered on 03/24/25. Physical therapy alerted her, and she informed her Unit Manager who instructed her it would be measured the next day since Tuesdays are wound measurement day. LPN #104 verified no treatment and assessment was completed and implemented when the wound was discovered on 03/24/25. Review of the facility policy titled Pressure Ulcer/Skin Breakdown-Clinical Protocol revised 03/20/24 revealed residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing and prevent new ulcers from developing. The plan of care for prevention and /or treatment is to include a turning schedule/offloading care.

Based on observation, record review, interview and facility policy and procedure review, the facility failed to ensure physician ordered fall interventions were in implemented as ordered for two residents (#6 and #40) with known falls. This affected two residents of six residents reviewed for accidents. The facility census was 81. Findings Include: 1. Review of the medical record for Resident #6 revealed an initial admitted [DATE] with the diagnoses including but not limited to Alzheimer's disease, atherosclerotic heart disease of native coronary artery, hypothyroidism, anxiety disorder, diverticulosis, dementia with other behavioral disturbances, psychosis, mood disorder, hyperlipidemia, insomnia, polyneuropathy, osteoarthritis, gastro-esophageal reflux disease, cardiomyopathy and dysphagia. Review of the plan of care dated 07/28/23 and last revised on 04/16/25 revealed the resident was at risk for falls/injury related to bladder incontinence, generalized weakness, history of falls, impaired cognition with decreased safety awareness, inability to use call light due to confusion, psychoactive medications use, lack of coordination, unsteadiness on feet and resident removes dycem from recliner. Interventions included encourage resident to rest whenever having periods of prolonged ambulation, non-skid strips to left side of bed, non-skid strops in front of recliner, staff education when aware of fire drill make sure she is aware of drill, therapy screen/evaluation/treat as needed, encourage resident to keep needed items within reach, encourage resident to wear glasses; assist with applying as needed, ensure the resident's room is free from accident hazards, non-skid footwear to reduce the risk of slipping as the resident allows, observe for changes in mobility, and place call light within reach. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident had one fall with injury since the prior assessment was completed. Review of the fall risk evaluation dated 04/06/25 revealed a score of six indicating the resident was at risk for falls. Review of the resident's monthly physician orders for April 2024 identified orders dated 01/12/23 right side of bed against wall per family request, 01/14/25 non-skid strips to left side of bed every shift for fall intervention, encourage grippy socks or proper footwear when out of bed and non-skid strips in front of recliner, check placement every shift. On 04/14/25 at 3:01 P.M., observation of Resident #6' room revealed no dycem to the seat of the resident's recliner, and no nonskid strips to the left side of the bed. On 04/15/25 at 3:20 P.M., interview with Licensed Practical Nurse (LPN) #189 verified the resident's physician ordered fall interventions were not implemented as ordered. 2. Review of the medical record for Resident #40 revealed an initial admitted [DATE] with the latest readmission of 02/10/23 with the diagnoses including but not limited to dementia with behavioral disturbances, chronic obstructive pulmonary disease, seizures, atrial fibrillation, schizophrenia, cardiomyopathy, secondary Parkinsonism, hypertension, dysphagia, aphasia, ataxia, anxiety disorder, gastro-esophageal reflux disease, anemia, major depressive disorder and hyperlipidemia. Review of the plan of care dated 08/10/23 and last revised on 01/24/24 revealed the resident was at risk for falls/injury related to bowel and bladder incontinence, generalized weakness, history of falls, impaired cognition with decreased safety awareness, opioid medication use, seizures, lack of coordination, difficulty walking, at risk for injury from hot liquids and will turn off pressure alarm. Interventions included dycem to wheelchair, fall mat to right side of bed, non-skid strips in front of toilet, do not leave unattended in the dining room, sensor pad alarm to bed, sensor pad alarm to wheelchair, sign in room for reminder to use call light, staff education assist resident up for meals, ensure alarms are in place and functioning, toilet frequently, toilet before and after meals, encourage resident to keep needed items within reach, encourage resident to keep wheelchair within reach, encourage resident to use call light, monitor resident's position to reduce the risk of slipping as the resident allows, observe for changes in mobility, place call light within reach, therapy screen/evaluation/treat as needed, skin breakdown, symptoms of delirium, falls, accidents, injuries, agitation, or weakness, observe for, record, and report to the nurse and/or physician any changes regarding the effectiveness of the bed modification or adverse or negative effects as a result of the bed modification, periodically evaluate the need for the resident's bed modification(s) and record continued risks and benefits of continued use of the bed modification(s), alternatives, and need for ongoing use and cool hot liquids prior to serving. Review of the resident's monthly physician orders for April 2025 identified orders dated 01/14/25 resident to have dycem present to wheelchair seat, non-skid strips in front of toilet, check placement every shift and sign in room for reminder to use call light and ask for assistance. On 04/15/25 at 3:15 P.M., observation of the resident with Certified Nursing Assistant (CNA) #126 revealed the resident had no dycem to the seat of his wheelchair. On 04/15/25 at 3:20 P.M., observation of the resident's room with LPN #189 revealed the resident had no nonskid strips in front of his toilet and the sign to remind the resident to use the call light and ask for assistance was behind the privacy curtain out of his sight. LPN #189 verified the fall interventions were not implemented as physician ordered, including the physician ordered dycem to his wheelchair seat. Review of the facility policy titled, Fall Prevention Program, dated 10/30/02 revealed each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls.

Based on observation, interview, record review, and facility policy review, the facility failed to obtain a physician's order for the administration of oxygen therapy and post an oxygen warning sign. This affected one resident (#48) of one resident reviewed for respiratory care. The facility census was 81. Findings include: Review of the medical record for Resident #48, revealed an admitted [DATE]. Diagnoses included but were not limited to acquired absence of left leg below knee, need for assistance with personal care, weakness, cerebral infarction, atherosclerosis of native arteries of extremities with gangrene, left leg, hemiplegia, affecting left nondominant side and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 which suggests moderate cognitive impairment. The resident was assessed to require substantial/maximal assistance with shower/bathe self, bed mobility and total dependence on toilet hygiene and transfers. This resident was also assessed to be at risk for developing pressure ulcers and to have an unstageable deep tissue injury not on admission and a surgical wound. Review of the plan of care dated 03/23/25 for Resident #48 revealed this resident had an impaired pulmonary/respiratory status related to chronic obstructive pulmonary disease with an intervention to provide oxygen as needed when the resident exhibits signs/symptoms of difficulty breathing. Review of the active physician orders for Resident #48 revealed no order for oxygen therapy. Observation on 04/14/25 at 10:38 A.M. of Resident #48 revealed his door did not display an oxygen in use sign. Further observation revealed the resident in bed with his nasal cannula on the bed with an oxygen concentrator set to 2 liters. Observation on 04/15/25 at 10:26 A.M. of Resident #48 revealed his door did not display an oxygen in use sign and the resident to bed in bed with his nasal cannula on with the oxygen concentrator to be set to 2 liters. Observation and Interview on 04/15/25 at 9:31 A.M. with Registered Nurse #196 of Resident #48 verified no oxygen in use sign on his door and the resident to have a nasal cannula attached to an oxygen concentrator. Also verified no oxygen therapy physician order for the resident. Review of the facility policy titled Oxygen Administration revised 10/26/2023 revealed oxygen warning signs must be placed on the door of the resident's room where oxygen is in use and oxygen is administered under orders of a physician.

Based on record review, interviews and facility policy and procedure review, the facility failed to comprehensively assess and develop a comprehensive plan of care for one resident (#31) with post traumatic stress disorder (PTSD). This affected one of four residents reviewed for mood/behavior. The facility census was 81. Findings Include: Review of the medical record for Resident #31 revealed an initial admitted [DATE] with the diagnoses including but not limited to psychosis, schizoaffective disorder, depressive type, hypertension, hypothyroidism, drug induced subacute dyskinesia, obstructive sleep apnea, tremor, anxiety disorder, severe morbid obesity, constipation, dissociative and conversion disorder, post-traumatic stress disorder, chronic kidney disease, insomnia, borderline personality disorder, major depressive disorder, bipolar disorder, osteoarthritis and overactive bladder. Review of the resident's initial social service history dated 01/19/23 revealed the resident did not have PTSD. Review of the resident's social service progress review dated 01/06/25 revealed the resident did not have PTSD. Review of the psychiatric progress note dated 03/20/25 revealed the resident's PTSD was chronic and controlled. The resident is currently on a regimen of Depakote, Latuda, Topiramate, Ingrezza, Buspar, and Wellbutrin. No new symptoms or concerns were reported during this visit. The plan was to continue with the current medication regimen. Encouraged resident to report any increase in PTSD symptoms or any side effects from the medication. Regular follow-ups will be scheduled to monitor the patient's response to the medication. Review of the resident's social service progress review dated 04/01/25 revealed the resident did not have PTSD. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident had displayed hallucinations, delusions and behaviors not directed towards others. The assessment indicated PTSD was a current diagnoses. Review of the resident's plan of care revealed no care plan addressing the resident's triggers PTSD. On 04/17/25 at 9:48 A.M., interview with Regional Registered Nurse #207 verified the resident was not assessed for PTSD and a comprehensive plan of care was not developed to assist with the care of the resident's PTSD. Review of the facility policy titled, Trauma Informed Care, dated 10/18/20 and last revised 10/24/22 revealed the policy of the facility to ensure residents who are trauma survivors receive culturally competent trauma informed care in accordance with professional standards of practice. Each resident will be screened for a history of trauma on admission. The facility social worker or designee will conduct the screening in a private setting. If the screening indicated the resident had a history of trauma and/or trauma related symptoms a physician's order will be obtained for the resident to be evaluated by a mental health professional. The facility will account for the resident's experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. A care plan will be initiated/updated to address those residents identified. Individualized approaches will be identified and interventions put into place.

Based on review of facility alternative dispute resolution agreements, resident interview, staff interview, record review, and policy review, the facility failed to ensure residents understood the agreement they signed. This affected two of three residents reviewed for arbitration agreements (Residents #15 and #68). The facility census was 81. Findings include: 1. Review of the record for Resident #68 revealed an admitted [DATE]. Review of a Minimum Data Set (MDS) assessment completed 01/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of a facility Alternative Dispute Resolution Agreement dated 01/23/25 revealed Resident #68 signed the agreement on 02/14/25. The agreement stated it demonstrated a mutual intention to resolve disputes between them outside of court and to submit their disputes to Alternative Dispute Resolution through mediation and/or arbitration. The form also stated that the resident had been offered to, or had been able to view an audio/visual recorded video that details this agreement and what it includes. Interview with Resident #68 on 04/16/25 at 4:05 P.M. revealed it was her signature on the agreement. However, she stated she did not watch a video and did not understand what she was signing. 2. Review of the record for Resident #15 revealed an admitted [DATE]. Review of a MDS assessment completed 12/13/24 and 04/15/25 revealed a BIMS score of 14, indicating intact cognition. Review of a facility Alternative Dispute Resolution Agreement dated 12/07/24 revealed Resident #15 signed the agreement on 12/16/24. The agreement stated it demonstrated a mutual intention to resolve disputes between them outside of court and to submit their disputes to Alternative Dispute Resolution through mediation and/or arbitration. The form also stated that the resident had been offered to, or have been able to view an audio/visual recorded video that details this agreement and what it includes. Interview with Resident #15 on 04/16/25 at 3:15 P.M. revealed she did not remember signing the dispute resolution agreement. She stated that is was not her signature on the form. She stated anytime she signed a document, she used her middle initial between her first name and last name. The signature on the agreement did not include a middle initial. She stated she probably would not have signed the agreement anyway if she understood what it was. Review of other documents signed by Resident #15 dated 12/05/24 including consents for flu vaccine, RSV vaccine, and bed rails revealed the resident used her middle initial when signing the forms. Interview with Regional Registered Nurse #207 on 04/16/25 at 3:20 P.M. confirmed other forms signed by Resident #15 contained her middle initial and the Dispute Resolution Agreement did not. She further stated the Admissions Director who also signed the agreement no longer worked at the facility. Interview with Admissions Director #192 on 04/17/25 at 7:26 A.M. revealed the facility has a video for residents to watch that explains the arbitration agreement. Review of the facility policy titled Binding Arbitration Agreements dated 07/28/20 and revised 11/01/22 revealed this facility asks all residents to enter into an agreement for binding arbitration. The facility shall explain to the resident or his or her representative in a form and manner that he or she understands.

Based on observation, record review, review of online manufacturer guidance, and interview the facility failed to ensure equipment was maintained in a safe manner to prevent falls with injury for Resident #43 and Resident #50. The facility failed to provide adequate supervision and assistance to prevent Resident #48 from falls and eloping. Actual harm occurred on 02/03/23 when Resident #50 sustained a fall when the anti-rollbacks on his wheelchair were not properly functioning. The resident complained of severe pain for three days following the incident, with a decrease in functional mobility without any type of interventions. On 02/06/23 the resident was admitted to the hospital with a fractured right hip. Actual harm also occurred on 06/01/23 when Resident #43, who required staff assistance for personal care fell from a shower gurney after the rail of the gurney broke sustaining a fractured femur. Prior to the incident, there was no evidence the facility conducted any type of preventative maintenance or inspection of the shower gurneys. This affected three residents (#43, #48, and #50) of the six residents reviewed for falls. The facility census was 80. Findings include: 1. Record review for Resident #50 revealed the resident was admitted to the facility on [DATE]. Resident #50 had diagnoses including nondisplaced fracture of greater trochanter of right femur, chronic obstructive pulmonary disease, other seizures, paroxysmal atrial fibrillation, schizophrenia, ischemic cardiomyopathy, dementia with behavioral disturbance, secondary parkinsonism, hypertension, abnormal posture, dysphagia, aphasia, ataxia, need for assistance with personal care, cognitive communication deficit, and difficulty walking. Review of a facility fall investigation, dated 02/03/23, revealed Resident #50 was observed trying to scoot himself back in his wheelchair. When attempting to stand, the wheelchair rolled partially out from under him. The anti-rollback wheels did not lock when the resident stood to shift weight back in his chair. The resident was assessed to complain of some pain to the right leg area. Record review revealed there was no nursing progress note related to this incident on 02/03/23. Review of the facility Fall - Initial assessment, dated 02/03/23, revealed the resident complained of new pain to the right middle leg at a pain level rated a four out of 10 on a scale of one to 10. Review of the facility Fall - Follow-up assessment, dated 02/04/23, revealed the resident have a pain level of three out of ten with bruising noted to the right posterior leg and knee. Review of the facility Fall - Follow-up assessment, dated 02/05/23, revealed the resident had a pain level rated a four out of ten and was refusing to stand or apply weight to the right leg. Review of the facility Fall - Follow-up assessment, dated 02/06/23, revealed the resident was assessed to have a pain level rated a seven out of ten and was at the emergency room (ER) for hip pain. Review of the Medication Administration Record for 02/2023 revealed Resident #50 was documented to have been administered as needed Tylenol for pain once on 02/05/23 and twice on 02/06/23 which staff documented to be effective. Review of Resident #50's medical record revealed there were no comprehensive assessments of the resident's hip, range of motion/mobility status, changes in medical condition and/or notification to the physician prior to 02/06/23. Review of the nurse's progress note, dated 02/06/23, revealed Registered Nurse (RN) #173 received during report information that Resident #50 had fallen on 02/03/23 and had been complaining of pain since the fall. STNAs reported to RN #173 that Resident #50 had a substantial decrease in ADL's related to standing, ambulation, and transfers. RN #172 notified the physician at this time and new orders were received to obtain an x-ray of the knee and hip area. Review of the facility Work Order #1751, created on 02/06/23, revealed anti-rollbacks on wheelchair not functioning properly. On 02/07/23 the work order was updated to set to be completed. Review of the hospital progress note dated 02/06/23 revealed Resident #50 was admitted to the hospital on 02/06/23 after being found to have a right intertrochanteric hip fracture which required surgical repair while the resident was in the hospital. Review of the most recent annual MDS 3.0 assessment, dated 04/06/23, revealed Resident #50 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 03 out of 15. This resident was assessed to require extensive assistance from two staff members for transfers, toileting, and bed mobility and to require supervision with setup assistance only for eating. Review of the care plan, revised 06/14/23, revealed Resident #50 was at risk for falls. Interventions included maintenance to repair anti-rollbacks on 12/14/22 (after sustaining a fall with no injury on 12/14/22) and maintenance to check function of anti-rollbacks and repair as needed on 02/06/23. Interview with RN #173 on 06/27/23 at 9:00 A.M. revealed upon coming back to work after being off for four days facility STNA's reported Resident #50 had a decline in ADL's since falling on 02/03/23 and was not wanting to eat or bear weight. RN #173 stated Resident #50 was ambulatory and fairly independent prior to his fall on 02/03/23. RN #23 further stated Resident #50 did not typically complain of pain and while being assessed by RN #173 the resident verbalized complaints of severe pain to his right hip and leg. RN #23 stated she notified the physician who ordered an x-ray which revealed a fracture, and the resident was sent to the hospital for evaluation and treatment. Interview with Resident #50 on 06/27/23 at 9:12 A.M. revealed the resident had fallen while attempting to stand and had to go to the hospital and have surgery. Resident #50 stated he had severe pain to the right hip and leg which he had verbalized to facility staff in the days following his fall. Interview with Director of Nursing on 06/29/23 at 9:00 A.M. verified Resident #50 had a fall on 02/03/23 and was sent out to hospital on 02/06/23 for evaluation and treatment for right hip fracture. 2. Record review for Resident #43 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypercapnia, anemia, dependence on supplemental oxygen, bipolar disorder, adult failure to thrive, schizoaffective disorder, contracture of left hand and elbow, muscle wasting, tremor, and muscle weakness. Review of a fall investigation, dated 06/01/23, revealed a State tested Nursing Assistant (STNA) opened the door to the room of Resident #43 and informed the nurse the shower gurney had broken prior to the Hoyer lift transfer back into the bed and the resident had fallen on the floor. The STNA stated her, and her partner rolled resident on the gurney when the railing of the gurney snapped. Upon entering the room, the resident was observed lying on the floor and was yelling out in pain. The resident was assessed and found to have a hematoma to her right and left hands, bruising on the left side of her forehead, and was observed to yell out in pain every time her left leg was touched with a pain level of eight using the PAINAD pain scale. The physician was notified, and the resident was sent to the emergency room (ER) for evaluation. Review of the medical record for Resident #43 revealed no nurse's notes regarding the fall that occurred on 06/01/23. Review of the witness statement provided by STNA #133, dated 06/01/23, revealed she and STNA #5 showered Resident #43 on the shower gurney. When finished, the two STNAs took the resident back to her room to put her in bed. While getting the Hoyer lift ready for the transfer, the two STNAs rolled the resident toward them to get a Hoyer pad underneath her and the left side of the gurney came down and the resident fell . Review of the witness statement provided by STNA #5, dated 06/01/23, revealed Resident #43 was on the shower gurney and STNA #133 and STNA #5 were both on the side of the gurney they were rolling her towards when the gurney snapped, and the resident fell on to the floor on her left side. Review of the hospital progress note, dated 06/01/23, revealed this resident was diagnosed with a displaced intertrochanteric fracture of the left femur. Review of the care plan, revised 06/09/23, revealed the resident had a fall. An intervention (initiated 06/02/23) included staff education to inspect shower equipment prior to use. Review of the most recent significant change Minimum Data Set (MDS) assessment, dated 06/20/23, revealed Resident #43 was rarely/never understood. The assessment revealed the resident required extensive assistance from two staff members for bed mobility and toileting, required extensive assistance from one staff member for eating, and was dependent on two staff members for transfers. Interview with Maintenance Director (MD) #47 on 06/27/23 at 3:19 P.M. revealed the pipe on the shower gurney had broken during use with Resident #43. MD #47 was unsure if it was cracked before being used to shower Resident #43 as routine inspection and maintenance of the shower gurney had not been done prior to the residents fall. Maintenance Director #47 stated he was unsure of the recommendations for routine maintenance on the shower gurney but stated he would attempt to find them. Interview with Maintenance Crew employee #157 on 06/27/23 at 3:34 P.M. revealed the side rails of the shower gurney were up and the pin went through the PVC pipe on the shower gurney causing it to break and for the resident to fall. Maintenance Crew employee #157 stated prior to Resident #43's fall, there was not routine maintenance or inspection of the shower gurney, but following the incident staff were to inspect them monthly. Interview with the Director of Nursing (DON) on 06/29/23 at 8:51 A.M. verified there had not been routine maintenance or inspections of the facility shower gurneys prior to the fall experienced by Resident #43. The DON also verified the facility did not have a manual or policy for the shower gurney providing instructions on how to use, clean, or maintain the gurney in good, working condition. Review of the online guidance from Healthline Medical Products titled Recommendations from the manufacturer (https://www.healthlinemedical.com/instructions/healthline-medical-shower-gurney-maintenance/), not dated, revealed recommendations regarding gurney maintenance and use procedure revealed drop rails were not designed to hang on them and all joints of the shower gurney should be checked on a regular basis to make sure the pipes and fittings were secured. 3. Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE]. Resident #48 had diagnoses including alcohol-induced persisting dementia, seizure disorder, chronic obstructive pulmonary disease, osteoarthritis, repeated falls, difficulty walking, unsteadiness on his feet and muscle weakness. Review of Resident #48's fall risk assessment completed on 12/20/22 revealed the resident was not indicated to have had any falls occurring in the previous 90 days. He was ambulatory with the use of assistive devices. He had diagnoses and the use of certain medications that increased his risk for falls. His overall score was nine, which did not indicate the need for any fall prevention interventions at that time. A review of Resident #48's nurses' progress notes revealed the resident had an unwitnessed fall on 01/04/23 at 7:45 P.M. The note indicated the resident was previously seen sitting in his wheelchair in the dining room watching a movie. Another resident had come to the nurses' station and informed the nurse that the resident had fallen. The nurse noted the resident was already back in his wheelchair when she was made known of the fall. She asked the resident if he had fallen and he reported to the nurse that he had. He was unable to provide any further description of the fall. A review of the facility's fall investigation for the fall occurring on 01/04/23 revealed the immediate action taken to prevent further falls from occurring included the use of Dycem to his wheelchair. Review of Resident #48's quarterly/significant change evaluation dated 05/03/23 revealed the resident's risk for elopement was assessed as part of the quarterly evaluation under the cognitive/ communication assessment of that evaluation. The resident's risk factors for elopement included being cognitively impaired, having the diagnosis of dementia, being able to ambulate independently with the use of a wheelchair, and being known to wander aimlessly. He was not known to have a history of eloping when at home, leaving the facility unsupervised, or leaving the facility without informing the facility staff. As a result of that assessment, he was not deemed to be at risk for elopement at that time. A review of a nurse's note dated 05/15/23 at 5:00 P.M. revealed the resident had a witnessed fall on that date. The note indicated the resident was in the dining room when staff witnessed the resident had slid out of his wheelchair onto his buttocks on the floor. The resident reported that he had slid out of his wheelchair. The intervention added was again to use Dycem to his wheelchair that had been previously ordered with his fall occurring on 01/04/23. A review of the facility's fall investigation for the fall occurring on 05/15/23 revealed the immediate action taken following the fall included providing staff education to ensure Dycem was in place to his wheelchair as was previously ordered. A review of Resident #48's physician's orders revealed an order, dated 05/15/23 for the use of Dycem to his wheelchair at all times. Review of Resident #48's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident rarely/ never made himself understood and was rarely/ never able to understand others. He had both short- and long-term memory impairment and his cognitive skills for daily decision making was severely impaired. He was not coded on the MDS as having had any behaviors during the seven-day assessment period and was not known to reject care or display any wandering behavior. He required a limited assist of one for transfers. He required supervision with set up help for ambulation in his room. Ambulation in hall only occurred once or twice, but he only required set up help for that when it did occur. He required supervision with the assist of one for locomotion on and off the unit. Balance issues were noted but he was able to stabilize without staff assistance. A wheelchair was the only mobility device used. The resident was identified as having had falls since his prior assessment. He had two or more falls without injury, one fall with injury that was not major injury, and one fall with major injury. A review of Resident #48's active care plans revealed he had a care plan in place for being at risk for falls related to dementia, weakness, unsteadiness on feet, difficulty walking, lack of coordination, and a history of falls. The care plan originated on 12/20/17 and was last revised on 06/14/23. The goals were to reduce the risk of serious injury in the event of a fall and for the resident to be free of falls. The interventions included ensuring his call light was within reach and to encourage the resident to use it for assistance as needed. That intervention was added to the care plan on 12/20/17. The interventions also included the use of Dycem (a tacky pad that could be placed on a seat of a chair to prevent sliding) to his wheelchair. That intervention was added on 01/05/23. The care plan directed them to review information on past falls and attempt to determine the cause of falls. They were to record the possible root causes and to remove any potential causes if possible. The care plan was revised to include the intervention of educating staff to ensure proper placement of Dycem on 05/18/23. On 06/26/23 at 12:47 P.M., an observation of Resident #48 noted him to be lying in bed. His call light was on the floor under his bed and out of his reach. Further observation of Resident #48 on 06/27/23 at 10:29 A.M., noted him to be lying in bed with his call light still on the floor under his bed and out of reach. Findings were verified by LPN #135. On 06/27/23 at 10:48 A.M., an interview with LPN #135 revealed Resident #48 was at risk for falls. They typically laid him down after meals and one of the aides would have helped him to bed after breakfast. She reported his fall prevention interventions included ensuring his call light was in reach. She confirmed the resident did not have his call light in reach, as it was found under his bed on the floor. She retrieved it from the floor and secured it to the assist bar that was on the right side of his bed near his head. On 06/27/23 at 3:10 P.M., an interview with the DON confirmed Resident #48 has had multiple falls while in the facility. She confirmed the use of Dycem was added as a fall prevention intervention following the fall the resident had on 01/04/23. She also confirmed they provided education to staff to ensure the Dycem was in place in his wheelchair, after he fell again on 05/15/23. She acknowledged the fall on 05/15/23 could not be considered an unavoidable fall due to previously ordered fall prevention interventions not being in place that contributed to his fall. She also acknowledged the fall prevention intervention to ensure his call light was in reach was not implemented as per the plan of care when observations noted it to be under his bed and out of reach on 06/26/23 and again on 06/27/23. In addition, a review of Resident #48's active care plans that were reviewed/revised on 06/14/23 revealed he did not have any care plan in place for being at risk for elopement or for unsafe wandering. Further review of Resident #48's nurses' progress notes revealed a nurse's note dated 06/25/23 at 3:00 P.M. that indicated a door alarm was alarming. The alarm announced was identifying the alarm as coming from the courtyard door on the second floor. The nurse and an aide tried multiple times to silence the courtyard door but was unsuccessful in doing so. The aide informed another staff nurse working that floor who also tried multiple times to silence the alarm without success. A maintenance employee was called to report the problems they were having with an alarm sounding that could not be silenced. While awaiting a return phone call, the aide went to check other residents and found the short hall exit door to be the one alarming. She entered the code to that alarm and was able to get the alarm to stop alarming. The staff then started checking on the residents and found Resident #48 to be missing. A facility search was started, and the resident was found outside in his wheelchair by the dumpsters by one of the nurses working on the second floor and the aide assigned that unit. The resident was found alert and his skin was warm and dry. He was not found with any injuries and was not noted to be in any distress. Staff assisted him back into the facility and into bed without incident. A review of a nurse's note dated 06/25/23 at 3:30 P.M. revealed the facility's DON was notified of the door alarm situation and the resident exciting building. A new order for the use of a Wander guard alarm was given as well and placing the resident on 15-minute checks until further notice. A review of the facility's investigation for Resident #48's elopement on 06/25/23 revealed the incident description of the event was consistent with what was documented in the progress notes. The resident was not able to provide a description of the event. Predisposing physiological factors of the incident included him being confused and impaired memory. Predisposing situation factors included him being a wanderer. Two staff members (LPN #89 and STNA #25) were identified as being witnesses to the incident and provided statements. LPN #89's statement indicated the resident was found in the parking lot by the dumpster after exiting the back hallway door. STNA #25's statement indicated the resident was found outside the facility in the parking lot after exciting the facility unassisted. The facility's investigation indicated the DON was notified on 06/25/23 at 3:30 P.M. On 06/27/23 at 3:35 P.M., an interview with Maintenance Assistant #157 revealed he was the maintenance employee called by the facility staff when Resident #48 eloped from the facility on 06/25/23. He reported they informed him they had a door alarm going off that they could not get silenced. He recalled the concern was with an alarm on the second-floor courtyard door. He came into the facility to check it out. By the time he arrived, the alarm was already silenced. He was informed the alarm that was going off was from the other door at the end of the hall and not the courtyard door as was being announced overhead. He indicated the courtyard door and the short hall exit door had the same code announcement and the overhead message would refer to them both as the courtyard door, even if it was the one at the end of the hall. He was informed a resident had gotten out when he arrived and was found at the bottom of the ramp by the facility's dumpsters. He confirmed by checking his phone that he received the call at 3:12 P.M. and he was in the facility by 3:30 P.M. in which the resident was already back in the facility. On 06/27/23 at 406 P.M., an interview with the DON revealed she was called about the elopement by Resident #48 on 06/25/23 at 3:28 P.M. The staff informed her of what had happened. It was reported to her that the nurse and the aides were in other residents' rooms. They then heard an alarm go off for the courtyard door. The overhead announcement indicated it was the courtyard door. The staff told her they looked outside but did not see any residents out there. They could not get the alarm to silence and called maintenance to come in to check it out. The staff realized the courtyard door was not flashing and it was the exit door at the end of the short hall that was flashing instead. They checked the residents and found Resident #48 to be missing. They went outside and found the resident at the end of the ramp near the dumpsters. On 06/27/23 at 4:10 P.M., an observation of the courtyard door on the 2nd floor revealed it led to the facility's designated smoking area. The alarm system on the courtyard door allowed the door to be immediately opened by turning the doorknob but would sound an audible alarm if the door was opened without entering the code into a keypad. The keypad alarm box on the wall would flash red if that was the door alarming in addition to an overhead announcement that identified the courtyard door as the door alarm that had been activated. The short hall exit door was checked and noted to have a delayed egress of 15 seconds before that door could be opened. A constant audible alarm sounded when the door's bar was pushed on until the door opened and then a different sounding alarm would go off accompanied by an overhead announcement. The courtyard door and the exit door at the end of the short hall both led to the same ramp that led down to the facility's side parking lot where the dumpsters were. The ramp was made of decking material and had a long, gentle slope with handrails on both sides. The side parking lot had a black tar pavement with a raised curb that enclosed it on the back end and the side. It led to the front parking lot where a steep driveway went down into the road the facility sat on. On 06/27/23 at 4:13 P.M., further interview with the DON revealed the alarm company had told them they could not program the alarm system to differentiate between the courtyard door and the short hall exit door, due to their proximity to one another. She indicated, when she was called, Resident #48 had already been found and brought back into the facility. She suspected he was not out there very long between the time the alarm sounded and when he was found. On 06/28/23 at 8:51 A.M., an interview with LPN #89 revealed she was one of the two nurses working on the second floor on 06/25/23 when Resident #48 eloped. She was the nurse assigned the long hall and not the short hall where the resident resided. She stated the overhead message indicated the courtyard door was alarming and they could not get it to stop. She confirmed the called maintenance to come in to check the alarm out and did not realize it was another door other than the courtyard door that was going off. STNA #25 noticed the keypad at the end of the short hall exit door did not look right. She punched in the code and the door alarm silenced. They realized at that point that someone could have gone through that door and not the courtyard as was originally thought. She and the aide went out into the courtyard when the door alarm first went off and did not see any residents out there. She was not sure if they exit door at the end of the short hall was sounding for the full 15 seconds, when the door was pushed on and before it released. She was down the long hall at the time and did not hear it alarming until the announcement was made overhead for the courtyard door. She was not sure where the nurse or the aide that was working the short hall was at that time or if they heard the short hall exit door alarm before being opened. They did a head count when they realized the exit door at the end of the short hall was the one sounding and noticed Resident #48 was missing. She and the aide went outside to look for the resident and he was noted to come out from behind the dumpsters still sitting in his wheelchair. She suspected he was only out there for five to seven minutes between the time the courtyard door alarm sounded and being found in the side parking lot. This deficiency represents non-compliance investigated under Complaint Number OH00143456.

Based on review of the facility's infection control logs, record review, staff interview, and policy review, the facility failed to ensure they maintained an effective infection control program that adequately identified organisms causing infections within the facility and properly track those infections to identify any trends or patterns. This had the potential to affect all residents residing in the facility. The facility's census was 80. Findings include: A review of the facility's infection control logs for the past 12 months revealed the facility's infection preventionist was utilizing a floor plan to identify where infections were noted throughout the facility for each month. She had a floor plan for the second floor and a floor plan for the third floor. The floor plan was color coded to show the locations of the rooms in which different types of infections occurred. One color was used to signify each type of the following infections: urine, respiratory, skin, and other. The floor plan did not indicate what organisms were present for the different types of infections identified. There were also infection line listing reports and antibiotic usage reports for each month reviewed. The antibiotic usage report included the resident's name, infection category (soft tissue, respiratory, UTI, or other), antibiotic ordered to include dose/ route, start date, stop date, and a place to document the organism involved. The antibiotic usage report did not have any organisms identified with any of the 13 entries made to include the infection categories that should have an organism easily identifiable such as with Urinary Tract Infections (UTI's). The infection preventionist typed in null under the column for organism with all 13 entries made. The infection line listing report included similar information as the antibiotic usage report and also failed to identify any organisms identified with the infections recorded. Under the column for organism, the infection preventionist entered no response for each of the 13 entries made to record resident infections. On 06/29/23 at 1:35 P.M., an interview with Registered Nurse (RN) #91 revealed she was the facility's infection preventionist. She confirmed the facility was not obtaining microbiology testing on a routine basis to identify organisms causing infections within the facility. She stated their medical director did not like ordering laboratory testing when treating residents for infections. She stated it was rare that the physician would order a urinalysis before treating a resident for a UTI based solely on symptoms and when he did he usually did not order a culture and sensitivity along with it. She acknowledged, without obtaining cultures when able, they were not identifying the organisms present that were causing the infections they were recording on their infection control logs. Without identifying the organism, they were not able to determine if there were any trends or patterns occurring in the facility involving any specific type of infection. She reported some of the residents were ordered antibiotics for wound infections when they were sent out for an appointment with the wound clinic or surgeon. Cultures were reported as having been obtained at those appointments but they had difficulty getting those culture results, even when requested, to be able to see what organism was causing the infection. A review of the facility's Infection Surveillance policy revised 10/24/22 revealed it was the facility's policy to develop a system of infection surveillance that served as a core activity of the facility's infection prevention and control program. Its purpose was to identify infections, monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. Infection surveillance was defined as an ongoing systematic collection, analysis, interpretation, and dissemination of infection-related data. The infection preventionist served as the leader in surveillance activities, maintained documentation of incidents, findings, and any corrective actions made by the facility and reported surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required. The facility would collect data to properly identify possible communicable diseases or infections before they spread by identifying data to be collected to include the infection site, pathogen (if available), signs and symptoms, resident locations, and the identification of unusual or unexpected outcomes, infection trends, and patterns. Data to be used in the surveillance activities may include, but was not limited to lab reports and antibiograms obtained from lab.

Based on review of the facility's infection control log, infection reports, record review, review of the McGeer's criteria, staff interview, and policy review, the facility failed to maintain and implement an effective antibiotic stewardship program to ensure residents only received antibiotics when warranted and antibiotics prescribed were appropriate for the infections being treated. This affected four (Resident #33, #75, #77, and #235) of five residents reviewed for infections. The facility census was 80. Findings include: 1. A review of Resident #33's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included adult onset diabetes mellitus and peripheral vascular disease. A review of Resident #33's physician's orders revealed she had an order in place to cleanse a wound to the left sole of her foot, pat dry, apply Betadine to the wound bed, and cover with a foam dressing daily. The treatment was ordered on 05/04/23. A review of Resident #33's skin and wound assessments revealed she had what was classified as a surgical wound to her left plantar foot. The wound progress was indicated to be stable and she was followed by wound care. A review of Resident #33's progress notes revealed a nurse's note dated 06/25/23 at 9:28 A.M. that indicated documents were received from the resident's appointment she had with the podiatrist on 06/23/23. The podiatrist recommended Doxycycline 100 milligrams (mg) for 3 weeks. The recommendation was reported to her primary care physician at the facility and he ordered Doxycycline 100 mg twice a day (BID) for three weeks. A review of Resident #33's consultation reports revealed she was sent out for a podiatry appointment on 06/23/23 as indicated in her nurse's progress note dated 06/25/23. The consultation report revealed the resident had increased redness of an unspecified area and it was recommended that she take Doxycycline 100 milligrams for three weeks. No other documentation was provided on the consultation report. A review of Resident #33's infection report dated 06/26/23 revealed someone had transcribed a 3 over the 6 for the day that was originally specified in the date of that report. The infection report indicated it pertained to a wound to the left foot per the podiatrist. Under skin, there was no indication of the resident having any symptoms to include heat, swelling, pain, redness, drainage, or odor. The bottom of the infection report included a section for infection management and specified the antibiotic ordered as Doxycycline 100 mg BID for three weeks. The treatment was to be initiated on 06/26/23 and continued through 07/17/23. Additional comments indicated the physician was aware and wanted to continue the antibiotic. On 06/29/23 at 1:35 P.M., an interview with Registered Nurse (RN) #91 revealed she had been the facility's infection preventionist since August 2022. She reported the facility followed the McGeer's criteria to ensure residents met the criteria for treating infections. She indicated Resident #33 was started on Doxycycline as recommended by the podiatrist when she went out for her appointment on 06/23/23. She stated the physician agreed with the treatment and wanted the antibiotic continued despite her not meeting criteria for the treatment of cellulitis or soft tissue wounds. 2. A review of Resident #75's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia, neurocognitive disorder with Lewy Bodies, and a need for assistance with personal care. A review of the facility's antibiotic usage report for May 2023 revealed she was ordered to receive Bactrim DS 800 -160 mg from 05/10/23 through 05/17/23 for the treatment of a Urinary Tract Infection (UTI). There was no organism recorded on the report to show what pathogen was causing her UTI. A review of an infection report for Resident #75 revealed the date symptoms were noticed was on 05/08/23. Symptoms included increased frequency/ urgency, dysuria, strong urine odor, and cloudy sediment in her urine. Under other comments, a urinalysis was indicated to have been obtained on 05/08/23 and results were obtained on 05/09/23. Under infection identification process, it was specified she had symptoms only. There was no indication a culture was done and organism was not identified. The section for infection management revealed Bactrim DS 800/ 160 mg was ordered BID for one week. A review of Resident #75's urinalysis report revealed nitrites were negative and 2+ Leukocyte Esterase was noted, which was abnormal. The urinalysis was not ordered to have a culture and sensitivity done with it so the organism involved was not identified and it was not clear if the antibiotic ordered was sufficient to properly treat her infection. A review of the McGeer's criteria used by the facility revealed UTI's without a catheter must have both criteria #1 and #2 met. In criteria #1, they must have at least one of the following, which included dysuria, fever or leukocytosis, and other symptoms. Criteria #2 must have at least 100,000 colonies/ milliliter of no more than two species of microorganisms in a voided urine sample or at least 100,000 colonies of any number of organisms in a specimen collected by in and out catheterization. On 06/29/23 at 1:35 P.M., an interview with RN #91 revealed their medical director did not usually order urinalysis to be completed when he suspected a resident had a UTI. He typically went by symptoms and just ordered the antibiotic he felt would be adequate to treat the infection. She stated even when a urinalysis was ordered he rarely ordered a culture and sensitivity to be done along with it. She acknowledged Resident #75 would not have met criteria for treatment of a UTI based on symptoms alone with out a urinalysis and culture being done to identify the presence of greater than 100,000 colonies of a microorganism being present in the urine sample. 3. A review of Resident #77's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a history of a stroke with hemiplegia and hemiparesis affecting his right dominant side, aphasia, difficulty walking, and need for assistance with personal care. A review of Resident #77's infection report revealed he had a symptom onset date of 06/13/23. The symptom section on the report indicated that he was having increased frequency/ urgency, pain, and hematuria. The section for the infection identification process revealed he had symptoms only. There was no indication a urine specimen had been obtained for a culture and no organisms were identified. The section for infection management revealed he was started on Bactrim DS BID for three days. Additional comments added revealed they were to continue the antibiotic per the resident's attending physician. A review of a urinalysis report for a urine specimen collected on 06/09/23 revealed his urine was positive for nitrites and Leukocyte Esterase. It was the final report and there was no indication that a culture was done to identify the organism involved or a sensitivity report to confirm whatever organism was present, it was susceptible to the antibiotic ordered. On 06/29/23 at 1:35 P.M., an interview with RN #91 confirmed there was not a culture and sensitivity (C&S) done as part of Resident #77's urinalysis. She acknowledged, without a C&S, it was not clear what organism was causing the resident's UTI or if the antibiotic ordered was effective in treating that infection. 4. A review of Resident #235's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a complete traumatic amputation of the left great toe, peripheral vascular disease, and atherosclerosis of a native artery of an unspecified extremity with gangrene. A review of the facility's infection control log for May 2023 revealed he was known to have a soft tissue skin infection with a date of onset as 05/30/23. He was started on both Levofloxacin and Doxycycline. The infection control log did not identify what organism was present that was causing the infection. A review of Resident #235's infection report revealed he had a date of onset as 05/30/23. Symptoms identified under skin included heat, swelling, and redness at the left great toe amputation incision site. Under the section for infection identification process, a specimen was indicated to have been collected for a culture on 05/30/23 at the podiatrist's office. There was no indication of what organism, if any, had been identified as a result of the culture obtained. The section for infection management indicated antibiotics were ordered by mouth that included Levofloxacin and Doxycycline. Additional comments indicated the antibiotics were to be continued per the attending physician. On 06/29/23 at 1:35 P.M., an interview with RN #91 revealed she did not receive a copy of the wound culture that had been obtained at the podiatrist's office as the infection report had indicated was collected on 05/30/23. She stated she called the podiatrist's office and requested the wound culture report, but it was never sent. She stated it was not uncommon for a wound culture to be done at another physician's office or the wound clinic that they could not get a hold of the results. She did not have access to the labs from the local hospital and was dependent on the physician's offices to send them to her. She acknowledged without those C&S reports she could not be certain the antibiotics ordered were effective in treating the organisms causing the infections. A review of the facility's Antibiotic Stewardship Program policy revised 10/24/22 revealed it was the policy of the facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The infection preventionist, with oversight from the DON, served as the leader of the antibiotic stewardship program and received support from the Administrator and other governing officials at the facility. The medical director and attending physicians were to support the program via active participation in developing, promoting, and implementing a facility-wide system for monitoring the use of antibiotics. The program included antibiotic use protocols and a system to monitor antibiotic usage. Antibiotic use protocols included laboratory testing being completed in accordance with current standards of practice. The facility was to use the McGeer's criteria to define infections. Antibiotics orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness.

Based on record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure a resident who was depended on staff for assistance with activities of daily living (ADL's) received the assistance needed with the trimming of his fingernails. This affected one (Resident #52) of two residents reviewed for ADL's. The facility census was 80. Findings include: A review of Resident #52's medical record revealed he was originally admitted to the facility on [DATE]. His diagnoses included heart failure, osteoarthritis, chronic pain, chronic fatigue, weakness, need for assistance with personal care, schizo-affective disorder, and major depressive disorder. A review of Resident #52's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and he was cognitively intact. He was not known to display any behaviors nor was he known to reject care during the seven days of the assessment period. He required a limited assist of one for transfers and ambulation in the hall. Supervision with the assist of one was needed for locomotion on the unit and personal hygiene. Supervision with set up help was needed for bathing. A review of Resident #52's care plans revealed the resident needed assistance with ADL's related to weakness, hypotension, bradycardia, obesity, need for assistance with personal care, lack of physical exercise, chronic fatigue, pain, unsteadiness on feet, and obesity. The care plan was originated on 04/24/19 and was last revised on 04/11/23. Interventions included during bathing/ showers they were to check nail length and trim and clean on bath days and as necessary. The care plan indicated he required supervision to limited assist of one with personal hygiene. A review of Resident #52's shower documentation under the task tab of the electronic health record for the past 30 days (05/31/23 to 06/24/23) revealed the resident was scheduled to receive showers every Wednesday and Saturday on the day shift. He was documented as last receiving a shower on 06/24/23. There was nothing under the task tab for the aides to document if nail care had been provided. On 06/26/23 at 10:04 A.M., an observation of Resident #52 noted him to be lying in bed in a supine position. His fingernails on both hands were long and in need of being trimmed. Some of the nails had a dark colored substance under the nails. An interview with the resident, at the time of the observation, revealed he would like to have his nails trimmed and needed the staff's assistance to do so. Subsequent observations on 06/27/23 at 8:45 A.M. and 06/28/23 at 8:35 A.M. noted his fingernails to remain long and in need of being trimmed. On 06/28/23 at 11:38 A.M., an interview with State tested Nursing Assistant (STNA) #155 revealed Resident #52 required some assist with his adl's but did a lot for himself. They provided him with set up help for his showers. The resident was compliant with showers and had already been showered that day. He was asked what care was provided as part of the resident's bathing activity and indicated it included nail care. He was then asked if he had checked the resident's nails that morning and indicated he did. He did not feel they needed to be trimmed when he looked at them. He was asked to check the resident's fingernails and accompanied the surveyor back to the resident's room. The resident was walking out of his room to go to the dining room for lunch. STNA #155 checked his fingernails and confirmed they were long and in need of being trimmed. He asked the resident if he wanted them trimmed and the resident told him he did. He then stated the resident would usually tell them when he wanted them trimmed. A review of the facility's Nail Care policy revised 01/01/22 revealed the purpose of the policy was to provide guidelines for the provision of care to a resident's nails for good grooming and health. Routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, would be provided on a regular basis and as the need arises.

Based on record review and interview the facility failed to provide an appropriate diagnosis for the use of an antipsychotic. This affected one resident (Resident #7) out of five residents reviewed for unnecessary medications. The facility census was 80. Findings include: Record Review of Resident #7 revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: dementia, atherosclerosis, hypothyroidism, spondylosis, anxiety, Alzheimer's disease, mood disorder, polyneuropathy, osteoporosis, falls, lack of coordination, cognitive communication deficit, and muscle weakness. Review of the Minimum Data Set(MDS) assessment completed on 06/16/23 revealed this resident is rarely/never understood. Review of Physician Orders revealed this resident is receiving the following medication: Seroquel 50 milligram (mg) 1 tablet by mouth three times a day for unspecified dementia. Review of current resident diagnoses revealed this resident does not have an active diagnosis of psychosis in the medical chart. Interview with the Director of Nursing on 06/27/23 at 10:15 A.M. verified unspecified dementia is an unacceptable diagnosis for the use of Seroquel.

Based on medical record review, resident and staff interview and facility's hydration review, this facility failed to ensure residents with a fluid restriction was monitored for appropriate fluid intake. This affected one (Resident #38) of one resident reviewed for fluid intake. Facility census was 80. Findings include: Review of the medical record for Resident #38 revealed an initial admitted [DATE] and a re-entry date of 03/01/22. Diagnoses included end stage renal disease, heart failure, and difficulty in walking. Review of the plan of care created 03/26/21 and revised 04/27/23 revealed Resident #38 had a potential fluid volume overload related to kidney failure, dialysis, non complaint with fluid restrictions such as drinking pop as desired, wants cups with ice and-or water at bedside. Interventions included to administer medication as ordered and monitor, provide diet as ordered, encourage that all snacks and beverages offered at activities comply with diet and fluid restrictions, monitor vital signs, and monitor for fluid overload and report, resident is on fluid restriction. Review of Resident #38's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision making abilities. No behaviors were noted with this assessment review. Resident #38 required supervision with set up assistance only for eating. Resident #38 was noted to be 61 inches tall and weighted 208 pounds with a noted weight gain. Resident #38 was noted to receive diuretics daily as well as dialysis services out side the facility. Review of the behavior charting for Resident #38 revealed no behaviors related to the resident being non-complaint with the physician ordered fluid restriction. Review of Resident #38's progress notes from 04/01/23 through 06/28/23 revealed no documentation indicating this resident was non-complaint with the physician ordered fluid restriction. Review of physician order revealed orders for Dialysis on Monday, Wednesday, and Friday with a chair time of 9:30 A.M. and pick up time varies between 8:45 A.M. and 9:15 A.M. A no added salt, renal diet, with regular textured food, and thin liquid consistency. 1500 milliliter (ml) fluid restriction, 360 ml with breakfast, 240 ml with lunch, 360 ml with dinner, 120 ml at bedtime, and nursing to provide 210 ml twice a day with medication administration. Torsemide 100 milligrams (mg) tablet, give 0.5 tablet daily for fluid overload related to end stage renal disease. Review of Resident #38's fluid intake for April 2023, May 2023, and June 2023, revealed most days of the month, Resident #38 was noted to go over her physician ordered fluid restriction of 1500 ml daily from the recorded fluid intake from meals and medication administration. Observation on 06/26/23 at 11:00 A.M. of Resident #38's room revealed two styrofoam cups sitting on the bedside table, noted to be filled with clear fluids. Observation on 06/27/23 at 12:00 P.M. and again at 3:00 P.M. of Resident #38's room revealed one styrofoam cup filled with a clear fluid and a full unopened can of soda sitting on the bed side tablet. Interview on 06/28/23 02:48 PM with the Director of Nursing (DON) revealed when the nurses complete their charting, they try to keep the behaviors charting the same as what the STNA chart on and they are limited on how many target behaviors they can put in the chart for the nurses to chart on each shift. Due to this, there is not a specific behavior to monitor related to being non-compliant with her fluid restriction. The DON claimed that Resident #38 will get her own fluids and her roommate will also give her cans of soda to drink almost daily. The DON claimed that dietary told her that even today the resident requested a extra bowl of chicken broth even though she was on a fluid restriction. The DON confirmed Resident #38's lacked documentation indicating the resident was non-complaint with the physician ordered fluid restriction and had been having a noted weigh gain. Review of provided policies and procedures revealed the facility did not have a policy and procedure related to fluid restrictions.

Based on record reviews and interviews the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed to reflect physician documentation of contraindications to Gradual Dose Reductions (GDR's). This affected two residents (#31 and #42) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 80. Findings include: 1. Record review for Resident #43 revealed this resident was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypercapnia, anemia, dependence on supplemental oxygen, bipolar disorder, adult failure to thrive, shizoaffective disorder, contracture of left hand and elbow, muscle wasting, tremor, and muscle weakness. Review of the significant change MDS assessment, dated 06/20/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility and toileting, to require extensive assistance from one staff member for eating, and to be dependent upon two staff members for transfers. This resident was assessed to have received antipsychotic medications on a daily basis and to not have the physician document a GDR as being clinically contraindicated. Review of the pharmacy recommendation, dated 11/30/22 and signed by the physican on 12/02/22, revealed a GDR was contraindicated at the time. Review of the quarterly MDS assessment, dated 12/06/22, revealed this resident was assessed to have not had the physician document a GDR as being clinically contraindicated. Review of the quarterly MDS assessment, dated 01/10/23, revealed this resident was assessed to have not had the physician document a GDR as being clinically contraindicated. Review of the quarterly MDS assessment, dated 04/02/23, revealed this resident was assessed to have not had the physician document a GDR as being clinically contraindicated. Review of the quarterly MDS assessment, dated 06/05/23, revealed this resident was assessed to have not had the physician document a GDR as being clinically contraindicated. Interview with MDS Nurse #71 on 06/26/23 at 10:40 A.M. verified the physician had documented a GDR as being contraindicated on 11/30/22 and the contraindication had not been documented on any of MDS assessments following the documentation. 41271 2. Review of the medical record for Resident #31 revealed an admitted [DATE] and re-entry on 08/04/18. Diagnoses included schizoaffective disorder bipolar type, cognitive communication deficit, anxiety disorder, and recurrent major depressive disorder. Review of the pharmacy recommendation, dated 02/14/23 revealed a GDR was contraindicated at the time due to the resident with a good response, maintain the current dose. Review of Resident #31's quarterly MDS 3.0 assessment dated [DATE] revealed the resident experienced long and short term memory problems and a severely impaired cognition for daily decision making abilities. Resident #31 was noted to display verbal behaviors directors others multiple times a week. Resident #31 was noted to be receiving antipsychotic, antianxiety, and antidepressant medication 7 days a week. This resident was assessed to have not had the physician document a GDR as being clinically contraindicated. Interview with DON on 06/29/23 at 1:00 P.M. verified the physician had documented a GDR as being contraindicated on 11/30/22 and the contraindication had not been documented on any of MDS assessments following the documentation. Review of the Centers for Medicare and Medicaid Services (CMS) Long Term Care (LTC) Resident Assessment Instrument (RAI) 3.0 Users Manual Version 1.71.0, dated 10/2019, revealed the steps for assessment included: 1. Review the resident ' s medication administration records to determine if the resident received an antipsychotic medication since admission/entry or reentry or the prior OBRA assessment, whichever is more recent. 2. If the resident received an antipsychotic medication, review the medical record to determine if a gradual dose reduction has been attempted. 3. If a gradual dose reduction was not attempted, review the medical record to determine if there is physician documentation that the GDR is clinically contraindicated.

Based on review of resident medical record, facility's self-reported incident report, facility's abuse policy and procedure, staff personnel file, and staff interview, this facility failed to ensure residents were free from verbal and physical abuse while receiving assistance with care by a staff member. This affected one (Resident #25) of two residents reviewed for abuse. The facility census was 80. Findings include: Review of the medical record for Resident #25 revealed an admitted [DATE] and a re-entry date of 07/01/20. Diagnoses included multiple sclerosis, dementia with behavioral disturbances, need for assistance with personal care, contracture of the right hand, and schizoaffective disorder bipolar type. Review of the plan of care dated 05/09/17 and revised 10/11/19 revealed Resident #25 displayed behaviors including attention-seeking related to resident has repetitive behaviors such as combing hair, wanting ice, and tying of shoes. Interventions included, cognitive/communication skill permitting, discuss behavior with resident, explain reinforce why behavior is inappropriate and unacceptable, medication as ordered. Review of the plan of care dated 01/23/19 and revised 08/29/22 revealed Resident #25 has at times physically aggressive or agitated related to poor impulse control, anger, depression, a history of harm to others, attention seeking obsessive behavior such as asking for hair to be combed, seeking medications, change of clothes, shoes, hoarding attends from other residents territorial, will rip attends to be changed when no sign of incontinence are evident, gets frustrated with staff when these request can not be attended to in residents when asked, request for lotion to be applied infrontal periarea, resident will place object in depends and in private orifices, noncompliant with pericare, will pull as tight as she can on shoes strings prior to letting staff tie them, history of altercations with other residents stacking things high up close to ceiling and heating vent. Resident will hide items in bags of chips or in depends while it is on. Interventions include to complete 15 minute checks, administer medication as ordered, provide physical and verbal cues to alleviate anxiety, redirect , refer to inpatient psych as needed, when becomes agitated, and intervene before agitation escalates. Review of Resident #25's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating an severely impaired cognition for daily decision making abilities. Resident #25 was noted to display physical and verbal behaviors directed towards others 4 to 6 days a week. Resident #25 was noted to require extensive assistance from two staff members for transfers, dressing, personal hygiene, and required physical help in part of bathing from two staff members. Resident #25 was noted to display impairment to one upper and one lower extremities and required the assistance of a wheelchair for mobility. Resident #25 was receiving antipsychotic, antianxiety, and antidepressant medication seven days a week. Review of Resident #25's physician orders included a treatment order dated 06/15/23 Apply Betadine to abrasion on top of right hand and leave open to air till area is healed. Review of facility's self-reported incident report tracking #236067 dated 06/14/23 revealed an allegation of physical abuse to a resident with the suspected or alleged perpetrator being a facility staff member. Summary of incident included, State tested Nursing Assistant (STNA) #193 was giving Resident #25 a shower along with STNA #199. STNA #193 reported that Resident #25 was agitated prior to shower due to not meeting her needs on her timeline, resident was wanting ice right then and resident was instructed she would get her more after her shower, but did have ice currently in her cup. During the shower Resident #25 became agitated due to wanting her nail care completed right then when she was getting shower, staff told her they would get her nail care after shower was completed. STNA #193 stated words were exchanged between STNA #199 and Resident #25, but couldn't remember what was said and then Resident #25 became more combative. STNA #193 then reported STNA #199 grabbed Resident #25's left wrist and was jerking it back and forth and yelled at Resident #25 I'll fuck you up. During the interview with STNA #199, she denied grabbing the residents wrist, she did report she placed her arm over Resident #25's arm to prevent this resident from hitting her and also did report she was yelling and saying curse words but didn't remember what exactly was said. Skin assessment and pain assessment completed, no pain noted. Did note bruising and abrasion noted to right hand, 3rd and 5th digits, resident was combative with care and the right arm is affected. STNA #193 reported that STNA #199 did not do anything with the right arm, and that Resident #25 was combative and swinging body around and right hand likely hit the shower chair. Resident #25 has a BIMS of 03, resident was interviewed on the night of the incident with no issues noted or any remembrance of situation, Social Services then interviewed the following day with no issues noted as well, Medical Director and Representative aware. STNA #199 was suspended pending investigation. Skin assessment completed on all residents with no issues noted, all alert and oriented residents were interviewed with no issues noted with STNA #199. A whole house education was provided for abuse, and how to address behaviors. Social Services following Resident #25 to see if any emotional or physical issues regarding the situation. Currently Resident #25 is continuing Activities of Daily Living (ADLs), going out to smoke, and coming out of personal room. Shows no signs of any distress regarding the situation. Area to 5th digit to right hand is now resolved and the area to the 3rd digit is now a scab. Reviewed STNA #199's personnel file with no findings. Facility substantiated accusation of verbal abuse, facility unable to determine if physical abuse occurred. As a result of the investigation, the facility has done the following: Reviewed STNA #199's personnel file with no findings, education provided for abuse and how to handle behaviors appropriately, Social Services monitored Resident #25. Skin assessments completed on all residents and interviews with all alert and oriented residents. Staff member STNA #199 was terminated from the facility. Review of the Statement of Witness document dated 06/14/23 created by STNA #193 revealed, STNA #199 and I were going to give Resident #25 a shower prior to going into the shower room, Resident #25 was at the ice cart, she was asking for ice before she got into the shower room. I attempted to redirect Resident #25 by explaining that she will have a fresh cup as soon as we were finished with her shower. Resident #25 became agitated with the situation and screamed, I hate you. Resident #25 then locked her wheelchair brake, STNA #199 then grabbed Resident #25's chair while the brakes was locked and yanked the chair backwards to take her to the shower room while in the shower room, I turned the water on and moved the shower chair. STNA #199 began taking resident #25's shoes and socks off, but while doing so she ripped then off of her feet and was very rushed. STNA #199 then yanked Resident #25's shirt up her back and pulled it forcefully over her head. It was time for Resident #25 to stand and STNA #199 was being aggressive with her. STNA #199 pushed Resident #25's wheelchair to the wall, where the shower bar is located aggressively and with force. STNA #199 failed to look or check to see if Resident #25's affected foot was in a safe position to transfer, STNA #199 continued to push the wheelchair close to the wall which caused Resident #25's affected foot to bend further against the wall. I told STNA #199 that her foot was against the wall, she then forcefully angled the wheelchair correctly. All while this occurred, STNA #199 seemed extremely hostile and rushed. STNA #199 instructed Resident #25 to grab onto the shower bar to pull herself to stand. STNA #199 stated she acts like she can't do anything for herself. I assisted Resident #25 to stand to transfer to the shower chair. Once in the shower chair, something happened between Resident #25 and STNA #199 that triggered and argument. Everything happened so quickly. They became physical with one another. Resident #25 swung her fist multiple times at STNA #199, while Resident #25 was swinging her fist, STNA #199 grabbed her left arm many times. STNA #199 began scramming and drew her fist back at Resident #25 and stated I'll fuck you up. Resident #25 made contact with STNA #199's upper body. STNA #199 then jerked Resident #25's arm and screamed at her. I can not remember what was said again, everything escalated so quickly. I was so overwhelmed and I intervened. I started shouting stop! stop! I help my hand up and attempted to place my arm between the two of them. I was able to hold Resident #25's hand which resulted in Resident #25 grabbing my arm and digging her nails into my arm. STNA #199 tried to get Resident #25 off of my arm, which I told her that Resident #25 was fine, that she needed to calm down. STNA #199 again grabbed Resident #25's arm and threw it down. While dressing Resident #25, I saw the open area to her right hand and a red mark that resembled the material from the shower chair on her right shoulder. After leaving the shower room, STNA #199 was telling everyone about how she was going to hit Resident #25. Shortly afterwards during nail care, STNA #199 acted as if nothing happened. Review of Statement of Witness document dated 06/14/23 created by STNA #199 revealed, We took Resident #25 to the shower. When in the shower room, she began to yell about wanting ice, we told her we could get her ice after her shower since we were taking her to bed afterward anyway. As well were undressing Resident #25, she began to insist on brushing her hair, she puts the brush back on her chair, I go to move the brush so that we can get her up into the shower chair. Resident #25 grabs the brush and attempts to hit me with it, she wanted it to stay on the chair arm. I managed to get the brush from her and then she calms down. Then as we begin to shower her again she mentions she wants nail care and we tell her we did not have the stuff to do it in the room but that we would find it after we are done in the shower room. She continues to obsess over nail care (repeatedly asking), we told her again we could not do it in that moment, she began to swing her arms and attempt to hit, she starts grabbing my clothes and hitting at the other aide in the room, at that time, she was wet and covered in soap, we were trying to calm her down. When starting peri care, resident was digging in between her legs, I asked her to mover her hand so that I can clean her. I go to use a rag to wipe her, I mention to her that her nails will cause more infections/irritation to her areas and I needed to wash it, she again asks for nail care and gets aggressive again when we tell her we could not do it in that moment. After shower was over we push the chair up to the rail for her to stand for transfer and she began to get aggressive again and swats at my face, I raise my arm to guard myself and the other aide was also trying to put her arm out to guard her from hitting. Resident #25 grabs the aids arm tightly and would not let go. I tell her we cannot help her if she is going to hit and scratch us. We finally get her calm and she is safely transferred and dressed. After leaving the shower room, I did nail care for her and she was calm. We then took her to her room and helped her to bed. Resident #25 had multiple outburst in the shower room any time she was told we couldn't do something or asked her to wait for us to do a certain task. She hit, scratched, grabbed, and yelled the entire time, but after she was out of the shower room, she calmed down. Review of the Statement of Witness document created by Licensed Practical Nurse (LPN) #145 revealed that approximately 10:00 P.M. on 06/14/23, I was seated at the nurses station charting when STNA #199 came out of the shower room with Resident #25 and approached the nursing station saying that Resident #25 was hitting her in the shower room. STNA #199 stated that she drew her fist back at her (while demonstrating what she did) and stated that she told Resident #25 If you hit me one more time, I'm going to fuck you up. I did not physically see her harming resident nor did I hear her say anything to the resident. This is what STNA #199 stated to me, LPN #77, STNA #133, and STNA #5 following Resident #25's shower. Review of the Statement of Witness document dated 06/14/23 at 10:00 P.M. created by LPN #77 revealed, I was sitting at the nurses station when STNA #199 came up yelling in a loud voice saying If Resident #25 tries to hit me one more time, I told her I would fuck her up. She also said she drew her fist back at her in the shower room. I did not visually see anything done or said to Resident #25, but this was what I witnessed from STNA #199. Review of the Statement of Witness document dated 06/14/23 created by STNA #133 revealed, STNA #199 was talking about when she was showering Resident #25 that she said If you hit me one more time, I'm going to fuck you up and stated that she pulled her fist back. Review of the Statement of Witness document dated 06/14/23 created by STNA #5 revealed, I was up at the nurses station when STNA #199 came out of the shower room with Resident #25 and stated she told resident If you hit me one more time, I'm going to fuck you up, and she said she pulled her fist back. Review of the personnel file for STNA #199 revealed a hire date of 04/15/21 and the last day worked was 06/14/23. STNA #199 was noted to have received education including Caring for Residents with Dementia on 04/26/21. All required background and abuse checks had been completed with no noted concerns. Interview on 06/29/23 at 1:30 P.M. with the Director of Nursing confirmed the noted incident between STNA #199 and Resident #25 had occurred and was investigated immediately upon being reported. STNA #199 was suspended pending investigation and was later terminated from the facility. STNA #199 was reported to the appropriate agency regarding suspected abuse. Resident #25 was assess and noted to have a scratch to the right hand on the 3rd digit and 5th digit. Review of the incident revealed STNA #199 had grabbed onto Resident #199's left hand and not the right hand so it was difficult to determine what the cause was for the injury to the right hand. Continue monitoring of Resident #25 revealed no concerns or issues regarding the incident. Review of facility policy titled Abuse, Neglect and Exploitation, dated 10/24/22 revealed Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Physical Abuse includes, but not limited to hitting, slapping, bunching, biting, and kicking. It also include controlling behavior through corporal punishment. It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. This deficiency represents non-compliance investigated under Complaint Number OH00143456.

Based on medical record review, interview, review of facility's Self-Reported Incidents, and review of the facility's abuse policy, the facility failed to ensure residents remained free from sexual abuse or sexual contact. This affected two of two residents (Residents #158, #200) of the two residents reviewed for sexual abuse. The facility census was 83. Findings include: Review of Resident #158's medical record revealed an initial admitted [DATE] and a re-entry date of 12/16/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #158's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #158 with a long- and short-term memory problem and a severely impaired cognition for daily decision making abilities. Noted to experience hallucinations and delusions. Requires extensive assistance from one staff member for bed mobility, transfers, ambulation, dressing, toilet use, personal hygiene, and limited assistance from one staff member for eating. No noted impairment to bilateral upper or lower extremities and requires the use of a cane/crutch or wheelchair for mobility. Noted to be frequently incontinent of bowel and bladder function. Noted to be free of any pressure issues or skin injures during this assessment. Review of the plan of care dated 03/16/17 revealed Resident #158 has anxiety related to dementia, lack of control over events, crying inconsolably, stating house was burning down with family in it. Interventions include to acknowledge concerns and give assurance, administer medications as ordered, be non-judgmental, teach relaxation techniques as much as resident is able to comply. Review of the plan of care dated 03/16/17 revealed Resident #158 exhibits socially inappropriate/disruptive behaviors at times related to cognitive deficits, yells out at times, and dementia. Interventions include to provide medication as ordered, observe behaviors and attempt to identify the root cause, psych consult as ordered, remove from public area when behavior is disruptive. Review of the plan of care dated 11/21/18 revealed Resident #158 needs activities of daily living assistance related to [CONDITION(S)], weakness lack of coordination, difficulty walking, [CONDITION(S)], dementia, and need for assistance with personal care. Interventions include to place an alarming stop sign to door, and aid as needed and required. Review of Resident #158's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Monitor target behaviors- tearful/sad, fidgeting restlessness, exit seeking, intrusive, socially inappropriate, resistive to care, hallucinations, delusions, -Stop sign to door, check placement every shift, every evening and night shift. Started 04/26/22 and discontinued on 05/02/22. Review of the progress note for Resident #158 dated 04/26/22 at 11:03 A.M. created by Certified Nurse Practitioner (CNP) #500 revealed, [AGE] year old white female being evaluated for acute visit. Staff state that they found a male resident on top of patient with both of their pants down. Staff states that patient was asleep when they arrived to room. Patient alert and can answer simple questions. Denies any pain. States that she does not remember anything happening. Interview on 05/02/22 at 12:50 P.M. with Resident #158 revealed she could not recall how long she had been a resident at this facility but that she was very happy and liked everyone. Resident #158 denied any issues or concern with other residents or staff members and claimed she felt safe. Resident #158 denied ever having a male resident in her room or touching her inappropriately. Review of the facility's Self-Reported Incident report number 8 dated 04/26/22 revealed, Nurse on staff witnessed Resident #200 leave his room then approximately two minutes later nurse was called to a female residents room where nurse aides walked by and found Resident #200 with his pants down on top of Resident #158. Residents were separated and male resident was removed from the room. Resident #158 had her legs closed and her pants were down to her thighs upon discovery, but resident does have a history of removing her own clothing and walking around. There was no evidence of penetration and no evidence of erection when staff entered the room. Nurse on staff completed a head to toe assessment of Resident #158 with no concerns noted. Resident #158 was noted to have her eyes closed when staff entered the room and did not open eyes until nurse completed the head to toe assessment. Resident #158 did not show any emotional distress or negative outcome. Resident #200 has a Brief Interview for Mental Status (BIMS) score of 4 and Resident #158 has a BIMS of 0. Neither resident was able to recall the incident when interviewed by social services. Resident #200 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident representative and the Medical Director were made aware of the incident. Skin sweeps were completed on residents residing on the same floor as Resident #200 and Resident #158 with no concerns noted. Alert and oriented residents were interviewed that resided on the same floor with no concerns noted. Resident #200 was placed on one on one with staff until sent to inpatient psych. A room change will be completed upon return from the hospital and resident will be assessed wth appropriate interventions implemented to ensure other residents safety. Resident #200 does not have a history of sexual behaviors towards staff or residents. Upon speaking with Resident #200's family, they reported decreased sexual drive for resident when he was home and that resident was unable to obtain an erection. The facility will unsubstantiated the allegation of sexual abuse due to resident is unable to understand the consequences of his behaviors. Continued review of the report revealed that the incident had been reported to the local Sheriff's Department on 04/26/22 to Officer #50 who after receiving the information claimed that they would just log the alleged incident without the need to report to the facility for an investigation and that Resident #158 did not need to be transported to the local hospital for evaluation. The report number was #22-0459. Interview completed with Resident #158 and Resident #200 revealed that neither resident could recall the incident. Review of the statement completed by Certified Nursing Assistant (CNA) #11 dated 04/26/22 , no time noted, revealed, I was walking down the hall and noticed Resident #200 on top of Resident #158. Neither had pants on or briefs and Resident #158's legs were straight and closed. Resident #200 was no top making movements with hips back and forth. I didn't see penetration. I went and got the nurse while other aide attempted to separate them. Review of the statement dated 04/26/22, no time noted, created by CNA #81 revealed, Notified by staff to assist, removed resident from other residents room. Review of the statement dated 04/26/22, no time noted, created by CNA #177 revealed, We were walking down the hall way, when I glanced into Resident #158's room and saw Resident #200 on top of Resident #158. Resident #200 didn't have pants on and Resident #158's pants were down around her thighs. I saw what looked like Resident #200 starting to make movements with his hips. Resident #158's legs were closed. I saw no penetration occurring. CNA #11 notified the nurse as I attempted to separate the two residents. Resident #200 didn't follow commands to get up until the nurse entered the room. Review of the statement dated 04/26/22, no time noted, created by CNA #157 revealed, I was in another residents room from 6:25 A.M. through 6:50 A.M. when I took this resident back to his room, I had to walk past Resident #158's room and other aids were bringing Resident #200 out of the room. Review of the statement dated 04/26/22, no time noted, created by Therapy #300 revealed, I was standing at the nurses station when I seen Resident #200 ambulating in the hallway down towards the dining room. I didn't witness him walk into any rooms. He didn't appear to be agitated at the time i seen him. I was in Resident #158's room about 15 minutes prior to the incident and Resident #200 was not in the room during that time. Review of the statement dated 04/26/22, no time noted, created by LPN #169 revealed, This nurse was alerted by State tested Nursing Assistants (STNA)'s around 6:40 A.M. on 04/26/22 that Resident #200 was in Resident #158's room on top of her. When I entered the room, Resident #200 was naked from he waist down and was on top of Resident #158. Resident #200 seemed to be attempting to have intercourse with Resident #158, he did not have an erection. Resident #158 had her pants pulled down to mid thigh and both of her legs were together, zero penetration was observed. Resident #158 did not have any skin issues, redness, irritation, bleeding or any other indication that penetration had occurred. Resident #158 was unaware of the incident and appeared to be sleeping with eyes closed, breathing easy and even, resident was pleasant upon awaking. Resident #200 had been observed prior to the incident at approximately 6:38 A.M. exiting his room for the first time all shift and was walking down the hallway. Therapy #300 had been in Resident #158's room at approximately 6:25 A.M. and was standing at the desk with this nurse when Resident #200 exited his room at approximately 6:38 A.M. Review of the medical record for Resident #200 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #200's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #200 with a Brief Interview for Mental Status (BIMS) score of 07 indicating an severely impaired cognition for daily decision making abilities. No behaviors noted during this assessment. Resident #200 required supervision with set up help only for bed mobility, transfers, mobility, locomotion, and eating, and required extensive assistance from one staff member for dressing and toilet use. No impairments noted to the bilateral upper or lower extremities and required the assistance of a cane for mobility Review of Resident #200's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #200 was noted to have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 09/08/21 revealed Resident #200 has limited physical mobility related to weakness, lack of coordination. Intervention includes to provide supportive care, and assistance with mobility as needed. Review of the plan of care dated 04/26/22 revealed Resident #200 is resistive to care, displays sexual behavior, and refuses to have clothing changed at times. Interventions include to provided one on one care and give a clear explanation of care before providing it. Review of the plan of care dated 08/31/21 revealed Resident #200 has impaired cognitive function/dementia or impaired thought processes. Interventions includes to administer medication as ordered and communicate with the resident and family members regarding resident's capabilities and needs. Review of the plan of care dated 09/08/21 revealed Resident #200 had a communication deficit related to dementia, hearing loss, and cognitive communication deficit. Intervention includes to ensure and provide a safe environment, and keep call light in reach. Review of Resident #200's progress notes from 08/31/21 through 05/09/22 revealed no evidence of Resident #200 displaying any inappropriate behavior including any sexual behavior towards another resident or staff member. Interview on 05/02/22 at 5:00 P.M. with the Administrator and the Director of Nursing (DON) regarding the Self Reporting Incident (SRI) number 8 dated 04/26/22 revealed, last Tuesday, 04/26/22, Therapy #300 was at the nurses station and observed Resident #200 ambulating down the hall which is a normal routine for this resident, she went back to charting and did not see where he went. A few minutes later LPN #169 claimed to heard the staff yelling for her so she ran down to Resident #158's room, where the other staff were yelling from. Upon entering the room LPN #169 claimed she saw Resident #200's pants were completely off and Resident #158's pants were down to her hips and Resident #200 was laying on top of Resident #158. The time frame from when LPN #300 says she last saw the Resident #200 to when LPN #169 heard another staff member yelling for help in Resident #158's room was no more than five minutes. LPN #169 claimed that when she saw Resident #200 on top of Resident #158, she noticed Resident #158's legs were tightly closed together, not spread open, none of the staff claimed to see any penetration, and LPN #169 claimed she did not see any erection. When the aides attempted to get Resident #200 off of Resident #158 by saying his name, he just laid there and did not move. When LPN #169 entered the room and yelled out Resident #200's name, he jumped up and ran out of the room and did not say anything. Resident #200 has never displayed any type of behavior like this before and has a Brief Interview for Mental Status (BIMS) score of 04 indicating he has an severely impaired cognition for daily decision making ability. Staff who witnessed the incident claimed that during the incident, Resident #158 appeared to be asleep with eyes closed no distress noted. Resident #158 did not wake up until the nurse completed a head-to-toe assessment. Resident #158 was free of redness, bleeding, or skin issues. Resident #200 was placed on one on one observation with a staff member until he could be seen by psych, who ordered for Resident #200 pink slipped to the hospital for a psych evaluation. Resident #200 was admitted to the facility in August of 2021 and has been nothing but pleasant and has displayed no previous sexual or inappropriate behaviors towards staff or other residents. The Administrator claimed contact with Resident #200's sister was made to informed her of the incident who claimed she was very surprised by this but did inform the facility that Resident #200's wife, but was not residing at the facility, was still alive and that maybe he mistaken Resident #158 for his wife. Resident #200's sister also revealed that Resident #200 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility contacted the local police department, and after telling them what had occurred, had decided to just take a verbal report and to log the incident but not to come out to the facility. Staff continue to monitor and assess Resident #158 with no negative outcome thus far. The very day the incident occurred, the CNP #500 was in the facility and assessed Resident #158 and claimed no negative outcome was noted. Review of facility policy titled Abuse, Neglect and Exploitation, dated 07/28/20, revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of residents property. Sexual abuse is non-consensual sexual contact of any type with a resident. This deficiency substantiates Master Complaint Number OH 328.

Based on record review, observation, resident interview, staff interview and policy review, the facility failed to ensure a resident received assistance with the application of an orthotic device to prevent contractures. This affected one (Resident #64) of three residents reviewed for contractures. Harm occurred for Resident #64, when he was discharged from occupational therapy with orders for a restorative nursing program for splint/ brace application, the restorative nursing was not performed resulting in worsening of a contracture to his left wrist/ hand. Findings include: A review of Resident #64's medical record revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #64's Occupational Therapy (OT) Discharge Summary for dates of service 04/28/21 through 06/24/21 revealed Resident #64 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . They had been working to increase his passive range of motion (PROM) to his left wrist in order to improve his dexterity skills, improve managing fastenings during dressing and improve functional grasps/ release of activities of daily living (ADL) items. He was able to safely wear a resting hand splint and a wrist cock-up splint on the left wrist and hand for up to two hours with minimal discomfort. Discharge recommendations for Resident #64 included discharging him with restorative nursing program (RNP) in place for PROM program and left upper extremity (UE) Wrist Hand Finger Orthosis (WHFO). The RNP established/ trained included gentle PROM to LUE to tolerance in wrist extension, digit flexion/ extension and general ROM to tolerance. The splint/ brace program established/ trained included the use of a left comfy splint WHFO for two to four hours during the day shift. His prognosis to maintain his current level of function was excellent with participation in RNP. A review of an OT Functional Maintenance Program referral form dated 06/22/21 revealed the occupational therapist had made a referral to RNP for a splint/ orthotic to the left hand/ wrist for two to four hours. The referral indicated the program should start on 06/25/21. A review of Resident #64's active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order date originated on 06/24/21. A review of Resident #64's care plans revealed he had a care plan in place for having a contracture of his hand. The goal was for him to remain free of any complications. Interventions included monitoring/ documenting the presence of a contracture formation/ joint shape changes. He also had a care plan in place for the use of a splint/ brace. The care plan indicated Resident #64 would benefit from a splint program for impaired physical mobility. The date the care plan was initiated was on 06/23/21. The goal was for the affected joint ROM to be maintained as evidenced by Resident #64 tolerating the splint/ brace without discomfort and would not demonstrate a decline in ROM through the review date of 02/08/22. The interventions included assisting Resident #64 with the application and use of a left hand/ wrist splint for two to four hours a day, six to seven days weekly. That intervention was initiated on 06/23/21. They were also to observe for changes in joint mobility which may indicate the need for splint/ brace. They were to refer to therapy as indicated. A review of Resident #64's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had adequate hearing and clear speech. He did not have any communication issues and was cognitively intact. He was known to have hallucinations, delusions, and verbal behaviors directed at others. He was not known to reject any care. Resident #64 required an extensive assist of two for bed mobility, transfers and dressing. He required supervision with the assist of one for ambulation and locomotion on and off the unit. He was coded on the MDS as having a functional limitation in range of motion (ROM) on one side of his upper extremity. Physical therapy (PT) and occupational therapy (OT) minutes were not indicated to have been provided. Restorative nursing programs coded to have been provided included active ROM and splint or brace assistance during five of the seven days of the assessment period. A review of Resident #64's treatment administration record (TAR) for November 2021 revealed the nurses were initialing the TAR to indicate Resident #64 was wearing a WHFO to his left hand for two to four hours on day shift. The nurses were indicating the WHFO was being worn daily and was last documented as having been worn on 11/18/21. A review of Resident #64's electronic health record (EHR) revealed the RNP for splint/ brace assistance was being documented under the task tab of the EHR. A Plan of Care (POC) Response History for the past 30 days revealed the aides were documenting the use of a splint/ brace and was assisting with the application and use of left hand/ wrist splint two to four hours daily six to seven days weekly as part of a level III restorative program. They documented the splint/ brace was applied 20 of the 30 days during that 30 day period. It was indicated the splint/ brace was not applied (did not occur) eight of the 30 days. It was not indicated to have been refused by the resident at any time during the past 30 days. A review of a therapy quarterly screening for Resident #64 dated 09/27/21 revealed the resident did not wear an UE orthotic/ splint. A ROM assessment was not completed as part of that screen. There was no evidence of any communication/ concerns being reported on Resident #64's behalf. On 11/17/21 at 11:13 A.M. and again at 2:56 P.M., observations of Resident #64 noted him to be in his room in bed with a contracture noted to his left wrist and deformities noted to the digits on his left hand. He was not noted to be wearing a WHFO during either observation. An interview with Resident #64, at the time of the first observation, revealed he did not have a contracture of his left wrist/ hand at the time he was admitted to the facility. He reported he did not have any problems with that until it started sometime in March 2021. He thought it may have been related to a stroke he had at that time. On 11/18/21 at 11:10 A.M., a follow up observation of Resident #64 noted him to be in bed without the WHFO in place to his left wrist/ hand. His left wrist remained contracted and the fingers to his left hand remained deformed. Findings were verified by State tested Nursing Assistant (STNA) #87. On 11/18/21 at 11:15 A.M., an interview with STNA #87 revealed she was aware Resident #64 had a contracture to his left wrist/ hand. His contracture happened around the time he got Covid-19 in the month of March or April 2021. She stated they were doing ROM exercises for him but he did not tolerate it very much. He had previously been receiving therapy. She did not mention the use of a splint/ brace to his left wrist/ hand. She was asked if he was supposed to wear one and if he had one available in his room for use. She was not aware he was supposed to have a WHFO to his left hand and could not locate one in his room. On 11/18/21 at 11:20 A.M., a follow up interview with Resident #64 revealed the WHFO had not been used since July 2021, when he was in therapy. He denied anyone had been putting it on him on a daily basis for two to four hours each day as per his orders. He indicated he would not be opposed to wearing it if it was offered to him. He thought he could probably tolerate wearing it for an hour or so but not sure if he could tolerate the two to four hours it was ordered to be used for. On 11/18/21 at 11:24 A.M., an interview with Registered Nurse (RN) #84 confirmed Resident #64 had an active order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that order had been in place since 06/25/21. She also confirmed the nurses were signing off the TAR to reflect the WHFO was being used daily for two to four hours per day as ordered. She indicated the nurse had even signed it off for 11/18/21 showing it had been applied despite Resident #64 reporting he had not worn it since July 2021. She checked Resident #64's room and verified he did not have a WHFO in his room. She checked laundry as well and did not locate it there either. On 11/18/21 at 11:30 A.M., an interview with Certified Occupational Therapy Assistant (COTA) #108 revealed Resident #64 was wearing an WHFO to his left hand/ wrist when he was receiving therapy back in June 2021. She reported they attempted this with him to help with stretching and to prevent further contracting of his left wrist. She stated they had trouble getting him to wear it for the full time and indicated he was wanting it applied only when he was in therapy. He was hesitant about having it in his room because he did not want it to get misplaced. She confirmed it was the intent of therapy for him to continue to use it after his therapy ended as he tolerated. She stated there would have been a referral made to restorative nursing for splint/ brace application/ assistance. On 11/18/21 at 12:00 P.M., an interview with the Director of Nursing (DON) revealed Resident #64's plan of care did include the use of a WHFO for his contracture to his left wrist. She acknowledged the nurses were initialing the TAR's to reflect the WHFO was being applied daily, even though it was not observed to be on during observations made during the past couple of days, and Resident #64 denied it had been used since July 2021. She also acknowledged the WHFO was not located when the STNA and RN had searched his room for it. She confirmed the facility did have a functioning RNP and included a restorative nurse and an aide that implemented that program. On 11/18/21 at 12:18 P.M., an interview Restorative Aide #44 revealed the floor aides were the ones who were responsible for applying the residents' splints if ordered to include those that had a RNP in place for such. She denied she assisted Resident #64 with the application of his WHFO to his left wrist/ hand as part of his restorative program. She only assisted him with bicycle peddling type activities, which he did not participate with. On 11/18/21 at 12:25 P.M., an interview with Occupational Therapist #103 revealed she found Resident #64's WHFO in his room. She stated it was in the bottom drawer of a two drawer plastic gray container he had on the floor in his room. It was shoved in the back of the bottom drawer behind some canned goods he stored in the front of that drawer. She stated she remembered putting it in there as Resident #64 was worried about it coming up missing. She stated she tried to put it on Resident #64 but it did not fit him as there had been some changes in his contracture since she last saw him. She reported Resident #64 did not have any deformities previously at the MCP (metacarpophalangeal) joints but now he did. She stated his fingers were more fixed and were flexed now. His wrist was the only thing that was contracted before and he had an increase in tone to his whole hand but could still move his fingers. She stated the ongoing use of his WHFO could have prevented the increase she now noted to his wrist flexion. A review of the facility's policy on Restorative Nursing Programs revised 10/30/21 revealed the goal of restorative nursing included improving and/ or maintaining independence in ADL's and mobility. A level III RNP indicated the resident's goal or highest functional level had been achieved. The goal now became prevention or minimization of functional decline or impact on ADL's. Programs based on technique included splint or brace assistance. The following types of residents could benefit from a restorative program but limited to contracture prevention and/ or management and skills practice/ training in contracture prevention and management. Areas that may indicate a referral to rehabilitation was warranted included end of therapy to continue goal achievement or maintenance and prevention decline. The restorative nursing program was led by the DON or designee. Each facility should establish a monitoring program to assure success. This deficiency substantiates Complaint Number OH 195.

Based on record review, observation and staff interview, the facility failed to ensure nutrition interventions were implemented as ordered for a resident with known weight loss. This affected one resident, Resident #134, of three residents reviewed for nutrition. Actual harm occurred for Resident #134 when the facility failed to provide snacks to the resident as ordered by the dietician to address the identified weight loss and prevent the resident from continuing to lose weight and had a significant weight loss (greater than 5% in one month). Findings include: A review of Resident #134's medical record revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of Resident #134's weights revealed she weighed 117 pounds upon admission. Weekly weights were obtained and she was noted to lose weight since her admission, weighing 115 pounds on 09/16/16 and 113 pounds on 09/23/16. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #134 did not have any communication issues. She had both short and long term memory impairment and her cognitive skills for daily decision making were severely impaired. She did not display any mood indicators such as poor appetite and no behaviors or rejection of care was noted to have occurred. She required supervision with the assistance of one staff for eating. Her height was 60 inches and her weight was 115 pounds. No significant weight loss was noted at that time. A quarterly nutrition assessment dated [DATE] revealed Resident #134's weight was down to 114.9 pounds. Her meal intakes had increased to 65% and she drank about 1300 milliliters (ml) of fluids a day on average. The dietician's note indicated the resident's intake had increased but her weight was down one pound. The dietician thought the weight loss may have been the result of her being on a diuretic, a medication to remove excess fluid. The nutritional plan was to continue weekly weights and implement additional interventions as needed. An interdisciplinary team (IDT) note dated 09/26/16 revealed the IDT team met and discussed Resident #134 in their weekly weight meeting. Resident #134 was noted to have a four pound weight loss over the past two and a half weeks. The plan was to add snacks to the resident's nutritional interventions and to continue to monitor her weight. On 09/26/16, a physician order [REDACTED].#134 to receive snacks at 10:00 A.M., 2:00 P.M. and at bedtime. The order indicated the snacks were added to address the resident's identified weight loss. A review of Resident #134's monthly physician's orders [REDACTED].M., 2:00 P.M. and bedtime were still included as part of her active orders. The monthly physician's orders [REDACTED]. A review of Resident #134's medication administration record (MAR) for October 2016 revealed snacks were to be given three times a day. The MAR also instructed the nurse to record the amount of the snack consumed. The nurses had initialed that the resident received a snack three times daily and indicated 100% of the snack had been consumed three times daily when the snack was provided. There was no indication of any snacks being refused or that less than 100% had been consumed by the resident. A copy of the MAR was requested and obtained at 1:40 P.M. on 10/26/16 prior to the 2:00 P.M. snacks being delivered to the unit or evidence of any being passed. The nurse on duty for day shift on 10/26/16 had already initialed that Resident #134 received her 2:00 P.M. snack and had consumed 100% of it. A review of Resident #134's weight on 10/06/16 revealed she had lost additional weight, weighing 110 pounds. An IDT note dated 10/10/16 revealed the team met again on that date and reviewed the resident in their weekly weight meeting. The dietician reviewed the resident's medical record. The resident was noted to have a 7 lb weight loss. The plan was to add super foods (foods with higher calories/protein) with meals and a nutritious juice with the breakfast meal. They also were going to place the resident at the restorative table for meals as much as she would allow/comply with and to continue with weekly weight monitoring. On 10/10/16, a physician order [REDACTED].#134 to receive super foods with meals and a nutritious juice to be given with breakfast. They were to continue weekly weights for ongoing monitoring for weight loss. On 10/14/16, Resident #134's weight was recorded as 109 pounds which was a significant weight loss of greater than 5% (6.84%) since her admission weight of 117 pounds on 09/09/16. On 10/17/16, an order was given for Resident #134 to be placed on a restorative dining program. A review of Resident #134's current care plan for the potential for nutritional deficits revealed the resident was at risk related to dementia with decreased intakes. The care plan had been initiated on 09/12/16. The goal was for the resident to maintain an adequate nutritional status as evidenced by the resident maintaining her weight. Interventions included providing and serving her diet as ordered. The registered dietician was to evaluate and make diet change recommendations as needed. A review of the nurses' progress notes revealed no evidence of the resident receiving snacks between 10/03/16 and 10/23/16. On 10/26/16 from 1:30 P.M. to 2:20 P.M., Resident #134 was observed sitting on a couch in the hall by the nurses' station. She was observed during that time with no interruption in observations being made. At 2:05 P.M. a tray with snacks arrived on the unit and was placed at the nurses' station. The tray had a variety of snacks to include fruit cups, pudding, supplements and sandwiches. Each snack had a label with the resident's name so the facility staff knew who it belonged to. There was not a snack for Resident #134. The entire snack pass was observed and snacks were passed by a variety of staff members to include the social service assistant, the MDS coordinator and an aide who passed snacks to another hall that Resident #134 did not reside on. The aide assigned to Resident #134's hall was not observed to pass any snacks. All snacks on the tray had been passed by 2:15 P.M. and Resident #134 was not observed to receive one. On 10/26/16 at 2:25 P.M., an interview with Licensed Practical Nurse (LPN) #65 revealed the dietary department delivered the ordered snacks for the 10:00 A.M. and 2:00 P.M. snack pass. She reported the snacks had the names of the residents on them and they were to be passed to that resident accordingly. She stated they documented the acceptance of supplements in the MAR. She indicated snack consumption would be recorded only after they were consumed to reflect the amount that was actually taken. She denied that they would record percentages of the snack taken prior to the snack being given. She denied that she was aware of Resident #134 having had any weight loss and would need to review the weights in the medical record to see if weight loss had occurred. She was unaware if the resident was receiving any snacks or supplements as part of her nutrition interventions without checking the MAR first. She reported she did not think Resident #134 received snacks. She then reviewed the MAR and confirmed snacks were to be given three times a day at 10:00 A.M., 2:00 P.M. and at bedtime. She verified she had marked the MAR to reflect Resident #134 had received a snack at 2:00 P.M. and consumed 100%, despite observations revealing the resident had not received one. She reported the kitchen would have record of the diet slip that showed whether or not snacks had been ordered. On 10/26/16 at 2:30 P.M., an interview with Registered Nurse (RN) #41 revealed when diet interventions such as snacks or supplements were ordered they record them in the diet book kept at the nurses' station. She indicated the yellow copy would then go to the kitchen so they were aware of any diet changes or added nutritional interventions. She verified that the order for Resident #134 to receive snacks three times a day was added to the diet book on 09/26/16. On 10/26/16 at 2:37 P.M., an interview with Dietary Manager #16 revealed he did not have an order for [REDACTED]. He stated if he received the yellow copy of the diet order that added snacks to Resident #134's nutritional interventions he would have added it into the computer and it would be reflected on the diet slip. He confirmed the resident's diet slip only showed the use of super foods with meals and nutritious juice at breakfast. He denied that they would have sent out any snacks from the kitchen for Resident #134 at the ordered times since they were not aware that the order was written. There were extra snacks sent up at bedtime without resident names that the staff could pass out if a resident requested one. He reported for the resident to receive a snack at 10:00 A.M. or 2:00 P.M. someone would have had to call the kitchen and ask for a snack to be sent up since they were not aware Resident #134 was ordered to receive a snack. On 10/26/16 at 3:35 P.M., an interview with State tested Nursing Assistant (STNA) #84, who was the aide assigned to Resident #134's hall, revealed they did not provide snacks to Resident #134 at 10:00 A.M. and 2:00 P.M. as ordered. He indicated he was not aware the resident was supposed to receive snacks at those times. On 10/26/16 at 3:40 P.M., a follow up interview with RN #41 revealed the dietary staff should have been aware of the need for the resident to receive snacks three times a day as ordered on [DATE]. She reported the added nutritional intervention was discussed in the weekly weight meeting in which Dietary Manager #16 was a part of. She confirmed there was no evidence of Resident #134 receiving snacks three times daily since the intervention had been added on 09/26/16. She acknowledged the nursing staff were initialing the MAR and recording that 100% of the snack was consumed when the snacks had not been sent from the kitchen and could not have been passed. She confirmed the resident continued to lose weight before her weight stabilized at it's lowest weight of 109 pounds on 10/14/16 which was a significant weight loss. On 10/26/16 at 4:05 P.M., an interview with the Director of Nursing (DON) confirmed the resident's nutrition care plan did not reflect the use of super foods, nutritious juice at breakfast or snacks three times daily as ordered. She stated she noticed these interventions were not listed when a copy of the care plan had been requested. The interventions were then added.

Based on medical record review, staff interview, and physician interview, the facility failed to promptly notify the physician of a critical lab value for one resident (Resident #92). This resulted in actual harm for Resident #92 when critically high potassium levels required hospitalization . This affected one of three residents reviewed for physician notification. The facility census was 91. Actual Harm occurred when Resident #92 had a critical potassium lab value and the physician was not notified timely. Resident #92 required hospitalized from [DATE]-11/08/15. Findings include: Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment completed on 11/15/15 indicated Resident #92 had moderate cognitive delay. Resident #92 was identified as requiring extensive assistance with bed mobility, toileting, personal hygiene and dressing, requiring limited assistance with transfers, was independent in eating and was documented as being non-compliant with medications, diet and treatments. Review of physicians orders for October 2015 included [MEDICATION NAME] 40 milligrams (mg) every evening for [MEDICAL CONDITION], [MEDICATION NAME] 80 mg every day for hypertension, potassium chloride 20 milliequivalents daily for hypertension, [MEDICATION NAME] 155 units twice daily for diabetes, [MEDICATION NAME] 100 mg twice daily for hypertension, [MEDICATION NAME]per sliding scale before meals and at bedtime, [MEDICATION NAME] 50 mg daily for hypertension, and a regular diet. The physicians orders also included a Basic Metabolic Profile every January and July, Fasting lipid panel every March and September, and a hemoglobin A1C (HgbA1C) every three months to monitor his blood sugar. The physician progress notes [REDACTED].#92's ulcer to his legs were showing signs of improvement and was finishing a second dose of [MEDICATION NAME]. The physician progress notes [REDACTED].#92 blood sugars had been running extremely high and the recent HgbA1C was markedly elevated. The physician assessment on this date described Resident #92 as having no neurological concerns and the swelling to the extremities appeared to be under 'decent' control. The plan of treatment indicated by the physician on 10/18/15 was to finish the course of [MEDICATION NAME], check lab work including a complete blood count, hepatic function and basic metabolic profile on 10/19/15, and increase [MEDICATION NAME] from 150 units twice daily to 155 units twice daily due to his recent HgbA1C elevated at 10.2. Review of laboratory report dated 10/19/15 indicated resident had the following labs drawn per physician order; complete blood count, complete metabolic profile, hepatic function and [MEDICAL CONDITION]-stimulating hormone levels. Review of the lab report dated 10/19/15 at 11:32 A.M. indicated that the physician was notified of the results of the complete blood count as indicated by a notation on the laboratory report stating the physician was notified and their were no new orders. The results of the complete metabolic profile and hepatic function drawn on 10/19/15 revealed a Blood urea nitrogen (BUN) level of 72 mg/Dl(the normal is 6-20 mg/Dl) and Potassium of 6.2 mmol/L 9 (the normal range is 3.4-4.5 mmol/L). The lab report stated they had attempted to notify the facility several times of the elevated level and could not reach anyone. Their was no documentation that the physician was notified of the abnormal BUN or Potassium results. Review of the physician progress notes [REDACTED]. The physician notes indicated that review of the medical record revealed Resident #92's renal function worsened and recommended to send to the emergency room for evaluation. Resident #92 was in agreement to transport to the emergency room . Review of the hospital admission record indicated Resident #92 was admitted with [DIAGNOSES REDACTED]. Resident #92 was hospitalized [DATE] through 11/08/15. The discharge summary from the hospital indicated Resident #92 refused to have any repeat labs drawn at the time of discharge. On 05/23/16 at 1:39 P.M. during an interview with the Director of Nurses (DON) she stated that on 11/01/15 when Resident #92's physician was reviewing the medical record, he noted the potassium level and felt Resident #92 should be sent to the emergency room for an evaluation. The DON stated that she and the Medical Director discussed the situation. She contacted the laboratory and provided them her personal cell phone number to be notified in case of any critical lab values were identified and the facility was unable to be notified. The DON stated that she in-serviced all staff on 11/02/15 regarding the procedure to be followed when labs were drawn and reports obtained. On 05/23/16 at 3:00 P.M. during an interview with Resident #92's physician, who also served as the Medical Director for the facility, reported that the facility would fax lab results to him on days he was working and when he was not in the hospital, they would call him with the results. When asked specifically about Resident #92 lab reports from 10/19/15 he stated that he felt he had been notified of the CBC, however he did not recall receiving a report from the BMP. Resident #92's physician stated that anytime he receives a result with a critical level, he would either have the level repeated immediately at the facility or have the resident transported to the hospital for follow up. Resident #92 physician described the resident as very demanding, non compliant with care, and stated he had ordered the lab work for 10/19/15 due to the multiple doses of antibiotics he had been on due to continued infections in his lower extremities. The physician stated that when he assessed Resident #92 before ordering him to be transported to the emergency room . Resident #93 did not present with signs of [MEDICAL CONDITION], however due to the resident receiving a potassium supplement per order, three diuretics, and his presenting symptoms of continued infection he felt that it would be in the residents best interest to send him to the emergency room . The physician stated that he did speak with the DON and felt that this was an insolated case that had been addressed. The physician stated that he was not aware of any other instances when he was not notified of lab results. Review of the Clinical Laboratory Service Agreement indicated that all critical results shall be telephoned without delay to the appropriate nurse in charge with a follow-up hard copy sent by remote printer or personal delivery. Review of the Facility Policy Test Results Dated 02/09/11 indicated that the resident's Attending Physician will be promptly notified of the results of diagnostic test. A copy of the email obtained from the laboratory provided indicated on 11/01/15 the DON provided them with a cell phone number which was to be notified of all critical lab values. This deficiency substantiates Complaint Number OH 352.

Based on observation, record review, and staff interview, the facility failed to ensure Resident #135's medication regimen was free from unnecessary medications. This resulted in harm to Resident #135 as the resident was sedated and experienced a decline in activities of daily living related to transfers and ambulation. The resident also developed a suspected deep tissue injury (SDTI) pressure ulcer as a result in the decline in condition attributed to the use of unnecessary medication. The facility failed to ensure Resident #121 was adequately monitored related to the use of an anti-psychotic medication. This affected two residents (Resident #135 and #121) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of the medical record for Resident #135 revealed the resident was admitted to the facility 02/28/14 with [DIAGNOSES REDACTED]. The resident did not have any pressure ulcers upon admission and was assessed as being at minimal risk for the development of pressure ulcers. Record review revealed the resident had a physician's orders [REDACTED]. The resident was being monitored for a target behavior of resisting care. An admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) was conducted with a score of seven, which indicated severe cognitive impairment. Review of a physical therapy note on 03/12/14 revealed the resident performed multiple sit to stands from wheelchair to wheeled walker with stand by assistance. Performed about 50 feet with wheeled walker with frequent standing breaks. On 03/17/14 physical therapy documented that the resident had met his gait training goal as the resident had ambulated about 50 feet two times that week. Record review revealed the resident had a hospital stay to replace a gastrostomy tube from 03/16/14 to 03/18/14. Upon readmission on 03/18/14, the resident no longer had a physician's orders [REDACTED]. Review of a physician readmission history and physical, dated 03/27/14 revealed it was documented that the resident just had an inpatient admission at the hospital. He had replacement of gastrostomy tube and they changed his psychoactive medications. Staff and family stated that he had been sedated and difficult to arouse ever since being changed and would like it changed back to the [MEDICATION NAME] which he was on prior. The physician documented that the patient was difficult to arouse. Review of nurse's notes revealed on 03/19/14 at 5:00 A.M. it was documented the resident was not easily aroused when transferred. There was no evidence the physician was aware and there were no further nurse's notes regarding signs of sedation until the physician's history and physical note on 03/27/14. On 03/27/14 the physician discontinued the anti-psychotic medication, [MEDICATION NAME] and restarted the anti-psychotic medication, [MEDICATION NAME] 20 mg twice per day. The physician's note on 03/27/14 did not address what type of behaviors the resident was experiencing to require the use of the anti-psychotic medication at that time. The note only stated that the resident had dementia with behavioral disturbance. Record review revealed the resident had a hospital stay from 04/08/14 through 04/12/14 [MEDICAL CONDITION], altered mental status, and [MEDICAL CONDITION] of the gastrostomy tube site. When the resident returned from the hospital on [DATE] the admission orders [REDACTED]. Review of a pain data and collection assessment dated [DATE] revealed the resident denied any pain or discomfort and none was noted by staff. Review of nurse's notes from 04/12/14 to 04/24/14 did not reveal any documentation of signs of or complaints of pain. On 04/24/14 the physician started the resident on an opioid [MEDICATION NAME] pain medication, [MEDICATION NAME] 7.5 mg three times per day for pain. An MDS completed on 04/17/14 revealed the resident's BIMS score was now a 3. Review of physical therapy notes revealed that on 04/16/14 it was documented the resident lived at home with his wife and was independent with all mobility without device, in and outside home, and was independent with all activities of daily living prior to December 2013. Has been a long term care resident the last few months (admitted [DATE]) and when last seen for physical therapy was hand held assist to maximal assist of two for transfers. Since last on the physical therapy case load (about one month ago), the resident has had decline in range of motion, multiple skin concerns, and overall decline in mobility. On 04/18/14 occupational therapy documented that the resident was very lethargic and difficult to arouse. On 04/24/14 physical therapy documented that the resident was hard to arouse. On 04/24/14 occupational therapy documented that the resident was very lethargic and difficult to remain awake and alert. Unable to arouse during treatment session. On 04/28/14 physical therapy documented that they were unable to arouse patient this date, startle reflex at times. On 04/28/14 occupational therapy documented difficulty arousing resident. Discussed wheelchair concerns with director of nursing (DON). DON concerned patient was poorly positioned and would like patient in a different wheelchair. Educated DON that wheelchair was a good fit for patient when he was not medicated to this extent. On 04/29/14 physical therapy documented the resident attempted sit to stand parallel bars with maximum assist of two and was unable. Patient lethargic and opens eyes at times for standing attempts. On 04/29/14 occupational therapy documented that the patient was very lethargic and difficult to arouse. Observations on 04/28/14 at 9:23 A.M. and 11:15 A.M. revealed Resident #135 was in bed. On 04/28/14 at 12:09 P.M. the resident was taken in a wheelchair to the dining room for lunch. The resident's eyes were closed and his head leaned back. State tested nursing assistant (STNA) #4 attempted to get the resident to wake up but there was no response from the resident. He kept his eyes closed. On 04/28/14 at 12:20 P.M. STNA #5 attempted to wake the resident up. STNA #5 said lets wake up and eat, but there was no response from the resident. He kept his eyes closed. On 04/28/14 at 12:40 P.M. STNA #4 attempted to feed the resident his lunch. The resident's eyes were closed and his head tilted back. He refused to drink from a straw and did not open his eyes. On 04/28/14 at 12:50 P.M. the resident was observed sitting in the wheelchair in the hallway. His eyes were closed and his head was tilted back against the wall. Another surveyor attempted to interact with the resident by talking to him. He did not respond verbally and did not open his eyes. Observation on 04/29/14 at 7:25 A.M. revealed the resident was in bed with his eyes closed. On 04/29/14 at 9:13 A.M. the resident was observed up in the wheelchair in his room. His eyes were closed. He did not open his eyes when his name was called or when he was touched lightly on the shoulder. Observation on 04/29/14 at 11:00 A.M. revealed the resident was up in a wheelchair in therapy. The resident's eyes were closed. At that time, occupational therapy assistant #6 stated the resident had started being more sleepy last week and was awake more prior to that. Observations on 04/30/14 at 9:25 A.M. and 10:43 A.M. revealed the resident was in bed with his eyes closed. Observation on 04/30/14 at 11:50 A.M. revealed the resident was up in a wheelchair in the dining room. The resident's eyes were closed and his mouth open. Observation on 04/30/14 at 2:50 P.M. of the resident's skin revealed that the resident currently had three pressure ulcers including the right outer ankle, the right buttock, and the left heel. The left heel had a four centimeter (cm) by 5.3 cm pressure ulcer with black eschar present. The resident had also developed a new two cm by 1.8 cm purple blister (suspected deep tissue injury) on the right mid outer foot which had not been identified by the facility. Review of the plan of care, dated 03/04/14 and 04/14/14 revealed the resident had a potential for side effects related to [MEDICAL CONDITION] drug use. The goal was for no negative outcomes resulting from the use of the [MEDICAL CONDITION] medications. The interventions included monitoring for periods of lethargy. Review of nurse's notes from 04/12/14 to 05/01/14 did not reveal any documentation regarding the resident showing any signs of sedation. Interview with STNA #7 on 04/30/14 at 2:45 P.M. revealed Resident #135 had been acting more sleepy since he came back from the hospital the last time. He confirmed the resident sits with his eyes closed. Interview with Registered Nurse #2 on 04/28/14 at 2:50 P.M. revealed she was wondering if the pain medication was making Resident #135 more sleepy. She stated that after she gives him the pain medication at 9:00 A.M., then the rest of the day he has his eyes closed. She confirmed she had also given him pain medication at 2:00 P.M. Interview with Physical Therapist #3 on 05/01/14 at 9:30 A.M. revealed Resident #135 had declined in his ability to walk since admission. She stated he was able to walk initially and now can no longer walk. Record review revealed there was no evidence the physician was aware of the resident's continued lethargy and no evidence the resident's medications had been reviewed for possible reductions. This was verified by the DON on 05/01/14 at 10:38 A.M. 2. Review of Resident #121 's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. Review of the April 2014 medication administration records revealed the resident received the medication four times in April 2014, none in March 2014, once in February 2014 and once in January 2014. Review of the consultant pharmacist report, dated 02/18/14 through 02/18/14 the pharmacist documented a recommendation for the resident to have an electrocardiogram (ECG) to monitor the side effects of the medication, [MEDICATION NAME]. The physician's signature on 02/21/14 stated acceptance of the recommendation and to please implement the monitoring plan outlined on the form. No indication of a plan was documented on the form. Record review revealed no evidence the ECG was performed in accordance with the physician order. The only documentation of an ECG performed on the resident was dated 12/11/13, prior to the resident's admission to the facility. On 05/05/14 at 8:21 A.M., interview with the DON revealed an ECG had not been completed for the resident following the recommendation of the pharmacist review, which was accepted by the physician in February 2014.

Based on observation, record review and staff interview the facility failed to ensure adequate interventions were in place to promote pressure ulcer healing and prevent Resident #135 from developing a new pressure ulcer to the foot. This resulted in harm, when Resident #135 developed an unstageable pressure ulcer to the foot. The facility also failed to ensure skin risk interventions were in place for Resident #101 who had a history of [REDACTED]. This affected two residents (Resident #135 and #101) of three residents reviewed for pressure ulcers. The facility identified five residents with pressure ulcers. Findings include: 1. Review of the medical record for Resident #135 revealed the resident was admitted to the facility 02/28/14 with [DIAGNOSES REDACTED]. The resident did not have any pressure ulcers upon admission and was assessed as being at minimal risk for the development of pressure ulcers. The resident had a hospital stay from 04/08/14 through 04/12/14 [MEDICAL CONDITION], altered mental status, and [MEDICAL CONDITION] of the gastrostomy tube site. Review of hospital notes revealed a wound care note on 04/09/14 which stated that Resident #135 had a less than one centimeter (cm) suspected deep tissue injury on the right lateral ankle, a less than one centimeter suspected deep tissue injury on the right lateral foot, and a six by seven centimeter suspected deep tissue injury, which was purple with no breakdown, on the left heel. The note stated the resident's heels were elevated and it was recommended the resident be turned every two hours and keep the heels elevated. A hospital wound care note on 04/11/14 stated Resident #135 now had a suspected deep tissue injury to the right upper buttocks to coccyx. It was noted there was a tear in the center of the pressure ulcer that had scant serous drainage. Around the wound the skin was purple/red. It was again recommended to turn every two hours and elevate heels. The resident was readmitted to the facility 04/12/14. Review of an admission skin assessment dated [DATE] revealed the resident had an eight by 20 centimeter blister on the left heel, a 0.5 by 4.0 by 0.25 centimeter deep Stage II ulcer on the right buttock, and 0.5 centimeter slit on the right outer ankle. No other pressure ulcers were noted on the admission assessment and no further description of the areas were noted on the admission skin assessment. Review of skin grids revealed on 04/12/14 the resident was noted to have an eight by 20 centimeter intact, dark purple/black blister that was described as a Stage I pressure ulcer. (The definition of a Stage I pressure ulcer on the skin grid form was intact skin with non-blanchable redness of a localized area usually over a bony prominence. The definition of a suspected deep tissue injury on the skin grid was a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). On 04/15/14 the skin grid indicated the pressure ulcer on the left heel was a suspected deep tissue injury measuring 6.4 cm by 13.2 cm. On 04/27/14 the skin grid indicated the pressure ulcer on the left heel was a Stage II area measuring five cm by seven cm with no depth listed. (The definition of a Stage II pressure ulcer on the grid was a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.) A second skin grid indicated on 04/12/14 the resident was readmitted with a Stage II pressure ulcer on the right buttock measuring four cm by 0.5 centimeters and was 0.25 centimeters deep. On 04/28/14 the resident was noted with a 4.5 cm by five cm Stage II pressure ulcer on the right buttock that was 0.1 centimeters deep. There was no further documentation or skin grids to indicate any other pressure ulcers present. Upon readmission on 04/12/14, a treatment was obtained from the physician for a dressing to the right outer ankle to be changed every three days. After the admission assessment, there was no further documentation of the size or description of the area. The treatment continued as of 04/30/14. On 04/12/14 the resident was assessed as being at moderate risk for the development of pressure ulcers. On 04/12/14 physician's orders were obtained for an alternating air mattress and to turn the resident every two hours. Review of an interdisciplinary team (IDT) progress note on 04/14/14 revealed the IDT had met to discuss the resident's readmission to the facility. The note was silent to the fact that the resident was readmitted with pressure ulcers. A Minimum Data Set (MDS) assessment completed 04/17/14 indicated the resident had a Brief Interview for Mental Status completed with a score of 3 which reflected severe cognitive impairment. The MDS revealed the resident required extensive assistance from two staff for bed mobility, transfers, toilet use, and personal hygiene, and it indicated that walking had not occurred. A physical therapy progress note on 04/22/14 stated that caregiver education continued with staff regarding positioning while in bed to aide with skin integrity by floating heels. A pressure ulcer risk assessment completed on 04/26/14 indicated the resident was only at a minimal risk of developing pressure ulcers, even though the resident currently had pressure ulcers. Observations on 04/28/14 at 9:23 A.M. and 11:15 A.M. revealed Resident #135 was in bed on his back with his feet and heels resting on a pillow. His heels were touching the pillow. Observation on 04/28/14 at 12:50 P.M. revealed the resident was up in a wheel chair in the hallway, his eyes were closed and his head was leaned back against the wall. The resident was wearing gripper socks on his feet and his feet were resting on the floor. On 04/28/14 at 3:35 P.M. the resident was observed in bed on his back. The resident had on socks and his heels were resting on the mattress of the bed. Observations on 04/29/14 at 7:25 A.M. revealed the resident was in bed on his back. The resident was wearing gripper socks and his heels were resting on the mattress of the bed. Observations on 04/29/14 at 9:13 A.M. and 11:00 A.M. revealed the resident was up in a wheelchair. The resident was wearing socks only and his feet were resting on the floor. On 04/29/14 at 1:50 P.M. the resident was observed in bed on his back. The resident was wearing gripper socks and his heels were resting on the mattress of the bed. Observation on 04/30/14 at 9:25 A.M. revealed the resident was in bed on his back. The resident had a gripper sock on the left foot only. The right foot was bare. His heels were laying on the mattress of the bed. On 04/30/14 at 10:43 A.M. the resident remained in bed on his back. His feet and heels were laying on a pillow with heels touching pillow. The resident continued with only a gripper sock on the left foot and a bare right foot. Observation on 04/30/14 at 2:50 P.M. of Resident #135's skin revealed a Stage II pressure ulcer on the right outer ankle measuring 1.8 cm by 1.4 centimeters. The area was open on one end and was surrounded by a five centimeter diameter red area. Registered nurse (RN) #2 confirmed the area was a Stage II pressure ulcer at the time of the observation. Even though a treatment was being provided to this area, there were no skin grids or documentation regarding a size or description of this area after readmission on 04/12/14. The resident was observed to have a Stage II pressure ulcer on the right buttock measuring 2.8 cm by 2.6 centimeters. The open area was superficial. The open area had a red center and was surrounded by a thin white section which was surrounded by a red open area. The physician's order for a treatment indicated the treatment was to be provided to the left buttock. However, the open area was on the right buttock and not the left buttock. This was confirmed by Registered Nurse #2 at the time of the observation. The resident was observed to have a 6.8 cm by 10.6 centimeter dry blister with a 4 cm by 5.3 centimeter section of black eschar in the center on the left heel. The skin grid on 04/27/14 did not indicate any eschar and stated the area was a Stage II pressure ulcer. The resident was observed to have a 2 cm by 1.8 centimeter purple blister area on the right mid outer foot. Registered Nurse #2 stated this was a suspected deep tissue injury at the time of the observation. There was no evidence that this area had been identified by the facility prior to the treatment observation. Observation on 04/30/14 at 3:30 P.M. revealed staff left the resident's room after finishing the treatments. Resident #135 was observed to be in bed on his right side. The resident had a wedge cushion under his legs but his heels were still touching the mattress on the bed. Review of the plan of care revealed a skin integrity prevention and treatment care plan dated 02/28/14 and revised 03/10/14 and 04/17/14. The plan of care stated the resident was at minimal risk of developing a pressure ulcer per the Braden Risk assessment score and the goal was for the resident to remain free of open areas. The plan of care did not indicate the resident had pressure ulcers on the right outer ankle, right buttock, left heel, or right mid outer foot. The plan of care did not include a turning and repositioning program, did not include the use of the alternating air mattress, and did not address relieving pressure from the heels. There was no evidence that the physician had seen the pressure ulcers or was aware of the eschar present in the left heel pressure ulcer. Review of the facility policy on wound prevention and treatment dated November 1998, revised January 2006 and April 2009 revealed the facility would consider all residents at risk for skin impairment and would implement interventions to prevent the development of pressure ulcers including reducing occurrence of pressure over bony prominences to minimize injury. The policy further stated a skin grid would be completed for each area of skin impairment and updated weekly and if the condition of the skin impairment changes, or with a dressing change. Interview with Physical Therapist #3 on 05/01/14 at 9:30 A.M. revealed Resident #135 had declined in mobility since admission on 02/28/14. She stated the resident was able to walk on admission and was no longer able to walk. She confirmed the staff education on floating the resident's heels. Interview with the director of nursing on 05/01/14 at 8:45 A.M. revealed she had not seen Resident #135's pressure ulcers. She confirmed there were no skin grid for the right outer ankle. She confirmed the left heel would not be a Stage II pressure ulcer if it had black eschar and would be unstageable. She confirmed although the treatment was written for the left buttock, it was actually the right buttock with the pressure ulcer. She confirmed a pressure ulcer to the right mid outer foot was not currently being addressed in the medical record. She confirmed the plan of care did not address the resident had pressure ulcers on the right outer ankle, right buttock, left heel, or right mid outer foot. She confirmed the plan of care did not address how often the resident was to be turned or how to relieve pressure on the heels. She confirmed the facility policy did not address what specific interventions were to be put in place for pressure reduction. 2. Review of Resident #101's medical record revealed a re-admitted 03/04/14 with [DIAGNOSES REDACTED]. Review of Resident #101's admission skin assessment dated [DATE] revealed no evidence of skin breakdown or any type of deep tissue injury (SDTI) to the resident's right heel. Review of Resident #101's skin check shower sheets dated 03/07/14, 03/11/14, 03/14/1403/18/14,03/21/14, 03/25/14 and 03/28/14 on the evening shift revealed no documented evidence of skin impairment to the right heel. Review of Resident #101's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status score of three which revealed the resident exhibited severe cognitive impairment. Resident #101 required extensive assistance from two staff for activities of daily living. Further review of the MDS revealed Resident #101 was coded as being at risk of developing pressure ulcers. Resident #101 had no skin conditions coded on the MDS. Review of Resident #101's physician's orders revealed an order dated 04/08/14 for heel protectors to the resident's bilateral feet. The order indicated to remove for skin care, reapply and apply skin prep to bilateral heels twice daily. Further review of the residents physician's orders revealed an order dated 04/28/14 to float heels off pillows. Review of Resident #101's Braden skin risk assessment dated [DATE] revealed a score of 14 (13-14 moderate risk). Review of Resident #101's progress note dated 04/07/14 revealed the therapy department reported the resident had a bruise to the right heel area. Upon inspection of the right heel the resident was noted to have a SDTI from an old blister. Review of the skin grid revealed the SDTI measured 1.0 centimeter by 1.6 centimeters and was dark brown in color. Further review of the skin grid revealed the primary care physician assessed the right heel and was in agreement with the staging of SDTI. Further review of the skin grid revealed the SDTI to Resident #101's right heel was healed on 04/28/14. On 04/30/14 at 3:45 P.M. RN #11 was observed applying skin prep to the resident's right heel. The area, previously noted to be a SDTI was observed to be healed. On 04/30/14 interview with RN #11 verified the facility's therapy department noted the area to the resident's right heel and notified the nursing department. On 05/01/14 at 2:40 P.M. observation of Resident #101 revealed the resident's heels were not being floated while the resident was in bed as per ordered and care planned. On 05/01/14 at 2:40 P.M. interview with STNA #8 verified Resident #101's heels were not being floated while the resident was in bed.

Based on record review, staff and resident interview, observation, and review of the facility Wound Prevention and Management policy and procedure, the facility failed to provide timely identification and treatment to promote healing of a newly developed pressure ulcer, and failed to provide timely care and treatment to promote healing of an existing pressure ulcer. This resulted in actual harm with worsening of a pressure ulcer to an unstagable level for one of three residents reviewed for pressure ulcers (Resident #134), of eight residents identified with pressure ulcers. The facility census was 104 residents. Findings include: 1. Record review revealed Resident #134 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 01/08/13, revealed a Brief Interview for Mental Status score of 13 out of 15 (indicating the resident was cognitively intact). Further review of the MDS revealed Resident #134 required extensive staff assistance for bed mobility, transfers, and hygiene. The MDS revealed the resident had one Stage II pressure ulcer (Stage II-Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister). Review of a Braden pressure ulcer risk assessment completed upon admission revealed the resident was at high risk for pressure ulcers. Review of Resident #134's plan of care, dated 01/05/13, revealed the resident had a Stage II pressure ulcer to his coccyx. Review of the plan of care for behaviors (01/14/13) revealed Resident #134 rejects care or turning and repositioning. Review of wound chart details from the wound clinic revealed Resident #134 was assessed and treated at the clinic on 02/14/13. The wound clinic documented a pressure ulcer present to the right foot that measured 0.9 cm long by 0.7 cm wide by 0.1 cm deep. No stage of the wound or appearance was documented on the wound clinic report. Further review of the facility wound documentation and skin grids revealed the area (right outer ankle) was not identified by the facility until 02/17/13. No pressure ulcer treatment was ordered for the area until 02/17/13. Review of a nursing progress note on 02/17/13 revealed an ulcer was found to the right lateral malleoli (ankle bone) which "presents as arterial " and "has a punched out look". The ulcer was described to have a black wound bed and no drainage. The physician was notified and new orders were written at that time. Review of the skin grid (initial identification 02/17/13), revealed the area to the right post malleoli measured 0.8 cm long by 0.5 cm wide by 0.5 cm deep. The color was documented as "B" (black). The comment documentation revealed the wound "covers with black eschar." Observation of pressure ulcer care on 02/22/13 from 1:15 P.M. to 1:55 P.M. revealed a round shaped pressure ulcer present on Resident #134's right ankle. The center of the cratered area was red in color with a small amount of brownish black tissue near the outer border. There was a moderate amount of serosingineous drainage noted on the old dressing pad that was removed. The area was identified as a pressure ulcer at the wound clinic on 02/21/13 and measured 0.7 cm. by 0.7 cm by 0.1 cm deep. The wound clinic documented the ankle ulcer was debrided of [MEDICATION NAME]/slough. Interview with facility Regional Director of Clinical Services, Registered Nurse (RN) #1 and Unit Manager RN #3 on 02/21/13 at 3:15 P.M. verified the area to the right foot identified at the wound clinic on 02/14/13 was the same area with the "black wound bed" that was first noted at the facility on 02/17/13. RN #1 verified there was no evidence to support the area was an arterial wound and that the wound clinic identified the area as "pressure" on 02/14/13. RN #3 verified the facility had not received the documentation from the wound clinic appointment of 02/14/13 until 02/19/13 when it was faxed to the facility. RN #3 verified the facility did not identify the area until three days later on 02/17/13 when the wound was covered with black eschar. RN #1 verified the area was unstageable (Full thickness tissue loss in which the base of the ulcer is covered with slough, yellow, tan, gray, green or brown, and/or eschar, tan, brown or black in the wound bed). RN #1 and RN #3 further verified the facility had not followed up with the wound clinic to obtain information from the appointment prior to the documentation and treatment order being faxed from the wound clinic to the facility on [DATE]. They further verified there was no evidence the pressure ulcer to Resident #134's right ankle was assessed or treated at the facility from 02/14/13 to 02/17/13. 2. Review of Resident #134's hospital discharge External Skin and External Patient Transfer Forms (dated 01/02/13) revealed the resident had a Stage II pressure ulcer to his coccyx which measured 6.5 cm. long by 3 cm. wide with no depth . The forms further revealed a Meplix (an absorbent, soft, silicone foam) dressing was intact and the resident received daily dressing changes. The ulcer was described on the discharge transfer form as "edges approximated, redness, scabbed over, dry and intact. " Review of the facility Admission Skin Assessment, dated 01/02/13, revealed Resident #134 had a pressure ulcer to his coccyx that measured 9.5 centimeters (cm) long by 3.2 cm. wide. Review of a pressure ulcer skin grid (also dated 01/02/13) further revealed the color of the wound was "RPB" (per facility key- red, pink and black) with serosingineous (blood tinged) drainage. The facility stage of the pressure ulcer was a Stage II. Review of the Admission Physician Orders for Resident #134 (01/02/13) revealed no evidence of a treatment order for the coccyx pressure ulcer. Review of the Treatment Administration Record (TAR) for January 2013 revealed no evidence any treatment was provided to the coccyx wound from 01/02/06 until 01/06/13 when a physician order was obtained to cleanse the coccyx wound with saline, apply skin prep, apply wound gel to the wound edges, cover with [MEDICATION NAME] and an ABD (abdominal-a large dressing pad) and secure with tape. There was no assessment of the wound documented on 01/06/13 to determine the appearance of the wound as compared to the appearance on admission. Further record review and review of facility skin grid forms revealed the next assessment of the coccyx ulcer was not completed until 01/15/13 (13 days after the initial assessment). Review of the facility skin grids for Resident #134's coccyx ulcer revealed: - (01/15/13) The coccyx ulcer was a Stage II, measured 9.0 cm long by 4.5 cm wide, had serosanguineous drainage, and was red, pink and black in color. -( 01/22/13) The coccyx ulcer was a Stage II, measured 9.2 cm. long by 4.7 cm. wide, had serosingineous drainage and was red, pink and black. - (01/28/13) The coccyx ulcer "visualizes stage IV wound" (Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). The comment further revealed the wound bed was a mixed tissue of slough and eschar with pink [MEDICATION NAME] tissue as well and with purulent drainage. Some tissue loosely adhered to the wound bed. On 02/22/13 from 1:15 P.M. to 1:55 P.M. observation of wound care to Resident #134's pressure ulcers was completed. The coccyx pressure ulcer dressing was removed by RN #5 and revealed a large amount of yellowish/tan drainage on the old dressing. The coccyx ulcer had a small amount of yellow drainage present in the crater area of the wound before being cleansed with sodium chloride as ordered. The wound bed was red and no odor was noted to the wound. Review of wound chart details from the hospital wound clinic appointment of Resident #134 on 02/21/13 revealed the wound measured 10 cm long by 8 cm wide by 4 cm in depth. The wound clinic classification was Stage III (Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). Interview with facility Registered Nurse (RN) #29 on 02/20/13 at 8:15 A.M. revealed Resident #134 was non-compliant with turning in bed. RN #29 stated the resident did not resist positioning of his feet but resisted turning (on his sides). Interview with Resident #134 on 02/20/13 at 9:30 A.M. revealed he stays positioned mostly on his back in bed. He stated staff will ask him if he wants to turn and he will tell them if he wants to turn. Resident #134 stated it bothers his shoulders to lie on his side. He further verified he will only turn on his right side as he cannot lie on his left side. Interview with a facility regional nurse, RN #1 and facility unit manager, RN #3 on 02/21/13 at 3:15 P.M. verified that per the hospital discharge skin assessment Resident #134 had a Stage II pressure ulcer. RN #1 stated that per the hospital description of the size of the wound and description of "scabbed over" the wound would not have been a Stage II but unstageable. RN #1 stated the facility assessment of the wound as a Stage II was based on the hospital staging of the wound. RN #1 and RN #3 further verified there was no physician order for [REDACTED].#3 further verified there was no evidence the facility provided any treatment to the wound to promote healing and prevent worsening from 01/02/13 until 01/06/13. RN #1 and RN #3 verified the facility was to do weekly wound assessments of pressure ulcers and no wound assessment was completed on Resident #134's coccyx pressure ulcer from his 01/01/13 admission until 13 days later on 01/15/13. Review of Wound Prevention and Treatment Procedure, revised April 2009, revealed the facility strives to ensure a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates unavoidable skin breakdown. The procedure further revealed progression of wound healing would be documented by length, width and depth measurements and shall also include drainage/exudate, color, odor, tunneling/undermining, peri-wound condition, wound edges, location, pain, signs and symptoms of infection and wound base. Nursing services would do a weekly assessment. Review of the Procedure for Skin Grid-Pressure revealed one form is completed for each area of skin impairment on identification and updated weekly and if the sin impairment changes.