Every finding on record at Autumn Hills Care Center

Based on review of the facility's staffing schedules, resident and staff interviews, record review, and policy review, the facility failed to ensure sufficient staffing was provided to meet residents' care needs. This affected eight (Residents #80, #3, #7, #64, #77, #4, #31, and #15) and had the potential to affect all 104 residents residing in the facility.Findings include:1. An interview with Resident #80 on 08/17/26 at 11:48 A.M. revealed he hadn't been shaved or showered in over a week because there wasn't enough staff on the floor.Record review showed Resident #80 required extensive assistance with all activities of daily living (ADL). Interview on 08/17/26 revealed he had not been shaved in a week and had not received a shower since 08/11/26, despite being scheduled twice weekly. This was confirmed through observation of significant facial hair growth and review of shower sheets showing no showers documented after 08/11/26. On 08/19/26, Certified Nursing Assistant (CNA) #513 verified the resident required full assistance for bathing and shaving and stated she did not have time to provide the care due to staffing shortages. (Refer to F677 for additional information).2. Record review showed Resident #3 required total assistance with ADL. On 08/17/26, observation revealed long, dirty fingernails on her left hand with debris present. On 08/18/26, Licensed Practical Nurse (LPN) #603 assessed the resident's right contracted hand and noted foul odor and long, jagged fingernails. LPN #603 could not state when the resident's hands were last washed and confirmed the resident eats with her left hand, yet food debris remained under the nails. (Refer to F677 for additional information).3. Review showed Resident #7 was dependent on staff for bathing. Interview on 08/17/26 revealed he was not receiving showers as scheduled or as desired. Review of shower logs for May-July 2026 identified multiple missed shower opportunities without refusals documented. On 08/25/26, the Interim Director of Nursing (DON) confirmed missed showers for multiple residents and stated CNAs would need to be reassigned to address bathing deficits. (Refer to F677 for additional information).4. Record review showed Resident #64 required maximum assistance with bathing. Review of shower sheets between 05/01/26 and 08/16/26 identified missing documentation for multiple scheduled shower days. Only one nursing progress note documented a bathing refusal (08/08/26), with no further entries for refusals, reattempts, or physician notification. On 08/18/26, the resident stated he was not receiving showers consistently. On 08/25/26, the Administrator confirmed several missing bathing opportunities. (Refer to F677 for additional information).On 08/24/26 at 10:30 A.M., an observation of incontinence and catheter care conducted with CNA #637 revealed Resident #77 was wet with urine. Two adult wet wipes were found stuffed in her perineal area from prior care, which she denied placing. She was unsure when she had last been changed. The bedding beneath her was saturated with urine, and a strong odor was present. CNA #637 verified these findings and was unable to state when Resident #77 had last been checked. These findings demonstrate insufficient staff availability to complete timely incontinence and catheter care. (Refer to F690 for additional information).5. Record review showed Resident #64 had extensive diagnoses, was dependent for toileting, and required frequent incontinence care. His care plan identified bladder incontinence and risk for skin breakdown.On 08/24/26 at 10:20 A.M., observation with LPN #519 and CNA #559 revealed Resident #64's brief was heavily saturated with urine. He stated his last change was at 4:30 A.M. His scrotum was markedly reddened and his buttocks were extremely red, excoriated, and bleeding during wiping. He stated he was not excoriated upon admission. CNA #559 verified she had not checked him since her shift began at 7:00 A.M. (Refer to F690 for additional information).6. Record review showed Resident #77 had spina bifida, paraplegia, neuromuscular bladder dysfunction, and required assistance with all personal care. She had an indwelling Foley catheter with orders for catheter care each shift and as needed. Review of the MDS dated [DATE] reflected she was cognitively intact, dependent on staff for toileting, and always incontinent of bowel.An interview with Resident #4 on 08/17/26 at 10:00 A.M. revealed residents did not get showered on the weekends because there were never enough staff.An interview with Resident #31 on 08/17/26 at 12:10 P.M. revealed she waited a long time for help, especially on the weekends.An interview with Resident #15 on 08/18/26 at 9:41 A.M. revealed he was lucky to get any care at all on the weekends.An interview with CNA #513 on 08/19/26 at 2:15 P.M. revealed there were not enough staff here to meet the needs of the residents. She also stated the facility has lost several staff members recently who have not been replaced, and staffing was an issue before that. CNA #513 further stated management will come in on the weekends to pass trays or answer lights, but nursing management will not work on the floor to assist with bathing, toileting, checks and changes. CNA #513 stated she had never witnessed nursing management work on the floor and stated the facility did not and would not use agency, so aides often work short.An interview with CNA #591 on 08/26/26 at 10:35 A.M. revealed shower aides get pulled to the floor often and trying to get her assigned residents their showers along with all other needs met was difficult. She stated the facility needed more aides, and there were frequent call-offs at this facility.An interview with Registered Nurse (RN) #552 on 08/26/26 at 10:42 A.M. revealed there were usually enough nurses in the facility but not enough aides. She further stated shower aides get pulled to the floor often and then residents don't get their showers.Review of the facility staffing schedule and completion of the staffing tool for 07/03/26 through 07/06/26 revealed the facility did not meet the Ohio required minimum daily direct care staffing average of 2.50 hours on 07/05/26. The review also showed the facility did not have RN coverage on 07/04/26.An additional review of the staffing schedule and completion of the staffing tool revealed the facility did not have RN coverage on 07/11/26.An additional review of the facility staffing schedule and completion of the staffing tool for 07/17/26 through 07/20/26 revealed the facility did not meet the Ohio-required minimum direct care daily average of 2.50 hours on 07/19/26.The staffing tool noted 2.19 hours of direct resident care hours on 07/06/26 and 2.21 hours of direct care hours on 07/19/26.On 08/17/26 at 4:00 P.M. the staffing schedules, staffing ratios and time clock punches were confirmed with Corporate Human Resources Director and Recruiter #641 and Facility Scheduler/Medical Records Clerk #534.A review of the facility's undated policy titled Nursing Staffing/Services stated the facility would provide sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This will be determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment.This deficiency represents noncompliance investigated under Complaint Numbers 3134582, 3073858, 3015952, 2989902, and 2725272.

Based on review of the facility's staffing schedules, staff interviews, and policy review, the facility failed to ensure eight consecutive hours of registered nurse (RN) coverage each day as required. This had the potential to affect all 104 residents residing in the facility.Findings include:Review of the facility staffing schedule and completion of the staffing tool for 07/03/26 through 07/06/26 revealed the facility did not have eight consecutive hours of RN coverage in the facility on 07/04/26.An additional review of the staffing schedule and completion of the staffing tool revealed the facility did not have eight consecutive hours of RN coverage on 07/11/26.During an interview on 08/17/26 at 4:00 P.M., the Corporate Human Resources Director and Recruiter #641 and the Facility Scheduler/Medical Records Clerk #534 confirmed the documented staffing schedules, staffing ratios, lack of RN coverage, and time clock punches for the dates reviewed.Review of the facility's undated Nursing Staffing/Services policy revealed the facility was required to provide sufficient nursing staff with appropriate competencies and skill sets to ensure resident safety and to maintain the highest practicable physical, mental, and psychosocial well being of each resident, based on assessments, acuity, diagnoses, and the facility assessment.

Based on observation, interview, review of manufacturers guidelines, and policy review, the facility failed to store medications in a manner that preserved their efficacy and proper discard time frames. This had the potential to affect all residents in the facility. The facility census was 104.Findings include:On 08/19/26 at 4:15 P.M., an observation of the medication storage room on the 300 unit revealed a one milliliter vial of Tubersol (a serum used for Tuberculosis testing). The vial was open and not labeled with the date it was opened. Licensed Practical Nurse (LPN) #592 verified the opened and unlabeled vial at the time of the observation.A review of the manufacturer's package insert for Tubersol revealed: A vial of Tubersol which has been entered and in use for 30 days should be discarded.On 08/19/26 at 4:30 P.M., an observation of the medication room on the 200 hall revealed two opened bottles of CoQ10 (an over the counter supplement with antioxidant properties for cellular health), each 100 milligrams, stored in the upper cabinet with stock medications. The expiration date on both bottles was 04/2026. LPN #595 verified the expiration date at the time of the observation. A review of the facility policy titled Storage of Medication, dated 01/2026, revealed that medications and biologicals must be stored properly, following manufacturer or provider pharmacy recommendations, to maintain integrity and support safe, effective drug administration. The policy further stated that outdated, contaminated, discontinued, or deteriorated medications, as well as those in containers that are cracked, soiled, or without secure closures, must be removed from stock immediately.This deficiency represents non-compliance investigated under Complaint Number 3042906.

Based on record reviews, observations, interviews, and policy review, the facility failed to ensure essential daily care was provided to Residents #3, #7, #64, #77, #80 and #127. This affected six (Residents #3, #7, #64, #77, #80 and #127) of ten residents investigated for activities of daily living (ADL) services. The facility census was 104.Findings include: 1. A review of Resident #80's medical record showed he was admitted on [DATE] with diagnoses including left knee effusion, chronic obstructive pulmonary disease (COPD), muscle weakness, atherosclerotic heart disease, transient ischemic attack (TIA), cerebrovascular disease, major depressive disorder, history of falls, difficulty walking, chronic kidney disease, and osteoarthritis. Review of Resident #80's 5 day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition. The resident required staff assistance for all ADL, including setup/cleanup for eating and oral hygiene, dependence on staff for toileting, substantial assistance for bathing, partial to full dependence for dressing, substantial to maximum assistance for personal hygiene, and dependence for bed mobility and transfers. During an interview on 08/17/26 at 1:04 P.M., Resident #80 reported he had not been shaved in a week and had not received a shower since 08/11/26, despite being scheduled for showers twice weekly. A significant amount of facial hair was observed at this time. On 08/18/26 at 5:15 P.M., a second observation again showed marked facial hair growth, and the resident repeated that he had not been showered or shaved since 08/11/26. On 08/19/26 at 10:47 A.M., an interview with Certified Nursing Assistant (CNA) #513 acknowledged that Resident #80 required full assistance for showers and personal hygiene, including shaving, but could not explain why these services had not been provided. She admitted she wanted to get him shaved and showered before his medical appointment that day but did not have time. A review of shower sheets from 06/15/26 through 08/11/26 showed inconsistent provision of showers, with no documentation of any showers after 08/11/26. No additional records were available for review to verify that ADL care was provided as required. 2. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left side, muscle wasting and atrophy, vascular dementia, need for assistance with personal care. Review of the comprehensive annual MDS 3.0 assessment dated [DATE] revealed Resident #3 had a BIMS score of 09/15, which indicated moderate cognitive impairment. She required substantial or maximum assistance with eating and oral hygiene and was dependent on staff for all other ADL. An observation of Resident #3 on 08/17/26 at 3:20 P.M. revealed the fingernails on her left hand were long and dirty with brown and dark yellow debris caked under her fingernails. An additional observation of Resident #3 on 08/18/26 at 3:31 P.M. revealed her lying in bed, awake, alert, and pleasantly confused. Licensed Practical Nurse (LPN) #603 donned gloves and opened the resident's right contracted hand, which emitted a strong, unpleasant odor and showed long, jagged, brown fingernails. LPN #603 confirmed the condition and was unable to state when the resident's right hand was last washed. LPN #603 further verified that Resident #3 eats with her left hand and that each fingernail on her left hand had visible food debris caked beneath it. She was unable to confirm whether the resident's left hand was washed before or after meals. 3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including type II diabetes, chronic kidney disease, hemiplegia and hemiparesis following a cerebral infarction, generalized muscle weakness, hypertension, and major depressive disorder. Review of the care plan revised on 03/11/26 revealed Resident #7 had an ADL self-care performance deficit related to impaired mobility and hemiplegia. Interventions included assisting the residents with ADL as needed. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #7 was alert and oriented to person, place, and time. Resident #7 was dependent on staff for transfers, dressing, toilet use, and showers/bathing. During an interview on 08/17/26 at 11:30 A.M., Resident #7 revealed he was not receiving his showers/bathes as scheduled/or as he wanted. Review of the shower log for May, June, and July 2026 revealed Resident #7 was to receive showers on Monday and Wednesday from the 3:00 P.M. to 11:00 P.M. shift. Review of Resident #7's shower sheets revealed he received showers on 05/01/26, 05/08/26, 05/15/26, 05/19/26, 06/05/26, 06/08/26, 06/13/26, 06/16/26, 06/30/26, 07/03/26, 07/07/26, 07/17/26, 07/21/26, 07/28/26, 07/31/26, and 08/07/26. Resident #7 did not receive his showers and did not have refusals 05/05/26, 05/12/26, 05/22/26, 05/26/26, 05/29/26, 06/02/26, 06/23/26, 06/6/26, 06/30/26, 07/10/26, 07/14/26, 07/24/26, and 07/27/26. During an interview on 08/25/26 at 5:40 P.M., the Interim Director of Nursing (DON) verified there had been missed showers for multiple residents, but the facility was going to bring back the CNAs to just to give showers and address the issue. During an interview on 08/26/26 at 10:08 A.M., the Administrator was able to find one additional shower sheet completed for 06/16/26, but verified there was no documentation of showers or refusals for the rest of the missing showers/shower days. 4. Review of the medical record for Resident #64 revealed an admission date of 11/21/23 with diagnoses including congestive heart failure, morbid obesity and adult failure to thrive. Review of the care plan last revised on 10/15/25 for Resident #64 indicated he was non compliant with showers. Interventions included notifying the nurse if refusals continued, re offering the shower at a later time, educating the resident on the importance of routine bathing and potential negative outcomes, and informing the physician or nurse practitioner of ongoing refusals. Review of the ADL care plan last revised on 04/24/26 for Resident #64 revealed staff will assist as needed with daily hygiene and will assist with showering. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #64 had a BIMS score of 15/15 which indicated intact cognition. Resident #64 required maximum staff assistance for bathing. Review of the facility shower schedule revealed Resident #64 was supposed to receive shower on Tuesday, Thursday and Saturdays on day shift. Review of the shower opportunities from 05/01/26 to 08/16/26 revealed 46 bathing opportunities on 05/02/26, 05/05/26, 05/07/26, 05/09/26, 05/12/26, 05/14/26, 05/16/26, 05/19/26, 05/21/26, 05/23/26, 05/26/26, 05/28/26, 05/30/26, 06/02/26,0604/26, 06/06/26, 06/09/26, 06/11/26, 06/13/26, 06/16/26, 06/18/26, 06/20/26, 06/23/26, 06/25/26, 06/27/26, 06/30/26, 07/02/26, 07/04/26, 07/07/26, 07/09/26, 07/11/26, 07/14/26, 07/16/26, 07/18/26, 07/21/26, 07/23/26, 07/25/26, 07/28/26, 07/30/26, 08/01/26, 08/04/26, 08/06/26, 08/08/26, 08/11/26, 08/13/26 and 08/15/26. Review of the facility provided shower sheets for Resident #64 revealed sheets were provided for 27 out of 46 days on 05/02/26, 05/05/26, 05/07/26, 05/12/26, 05/16/26, 05/21/26, 06/02/26, 06/06/26 bed bath, 06/09/26, 06/11/26, 06/13/26, 06/23/26, 06/27/26, 06/30/26, 07/07/26, 07/09/26, 07/11/26, 07/14/26, 07/16/26, 07/18/26, 07/23/26, 07/25/26, 07/28/26, 07/30/26, 08/04/26, 08/08/26, and 08/11/26. Showers sheets were not provided on 05/09/26, 05/14/26, 05/19/26, 05/23/26, 05/26/26, 05/28/26, 05/30/26, 06/04/26, 06/16/26, 06/18/26, 06/20/26, 06/25/26, 07/02/26, 07/04/26, 07/21/26, 08/01/26, and 08/06/26, 08/13/26 and 08/15/26. Review of the nursing progress notes from 05/01/26 through 08/25/26 revealed only one entry on 08/08/26 indicating the resident refused bathing. No additional nursing progress notes were found documenting shower refusals, reattempts, or any notification to the physician regarding ongoing bathing refusals. During an interview on 08/18/26 at 9:53 A.M., Resident #64 stated he had not been getting his showers consistently. During an interview on 08/25/26 at 8:11 A.M., the Administrator confirmed the shower sheets provided for Resident #64 were all they found and confirmed the missing bathing opportunities for Resident #64. 5. Review of the closed medical record for Resident #127 revealed an admission from 01/02/26 to 01/19/26, followed by a readmission from 01/28/26 to 02/06/26. Diagnoses included congestive heart failure, pneumonia, and type II diabetes mellitus. Review of the five-day MDS 3.0 assessment dated [DATE] revealed Resident #127 revealed BIMS score of 14/15 which indicated intact cognition. Resident #127 was noted to require supervision for bathing. Review of the facility shower schedule revealed for the first admission from 01/02/26 to 01/19/26 showers were to be given on Thursday and Sunday during day shift. On the second admission from 01/28/26 till 02/06/26 bathing was to be provided on Wednesday and Sundays on night shift. Review of the shower opportunities for Resident #127 revealed shower opportunities on 01/04/26, 01/08/26, 01/11/26, 01/15/26, 01/18/26, 01/28/26, 01/31/26 and 02/04/26 for a total of eight bathing opportunities. Review of the facility's shower sheets for Resident #127 showed showers were provided on 01/04/26, 01/11/26, 01/18/26, and 01/28/26, reflecting bathing on four out of eight scheduled opportunities. Review of the nursing progress notes for Resident #127 revealed no documented evidence of bathing refusals. Review of the care plan, which was cancelled on 02/09/26 for Resident #127, showed he required assistance with activities of daily living. The interventions directed staff to provide assistance with daily hygiene and to ensure weekly showers were completed in accordance with facility policy. No care plan interventions were identified addressing resident refusal of care. During an interview on 08/24/26 at 10:00 A.M., the Administrator confirmed Resident #127 did not receive showers as scheduled. 6. Record review revealed Resident #77 was admitted [DATE] with diagnoses of spina bifida, paraplegia, end stage renal disease, and acute pancreatitis without necrosis or infection. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #77 was cognitively intact, required a wheelchair for mobility, needed maximal assistance for showers and lower body dressing, and was dependent for toileting hygiene, all transfers, and putting footwear on or off. Review of the care plan dated 07/18/26 revealed Resident #77 required assistance with ADL and care as needed. Review of the shower schedule revealed Resident #77 was to receive showers on Sunday, Tuesday, and Thursday. During an interview on 08/20/26 at 12:46 P.M., Resident #77 stated her scheduled shower days were day shift Sunday, Tuesday, and Thursday; however, she did not receive a shower on 08/16/26 and 08/18/26 because there was no shower aide. During an interview on 08/20/26 at 3:04 P.M., Scheduler #534 revealed there were two shower aides who worked weekdays and every other Saturday. The shower aides did not work Sunday's, so the scheduled aides were responsible for ensuring residents who had showers scheduled on Sunday received them. Scheduler #534 also confirmed that on 08/18/26 a shower aide was scheduled; however, she did not function in the capacity of a shower aide and worked as a regular aide providing necessary care to residents due to short staffing. Scheduler #534 confirmed it was common practice to pull the shower aide from her duties and have her work on the floor when short staffed; however, showers were still expected to be completed. During an interview on 08/24/26 at 10:11 A.M., CNA #559 stated she was normally a shower aide but was pulled to the floor today. When pulled to the floor, aides were responsible for the showers in their assigned section. During an interview on 08/24/26 at 10:29 A.M., CNA #616 stated she was the aide assigned to Resident #77 on 08/18/26 and reported having some issues completing showers due to short staffing. During an interview on 08/24/26 at 11:06 A.M., Resident #77 stated she did not receive a shower on 08/23/26. During an interview on 08/24/26 at 1:24 P.M., the Director of Nursing (DON) confirmed Resident #77 did not receive a shower on 08/23/26. Review of the August 2026 shower sheets revealed there was no documentation for Resident #77 on 08/02/26, 08/04/26, 08/09/26, 08/16/26, and 08/18/26 to indicate that showers were provided as scheduled. During an interview on 08/25/26 at 10:21 A.M., the Administrator confirmed there was no evidence to support that Resident #77 received showers on those dates. Review of the Resident Care Policy, dated June 2018, revealed that residents were to be bathed or assisted with showering routinely and as needed, in accordance with their preferences, with foot care provided per order or identified need. This deficiency represents non-compliance investigated under Master Complaint Number 3156656 and Complaint Numbers 2994130, 2725957, and 2705820.

Based on record reviews, staff interviews, and policy review, the facility failed to ensure resident weights were obtained according to physician orders. This affected four residents (Residents #2, #9, #62, and #117) of eight residents reviewed for nutrition. The facility census was 104.Findings include:1. Review of the medical record revealed Resident #9 was most recently admitted to the facility on [DATE] with diagnoses including fracture of the left femur subsequent closed fracture with routine healing, acquired absence of the larynx aftercare following joint replacement surgery, emphysema, chronic obstructive pulmonary disease, cancer of the larynx, and history of tracheostomy. Review of Resident #9's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15/15, indicating he was cognitively intact. The resident was independent on all activities except bathing, which the resident needed supervision/touching assistance. A care plan related to the issue of potential risk for malnutrition due to his chronic disease/cancer diagnosis and at risk for dehydration due to his use of diuretics revealed individualized nutritional and medical interventions with measurable goals. Review of the medical record revealed Resident #9 had only one weight documented since his admission on [DATE], a weight of 120.8 pounds recorded on 08/13/26. There was no admission weight and no documented weekly weights for the four weeks of July 2026 as ordered by the physician. Review of the nursing progress note on 07/13/26 at 4:19 P.M. revealed Resident #9 was approached several times that day to be weighed; he stated he wanted to sleep. He agreed to be weighed when he got his shower. There was no other documentation of the resident refusing being weighed for the month of July 2026. Resident #9 had no weights recorded for July 2026. During an interview on 08/24/26 at 12:10 P.M., Dietary Technician #619 confirmed she had recommended weekly weights for new admissions and that the physician had ordered weekly weights; however, the admission weight and all weekly weights for July 2026 were not completed for Resident #9. She further stated that obtaining resident weights had frequently been problematic at the facility. During an interview on 08/26/26 at 11:08 A.M., Dietitian #639 stated she did not have any additional weights beyond what was recorded in the electronic medical record. She confirmed that the only weight available for Resident #9 since his most recent admission on [DATE] was 120.8 pounds on 08/13/26, verifying that neither the admission weight nor the weekly weights ordered by the physician had been completed. Review of the undated facility policy titled Weight Policy and Procedure revealed that all new admissions and readmissions were to be weighed within 24 hours, and all new admissions were to be weighed weekly for four weeks following admission. 2. Review of the medical record for Resident #2 revealed an admission date of 02/20/26 with diagnoses including acute and chronic respiratory failure with hypoxia, dependence on a respirator, persistent vegetative state, type two diabetes mellitus, tracheostomy status, gastrostomy status and moderate protein-calorie malnutrition. Review of the physician order dated 02/21/26 for Resident #2 revealed an order for weekly weights for four weeks, followed by monthly weights thereafter. Review of the nutrition admission assessment dated [DATE] revealed Resident #2 was at risk for malnutrition. Review of the recorded weights under the vitals section of the electronic medical record (EMR) for Resident #2 revealed an admission weight of 175 pounds documented on 02/20/26, and the first weekly weight of 173 pounds on 02/21/26. The remaining three weeks of weekly weights were not documented on 02/28/26, 03/07/26 and 03/14/26. The next documented weight was not recorded until 03/17/26. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for February and March 2026 revealed Resident #2 had the first weekly weight of 173 pounds documented on 02/21/26. There were no weekly weights documented on 02/28/26 and 03/07/26, and the weight entry for 03/14/26 was marked as not applicable. Review of the medical record revealed Resident #2 was admitted to the hospital on [DATE] for bradycardia with elevated sodium levels and was discharged back to the facility on [DATE]. Review of the recorded weights under the vitals section of the EMR for Resident #2 revealed there was no re-admission weight completed on 03/10/26 or 03/11/26, and the next documented weight was not recorded until 03/17/26. Review of the nutrition assessment dated [DATE] for Resident #2 revealed the most recent weight available to the dietitian was from 02/21/26. Review of the physician orders dated 05/25/26 for Resident #2 revealed an order for weekly weights to be completed for four weeks, followed by monthly weights thereafter. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was in a vegetative state and was dependent upon staff for all care. Review of the weights documented under the vitals tab for Resident #2 revealed there were no weekly weights recorded for the physician order dated 05/25/26; however, a monthly weight was documented on 07/01/26. Review of the MAR and TAR for May and June 2026 for Resident #2 revealed no documented weekly weights for the physician order dated 05/25/26. Interview on 08/24/26 at 12:18 P.M. with Registered Dietetic Technician (RDT) #619 confirmed the above missing weights for Resident #2. A telephone interview on 08/26/26 at 10:30 A.M. with Registered Dietitian (RD) #639 confirmed that weights were required to be completed within 24 hours of admission or re-admission and verified the above missing weights for Resident #2. 3. Review of the medical record for Resident #117 revealed an admission date of 08/15/26 with diagnoses including acute respiratory failure, dependence on a respirator, contusion of neck and dysphagia. Review of the admission assessment dated [DATE] revealed Resident #117 was alert and oriented to person, place, and time and required assistance with activities of daily living. The assessment was incomplete with no admission weight or height noted. Review of the nutrition assessment dated [DATE] for Resident #117 revealed there was no height or weight available, and weight changes were unknown. The assessment noted Resident #117 had a potential for altered nutrition and hydration status related to receiving alternative nutrition via enteral feeding, increased estimated nutritional needs, being on a therapeutic diet, and being NPO. Resident #117 was admitted on [DATE] after a 21 day hospitalization for difficulty breathing, neck swelling, and respiratory arrest. During hospitalization, he experienced inadequate oral intake due to impaired respiratory function and was receiving orogastric enteral feeding. A percutaneous endoscopic gastrostomy (PEG) tube had been placed on 08/05/26. His hospital weight on 07/25/26 was documented as 196 pounds. During an interview on 08/24/26 at 8:12 A.M., the Administrator verified several areas of Resident #117's admission assessment, including height and weight, were not complete and should have been completed within 24 hours of admission. During an interview on 08/24/26 at 11:59 A.M., RDT #619 confirmed that no weight had been obtained for Resident #117 since his admission, and the hospital weight was being used. RDT #619 stated a weight had been requested but had not yet been completed. During an interview on 08/24/26 at 1:24 P.M., Resident #117 nodded his head left and right to indicate no when asked if anyone had attempted to obtain his weight since admission. Review of the undated facility policy titled Weight Policy and Procedure revealed that all new admissions and readmissions were to be weighed within 24 hours of admission. The policy specified that hospital and home weights were not acceptable. It further stated that any weight variance of three pounds or more, either an increase or decrease, within one week or one month must be reweighed within 24 hours. 4. Review of the medical record revealed Resident #62 had an initial admission date of 04/01/25. Significant diagnoses included acute and chronic respiratory failure, ventilator dependence, complete spinal cord lesion at T7–T10, dysphagia, and gastrostomy status. Significant physician orders included Nepro 1.8 at 50 milliliters per hour via feeding tube for 20 hours per day and weekly weights for four weeks, ordered on 08/06/26. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #62 had a BIMS score of 15/15, indicating he was cognitively intact. The accompanying nutrition assessment documented a height of 64 inches but no recorded weight and noted that weight changes were unknown. The assessment further indicated that the resident received 51 percent or more of his calories through tube feeding. Section M of the MDS documented that Resident #62 had four stage two pressure ulcers (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). Review of the care plan dated 08/07/26 revealed Resident #62 had a potential for alterations in nutrition and hydration status related to receiving alternative nutrition through a feeding tube. Interventions included obtaining weights as ordered and monitoring for significant changes, with prompt reporting to the physician. Review of the weights documented in the medical record revealed a weight of 147.6 pounds recorded for Resident #62 on 08/07/26. No subsequent weights were documented to show that the ordered weekly weights were being completed. During an interview on 08/26/26 at 10:40 A.M., Registered Dietitian (RD) #639 confirmed that weekly weights were not recorded for Resident #62. RD #639 further stated that obtaining weights as ordered was an ongoing problem within the facility and was currently being addressed with leadership. Review of the undated facility policy titled Weight Policy and Procedure revealed that all new admissions and readmissions were to be weighed within 24 hours of admission. The policy specified that hospital and home weights were not acceptable. It further stated that any weight variance of three pounds or more, either an increase or decrease, within one week or one month must be reweighed within 24 hours. This deficiency represents non-compliance investigated under Complaint Number 2705820.

Based on observations, review of facility menus and mealtimes, dining committee meeting minutes, and interviews, the facility failed to ensure meals were palatable. This affected three residents (Residents #57, #64, and #77) of three residents reviewed for meal services and had the potential to affect all residents receiving meals prepared by the kitchen. The facility reported four residents (Residents #2, #28, #62, and #117) as receiving nothing by mouth (NPO). The facility census was 104.Findings include:During an interview on 08/17/26 at 10:07 A.M., Resident #77 stated the food did not taste good, was cold at times, and lacked flavor.During an interview on 08/17/26 at 10:24 A.M., Resident #57 stated the food tasted bad, lacked seasoning, and commented that the facility buys the cheapest food. Resident #57 also stated they did not feel staff knew how to cook.During an interview on 08/18/26 at 9:48 A.M., Resident #64 reported the food was not palatable, preferences were not always followed, and residents received pork too frequently.A review of the facility menu revealed the Week 2 Wednesday lunch meal included sweet chili pork tenderloin, white rice, Italian blend vegetables, wheat bread, crushed pineapple, milk, and coffee or tea.Observation on 08/19/26 at 11:05 A.M. with [NAME] #554 revealed the following tray-line temperatures: pork cutlets 183 degrees Fahrenheit (F), chili sauce 169 degrees F, rice degrees 200 F, Italian blend vegetables 202 degrees F, wedding soup 202 degrees F, gravy 175 degrees F, pureed pork 182 degrees F, pureed rice 169.5 degrees F, pureed carrots 172 degrees F, mashed potatoes 165 degrees F, hamburgers 189 degrees F, hot dogs 195 degrees F, mechanical soft pork 165 degrees F, and lasagna roll ups 178 degrees F.-At 11:30 A.M. on 08/19/26, tray line was initiated.-At 12:40 P.M., [NAME] #554 ran out of chili sauce for the pork and requested more from the refrigerator. The cook placed the sauce in a pan, covered it with plastic wrap, and placed it in the steamer. Tray line was paused with meals remaining for six residents (Residents #42, #50, #52, #118, and #119).-Tray line resumed at 1:00 P.M. after the chili sauce temperature reached 166 F.-At 1:05 P.M., observation with [NAME] #554 revealed Residents #50 and #119 received mashed potatoes instead of rice due to running out of rice. Resident #50 also received a hamburger because pork ran out before tray line was completed.-At 1:10 P.M. on 08/19/26, the last meal cart left the kitchen for the dementia unit on the 300 hall. The cart contained meals for 19 residents (Residents #2, #4, #9, #16, #39, #42, #44, #45, #50, #52, #58, #62, #74, #92, #95, #104, #115, #116, and #117).Review of facility mealtimes showed the 300 unit (rooms 228-322) was scheduled to receive meals at 12:30 P.M.-At 1:12 P.M., the meal cart arrived on the 300 unit and tray pass began. The last tray was passed at 1:17 P.M.A test tray was completed on 08/19/26 at 1:18 P.M. with Registered Dietetic Technician (RDT) #619 and Dietary Manager (DM) #500. Food temperatures were recorded as follows: mashed potatoes 149 degrees F, mechanical port 138 degrees F, Italian vegetables were 143 degrees F, wedding soup was 122.8 degrees F, orange juice was 52.7 degrees F, and milk was 53.4 degrees F. During an interview at the time of the test tray with RDT #619 confirmed the food was warm but not to her preferred temperature and stated she would have preferred it to be warmer if she were a resident. Both RDT #619 and DM #500 confirmed the orange juice and milk were outside of safe temperature ranges and acknowledged tray line time increased due to running out of food and preparing more.Review of the facility dining committee minutes for the past 12 months revealed repeated concerns related to meal satisfaction, food quality, and food temperatures. These concerns were documented and signed by the Administrator.The following concerns were noted:-08/21/25: food temperatures rated as fair-09/26/25: overall meal satisfaction rated as fair, food quality as poor-12/18/25: overall meal satisfaction, food quality, and food temperatures rated as fair-01/22/26: overall meal satisfaction, food quality, and food temperatures rated as fair-02/26/26: food quality rated as fair-03/26/26: overall meal satisfaction, food quality, and food temperatures rated as fair-04/23/26: food quality and temperatures rated as fair-05/28/26: overall meal satisfaction rated as fair, food quality rated as poor-06/25/26: overall meal satisfaction rated as fairThis deficiency represents non-compliance investigated under Complaint Numbers 2705820 and 2668487.

Based on record review, observations, interviews, and policy review, the facility failed to provide the necessary care and assistance to ensure Resident #80's dignity was maintained. This affected one (Resident #80) of one resident investigated for dignity. The facility's census was 104. Findings include:A review of Resident #80's medical record showed he was admitted on [DATE] with diagnoses including left knee effusion, chronic obstructive pulmonary disease (COPD), muscle weakness, atherosclerotic heart disease, transient ischemic attack (TIA), cerebrovascular disease, major depressive disorder, history of falls, difficulty walking, chronic kidney disease, and osteoarthritis.Review of Resident #80's 5 day Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition. The resident required staff assistance for all activities of daily living (ADL), including setup/cleanup for eating and oral hygiene, dependence on staff for toileting, substantial assistance for bathing, partial to full dependence for dressing, substantial to maximum assistance for personal hygiene, and dependence for bed mobility and transfers.During an interview on 08/17/26 at 1:04 P.M., Resident #80 reported he had not been shaved in a week and had not received a shower since 08/11/26, despite being scheduled for showers twice weekly. A significant amount of facial hair was observed at this time. On 08/18/26 at 5:15 P.M., a second observation again showed marked facial hair growth, and the resident repeated that he had not been showered or shaved since 08/11/26.During an interview on 08/19/26 at 10:47 A.M., Certified Nursing Assistant (CNA) #513 acknowledged that Resident #80 required full assistance for showers and personal hygiene, including shaving, but could not explain why these services had not been provided. She admitted she wanted to get him shaved and showered before his medical appointment that day but did not have time.During an interview on 08/19/26 at 2:51 P.M., Resident #80 revealed he felt embarrassed and bothered being sent to a medical appointment without having been shaved or showered.A review of shower sheets from 06/15/26 through 08/11/26 showed inconsistent provision of showers, with no documentation of any showers after 08/11/26. No additional records were available for review to verify that ADL care was provided as required.A review of the facility's undated policy titled Residents' Rights stated the facility will ensure each resident's personal dignity, well being, and self determination are maintained.This deficiency represents non-compliance investigated under Master Complaint Number 3156656 and Complaint Numbers 3015952 and 2725272.

Based on record review, interview, and policy review, the facility failed to notify the family of a significant change in condition for Resident #117. This affected one (Resident #117) of three residents reviewed for change in condition. The facility census was 104.Findings include:A review of the medical record revealed Resident #117 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, dependence on a ventilator, encounter for surgical aftercare following surgery on the nervous system, encounter for surgical aftercare following surgery on the digestive system, respiratory arrest, tracheostomy status, gastrostomy status, in contusion of unspecified part of the neck, and dependence on supplemental oxygen. Review of the medical record revealed there was no Minimum Data Set (MDS) assessment completed on Resident #117 as he was a new admission.Review of the admission assessment dated [DATE] revealed Resident #117 was alert and oriented to person, place, and time.Review of the care plan dated 08/15/26 revealed Resident #117 had an actual fall where he was observed on his hands and knees crawling to the door with his head bleeding. The tracheostomy for Resident #117 was observed on the floor. Resident #117 was transferred to the emergency room (ER) for further clinical evaluation post fall. Interventions included assessing for injuries, fall mats to bilateral sides of the bed, neurological checks per facility policy, notifying the physician of the fall, and providing reminders to utilize the call light for assistance.A review of progress notes dated 08/16/26 at 9:40 A.M. and authored by Licensed Practical Nurse (LPN) #545 revealed the nurse heard a ventilator alarm and walked into Resident #117's to find the resident on his hands and knees crawling to the door with his head bleeding and tracheostomy equipment on the floor. Vital signs were assessed, and the tracheostomy tube was reinserted by the respiratory therapist. 911 was called and Resident #117 was transported to the ER for further evaluation. The progress note indicated that all parties were updated; however, it did not specify which individuals were notified.A review of the incident report regarding the fall that occurred on 08/16/26 revealed the physician was notified. There was no documente3d evidence to indicate the family of Resident #117 was contacted regarding the fall and subsequent transfer to the ER.On 08/17/26 at 3:32 P.M., an interview with the daughter of Resident #117 revealed the resident had a fall, and the family was never notified of the fall and transfer to the ER.On 08/20/26 at 7:40 A.M. an interview with LPN #545 who was identified as the nurse of record for the fall and transfer of Resident #117 revealed the family was not notified of the change in condition. LPN #545 stated no contact information was uploaded in the resident's file as he was a new admission.On 08/20/26 at 4:45 P.M. an interview with the Director of Nursing (DON) also verified the family was not notified of the fall and transfer to the ER for Resident #117.A review of the undated facility policy titled, Status Change in Resident Condition-Notification revealed the facility will promptly notify the resident, his or her attending physician, and responsible party of changes in the residence condition and or status. The policy further revealed unless otherwise instructed by the resident, the licensed nurse will notify the resident's responsible party when the resident is involved in any accident or incident which results in an injury, when there is a significant change in the resident's physical, mental, or psychosocial status and when there is a need to transfer the resident to a hospital. This deficiency represents non-compliance investigated under Master Complaint Number 3156656 and Complaint Number 2732059.

Based on record review, observations, interviews, and policy review, the facility failed to ensure resident equipment and furnishings were maintained in a clean and sanitary condition to provide a comfortable, homelike environment for Resident #70 and Resident #88. This affected two (Residents #70 and #88) of two residents investigated for environment and had the potential to affect all residents. The facility census was 104. Findings include:A review of Resident #88's medical record revealed an admission date of 12/31/20 and a readmission date of 07/22/22. Diagnoses included hydrocephalus, presence of cerebrospinal fluid drainage device, lack of coordination, major depressive disorder, hypertension, need for assistance with personal care, chronic pain syndrome, type II diabetes mellitus, cognitive communication deficit, acquired absence of right leg above the knee, and generalized anxiety disorder.A review of Resident #88's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Basic Interview of Mental Status (BIMS) score of 15/15, indicating intact cognition. Further review of the MDS revealed she required setup/cleanup with eating and oral hygiene, was dependent on staff for toileting and bathing, required substantial assistance with upper extremity dressing, was dependent with lower extremity dressing, required substantial/maximum assistance with personal hygiene and bed mobility, and was dependent with transfers. Ambulation was not attempted during the review period. A review of Resident #70's medical record revealed an admission date of 08/26/24 with diagnoses including Huntington's disease, schizophrenia, bipolar disorder, anxiety disorder, migraines, major depressive disorder, cognitive communication deficit and repeated falls.A review of Resident #70's annual MDS 3.0 assessment dated [DATE] revealed a BIMS score of 14/15, indicating intact cognition. Further review of the MDS revealed Resident #70 required setup/cleanup with eating, substantial assistance with oral hygiene, she was dependent on staff for toileting, bathing, and personal hygiene, required substantial assistance with dressing, and required partial/moderate assistance with bed mobility and transfers. An observation on 08/17/26 at 11:50 A.M. revealed Resident #88's wheelchair was dirty with visible debris. An interview with Resident #88 during this observation revealed no knowledge of her wheelchair ever having been cleaned. An interview with Housekeeper #584 during this observation confirmed the dirty wheelchair and stated she was unsure who was responsible for wheelchair cleaning.An observation on 08/17/26 at 11:52 A.M. revealed Resident #70's wheelchair and tray table were dirty with a buildup of dirt, grease, and food debris. An interview with Housekeeper #584 during this observation confirmed the condition of the equipment reflected more than one day of neglect. Housekeeper #584 stated housekeeping was usually responsible for cleaning tray tables, but the person assigned to that section was off that day.An additional observation on 08/19/26 at 11:35 A.M. revealed Resident #70's tray table still had dirt and debris present on the tray, legs and base, with no improvement from the previous observation. The observation also revealed Resident #70's and Resident #88's wheelchairs both remained dirty, with debris observed on the bases and wheels.An additional observation on 08/20/26 at 2:26 P.M. revealed Resident #88's tray table remained dirty with debris present on the legs and base. The observation also revealed Resident #70's and Resident #88's wheelchairs continued to show visible dirt and food debris on the bases and wheels.An interview on 08/24/26 at 4:24 P.M. with Housekeeping Supervisor #537 revealed that wheelchair cleaning had been a longstanding issue. He stated there was a pile of wheelchairs near therapy that were not being cleaned and explained that current facility policy assigned wheelchair cleaning to midnight aides. He further reported that resident rooms were expected to be cleaned daily, but acknowledged this did not always occur, particularly during periods of short staffing. He also stated housekeeping was responsible for wiping down tray tables and cleaning the legs and bases each day, but confirmed this was not being completed consistently.An interview on 08/24/26 at 4:31 P.M. with the Administrator confirmed that the midnight shift aides were responsible for wheelchair cleaning and further confirmed the wheelchair cleaning schedule was not being followed or implemented.An additional observation on 08/26/26 at 1:39 P.M. revealed Resident #88's tray table remained dirty, and Resident #70's and Resident #88's wheelchairs continued to show dirt, debris, and food particles.A review of the facility's Housekeeping Policy, dated 12/28/19, revealed housekeeping workplace/equipment will be maintained in a clean and sanitary condition, with a schedule of cleaning and decontamination based on the area of the facility, type of surface to be cleaned, type of soil present and tasks being performed in that area. The facility will be maintained and cleaned to meet a home-like environment for our residents.This deficiency represents noncompliance investigated under Master Complaint Number 3156656 and Complaint Numbers 3073858, 3042906, 2725957, 2705820, and 2668487.

Based on record reviews, observations, interviews, and policy review, the facility failed to dispense a respiratory inhaler as prescribed by the physician and failed to administer controlled substances in accordance with nursing standards. This affected two residents (Residents #50 and #114) of four residents observed during medication administration. In addition, the facility failed to change a resident's peripherally inserted central catheter (PICC) line dressing as ordered, affecting one resident (Resident #121) of one reviewed for intravenous therapy. The facility census was 104.Findings include: 1. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with a diagnosis including other disorders of the lung. Significant orders included Atrovent inhaler (short acting inhaled bronchodilator) 17 micrograms (mcg), two inhalations four times daily for chronic obstructive pulmonary disease (COPD). Review of the care plan dated 08/03/26 revealed Resident #50 was at risk for alterations of respiratory function. Interventions included providing respiratory treatments per doctor orders. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11/15, indicating Resident #50 had moderated cognitive impairment. On 08/19/26 at 8:40 A.M. an observation of medication administration for Resident #50 revealed Licensed Practical Nurse (LPN) #592 administer the Atrovent inhaler to Resident #50. LPN #592 administered one inhalation of the Atrovent. LPN #592 verified she administered one inhalation of the Atrovent at the time of the observation. LPN #592 also verified the order for the Atrovent inhaler was for two inhalations of the medication. 2. Review of the medical record revealed Resident #114 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the bladder, malignant neoplasm of unspecified lung, multiple fractures of ribs, intra-abdominal and pelvic swelling, and mass and lump of unspecified site. Significant orders included morphine sulfate (a controlled opioid medication utilized for pain) 30 milligrams (mg) extended-release tablet, one tablet by mouth every 12 hours and Xanax (a controlled substance for anxiety) two mg, one tablet by mouth every eight hours as needed for anxiety. Resident #114 was under hospice care. Review of the care plan dated 08/15/26 revealed Resident #114 was at risk for alteration in comfort secondary to bladder cancer with metastasis and thoracic spine pathological fractures. Interventions included administering medications as ordered. Review of an admission MDS 3.0 assessment dated [DATE] revealed a BIMS score of 14/15 indicating Resident #114 was cognitively intact. On 08/19/26 at 8:21 A.M., an observation of medication administration for Resident #114 revealed LPN #519 at the medication cart preparing medications for the resident. The resident's door was closed. LPN #519 stated she was preparing morphine and Xanax, dissolving the medications in liquid and drawing them into a syringe for oral administration. LPN #529 then opened Resident #114's door, took the prepared syringe from LPN #519, and closed the door behind her. LPN #529 later exited the room without the syringe and stated she had administered the medications. She also confirmed she did not prepare the doses she administered to Resident #114. Review of the undated facility policy titled: Medication Administration General Guidelines revealed medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices, and only by persons legally authorized to do so. The policy further stated the person who prepares the dose for administration is the person who administers the dose. 3. Review of the medical record for Resident #121 revealed an admission date of 08/07/26 with diagnoses including cellulitis or the right lower limb (methicillin resistant staphylococcus aureus infection), type II diabetes mellitus, emphysema, major depressive disorder, anxiety disorder, hypertension (high blood pressure), heart failure and chronic kidney disease. Review of Resident #121's plan of care dated 07/31/26 indicated she was at risk for infection or worsening infection due to surgical wounds and the presence of an intravenous (IV) PICC line. Interventions included providing treatment and care as ordered. Review of Resident #121's physician orders revealed an order dated 08/07/26 to change the PICC line dressing to the right arm every week on Saturday, beginning 08/08/26. Review of the 5-Day MDS 3.0 assessment dated [DATE] indicated Resident #121 had moderate cognitive impairment and had intravenous access while a resident. An observation on 08/17/26 at 10:54 A.M. of Resident #121 revealed a right arm PICC line with a dressing dated 08/07/26 as the last change. During an interview at the time of the observation, Resident #121, who stated she had been at the facility for three weeks, reported delays in receiving treatments such as dressing changes, stating it takes a long time. She believed the dressing had last been changed while she was in the hospital. Review of Resident #121's Medication Administration Record (MAR) for August 2026 showed the routine PICC line dressing change was scheduled to begin on 08/08/26 and to be completed every seven days thereafter. The MAR reflected a dressing change documented as completed on 08/15/26; however, this did not correspond with the date of 08/07/26 observed on the resident's PICC line dressing during the 08/17/26 assessment, indicating the dressing change had not been completed as ordered. During an interview on 08/17/26 at 3:20 P.M., LPN #258 verified that Resident #121's PICC line dressing was dated 08/07/26 as the last change and confirmed it had not been changed as ordered on 08/15/26, despite being documented as completed on the MAR. Review of the undated facility policy titled, Vascular Access Devices and Infusion Therapy revealed central venous access devices and peripheral midline dressings are changed every seven days and immediately if the integrity of the dressing is compromised. This deficiency represents non-compliance investigated for Complaint Numbers 3042906, 2989902, and 2725272.

Based on record review, interviews, and policy review, the facility failed to ensure thorough and complete fall investigations were conducted. The facility did not obtain required witness or staff statements and failed to assess or document critical resident risk factors, including the last time the resident was observed, the resident's mental status prior to the fall, and whether the call light was accessible. This deficient practice affected three residents (Residents #4, #82, and #117) of six residents reviewed for accidents. The facility census was 104.Findings include: 1. Record review revealed Resident #82 was admitted [DATE] with diagnoses of schizoaffective disorder, bipolar type, epilepsy, chronic obstructive pulmonary disease, and mild cognitive impairment of uncertain or unknown etiology. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #82 was cognitively intact, used a wheelchair and walker for mobility, and required supervision for toileting hygiene, showers, dressing, sit to stand movements, and transfers. Review of the progress notes revealed Resident #82 experienced an unwitnessed fall on 07/22/26. Resident #82 reported her knees gave out while ambulating in her room. Licensed Practical Nurse (LPN) #595 heard the resident calling for help and found her on the floor. Review of the fall investigation dated 07/22/26 revealed no staff statements were obtained and no post fall assessment was completed. The investigation did not contain documentation of when the resident was last observed by staff, whether his call light was within reach, or the resident's mental status prior to the fall. Review of additional progress notes showed Resident #82 suffered a witnessed fall on 08/09/26 in the dining room while attempting to move a table for Bible study. Another resident notified LPN #528 of the fall and reported that Resident #82 did not hit her head. Review of the fall investigation dated 08/09/26 again revealed no witness statements or staff statements were obtained and no post fall assessment was completed. 2. Record review revealed Resident #4 was admitted [DATE] with diagnoses of acute and chronic respiratory failure, type II diabetes mellitus with foot ulcer, major depressive disorder, and acute on chronic diastolic congestive heart failure. Review of the significant change MDS 3.0 assessment dated [DATE] revealed Resident #4 was cognitively intact, used a wheelchair or walker for mobility, was independent with eating, oral hygiene, toileting hygiene, and personal hygiene, and required supervision for showers, lower body dressing, rolling left and right, sit to lying, lying to sitting, sit to stand, and transfers. Review of the progress notes revealed Resident #4 suffered an unwitnessed fall on 08/03/26. Resident #4 was heard yelling for help by LPN #598 who responded to his room. Resident #4 reported he fell asleep and subsequently slid off the bed. Review of the fall investigation dated 08/03/26 revealed there were no staff statements obtained. The investigation did not contain documentation of when the resident was last observed by staff, whether his call light was within reach, or the resident's mental status prior to the fall. 3. Review of the medical record revealed Resident #117 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, dependence on a ventilator, encounter for surgical aftercare following surgery on the nervous system, encounter for surgical aftercare following surgery on the digestive system, respiratory arrest, tracheostomy status, gastrostomy status, contusion of unspecified part of the neck, and dependence on supplemental oxygen. Review of the medical record revealed there was no MDS assessment completed on Resident #117 because he was a new admission. Review of the admission assessment dated [DATE] revealed Resident #117 was alert and oriented to person, place, and time. Resident #117 was at risk for falls related to need for assistance with personal care. Interventions included resident education and providing rest periods. Review of the care plan dated 08/15/26 revealed Resident #117 had an actual fall in which he was found on his hands and knees crawling toward the door with bleeding noted from his head. His tracheostomy tube was observed on the floor. Resident #117 was transferred to the emergency room (ER) for further clinical evaluation following the fall. Interventions included assessing for injuries, placing fall mats on both sides of the bed, completing neurological checks per facility policy, notifying the physician of the fall, and providing reminders to use the call light for assistance. Review of the progress note dated 08/16/26 at 940 AM and authored by LPN #545 revealed the nurse heard a ventilator alarm and walked into the Resident #117's room to find the resident on his hands and knees crawling to the door with his head bleeding and tracheostomy equipment on the floor. Vital signs were checked and the tracheostomy tube was reinserted by the respiratory therapist. 911 was called, and the resident was transported to the ER for further evaluation. Review of the fall investigation dated 08/16/26 revealed Resident #117 was found on the floor after his ventilator alarm sounded. The investigation did not include documentation of when the resident was last observed by staff, whether his call light was within reach, or the resident's mental status prior to the fall. Two witness statements authored by Registered Nurse (RN) #540 and Respiratory Therapist (RT) #527 were included; however, neither statement documented the last time Resident #117 was checked. Additionally, no witness statements were obtained from the nurse assigned to Resident #117 on the day of the fall or the certified nurse aide (CNA) responsible for his care. During an interview on 08/20/26 at 7:40 A.M., LPN #545 who was identified as the nurse of record for the fall and transfer of Resident #117 revealed she was alerted to Resident #117 being on the floor due to the ventilator alarm sounding. LPN #545 was unable to state the last time Resident #117 was checked. During an interview on 08/20/26 at 4:45 P.M., the Director of Nursing (DON) verified the lack of a thorough fall investigation for Residents #4, #82, #117 The DON stated she does not get witness/staff statements if the reason for the fall is obvious Review of the facility's Fall Prevention Policy, dated 02/2021, revealed the purpose of the policy was to promote resident safety and identify measures to prevent falls. The policy stated that upon admission, staff would orient the resident to their surroundings, ensure the call light was within reach, maintain clear pathways, and provide adequate lighting. The policy further required fall risk assessments upon admission, quarterly, annually, with any significant change, after each fall, and as otherwise indicated. Appropriate fall prevention interventions were to be implemented based on the individual resident's assessed needs. The policy did not include guidance regarding conducting thorough investigations following a fall.

Based on record reviews, observations, interviews, and policy review, the facility failed to provide adequate and timely incontinence care. This affected two residents (Residents #64 and #77) of four residents who were investigated for incontinence care. The facility also failed to ensure urinary catheter care orders were in place. This affected one resident (Resident #124) of four residents who were reviewed for catheter care. The facility census was 104.Findings include: 1. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including spina bifida, paraplegia, neuromuscular dysfunction of the bladder, and a need for assistance with personal care. Significant physician orders included irrigating the Foley catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) with 50 cubic centimeters (cc) of normal saline solution as needed; providing Foley catheter care twice daily and as needed due to neuromuscular bladder dysfunction; applying Dermaseptin topically to the bilateral groin each shift and as needed; administering cranberry 450 milligrams (mg) orally each morning as a supplement; and administering oxybutynin 5 mg (an anticholinergic medication) orally twice daily for bladder spasms. Review of the care plan dated 06/28/26 revealed Resident #77 had an alteration in elimination related to the presence of an indwelling Foley catheter. Interventions included providing catheter care each shift and as needed, monitoring elimination patterns, and assessing the skin for redness or irritation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating Resident #77 was cognitively intact. Resident #77 was dependent on staff for toileting, had an indwelling urinary catheter, and was always incontinent of bowel. On 08/24/26 at 10:30 A.M., an observation of incontinence and catheter care for Resident #77 conducted with Certified Nurse Aide (CNA) #637 revealed the resident to be wet with urine. Resident #77 stated her catheter often leaked and that she needed to be changed. At the start of care, two adult wet wipes were observed stuffed in the resident's perineal area. CNA #637 verified the presence of the two wipes during the observation. Resident #77 denied placing the wipes there herself and expressed upset that they had been left in place during her previous incontinence care. She was unsure of the last time she had been changed. As care continued and the resident was turned to her side, the bedding underneath her was visibly saturated with urine, and a strong urine odor was noted. CNA #637 verified the wet bedding and odor at the time of the observation and was unable to state when the resident was last changed. 2. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, morbid obesity, urethral stricture, retention of urine, benign prosthetic hyperplasia with lower urinary tract symptoms, and obstructive and reflux uropathy. Significant orders included house barrier ointment topically to buttocks, coccyx, scrotum and heels every shift and as needed. Review of the care plan dated 06/22/26 revealed Resident #64 had bladder incontinence and was at risk for skin breakdown. Interventions included administering treatments per physician orders and assisting with toileting and incontinence care as needed. Review of the annual MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15/15 indicating Resident #64 was cognitively intact. Resident #64 was dependent on staff for toileting and was always incontinent of bowel and bladder. On 08/24/26 at 10:20 A.M., an observation of incontinence care for Resident #64 was conducted with Licensed Practical Nurse (LPN) #519 and CNA #559. Resident #64's brief was heavily saturated with urine. He stated the last time he had been changed was at 4:30 A.M. that morning. His scrotal area was noted to be significantly reddened. After turning Resident #64 to his side, his buttocks were observed to be extremely red and excoriated, with areas beginning to bleed during wiping. Resident #64 stated he had not been excoriated upon admission. LPN #519 and CNA #559 verified the observations at that time. CNA #559 further stated she had not checked Resident #64 for incontinence since the beginning of her shift that morning at 7:00 A.M. Review of the undated facility policy titled; Incontinence Care revealed the purpose of the policy is to maintain skin integrity, prevent skin breakdown, control odor and provide comfort and self-esteem for residents. The protocol is to be utilized on residents who are incontinent about and or bladder. 3. Review of the closed medical record for Resident #124 revealed an admission date of 06/11/26. He was sent to the hospital on [DATE]. His diagnoses included obstructive and reflux uropathy (structural or functional hindrance of normal urine flow), sepsis, congestive heart failure, spinal stenosis and necrotizing fasciitis (a rare, rapidly progressing bacterial infection that destroys soft tissue and can be life-threatening). Review of Resident #124's June 2026 physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) revealed orders dated 06/12/26 documenting the reason for the resident's Foley urinary catheter as obstructive uropathy and necrotizing fasciitis. Additional orders included placement of an indwelling 16 French Foley catheter with changes as needed, and irrigation of the catheter with 30 cc of normal saline solution as needed for blockage. There were no physician orders directing staff to provide routine catheter care or to measure urinary output. Review of the 5-Day MDS 3.0 assessment dated [DATE] revealed Resident #124's cognition was intact and he had an indwelling urinary catheter. He was dependent on staff for toileting hygiene. Review of care plan dated 06/17/26 revealed Resident #124's had an alteration in elimination as he had a colostomy and an indwelling urinary catheter secondary to obstructive uropathy. He was at risk for infection related to Foley status and had a history of urinary tract infections (UTIs). Interventions included changing urinary catheter per physician orders and as needed, catheter care every shift and as needed and monitor for signs of UTI. There was nothing in the care plan regarding monitoring his urinary output. Review of the June 2026 task bar in the electronic medical record (EMR) for Resident #124 revealed no documentation indicating that catheter care was completed or that urinary output was measured. During an interview on 08/25/26 at 2:15 P.M. with the Director of Nursing (DON) verified Resident #124 was at high risk for infection due to history of UTI and necrotizing fasciitis. She verified there were no physician orders for Resident #124 to have catheter care completed and/or the measurement of his urinary output. She verified she had no documentation that Resident #124's catheter care was completed and that his urinary output was monitored during his stay at the facility from 06/11/26 to 06/17/26. Review of undated facility policy labeled, Foley Catheter Care revealed the nursing staff would provide urinary catheter care in the morning, before the hour of sleep and as needed per physician's order. Staff would monitor intake and output and record the findings on the MAR, as needed. This deficiency represents non-compliance investigated under Master Complaint Number 3156656 and Complaint Numbers 3073858, 2994130, and 2668487.

Based on record review, observation, interview, and policy review, the facility failed to provide physician ordered medication. This affected one resident (Resident #50) of four residents observed for medication administration. The facility census was 104.Findings include:Review of the medical records for Resident #50 showed an initial admission date of 07/21/26 and a readmission date of 08/03/26. The resident was hospitalized from [DATE] through 08/03/26. Significant diagnoses included alcohol abuse and unspecified cirrhosis of the liver. Notable orders included Resmetirom 100 milligrams, one tablet by mouth daily, prescribed for noncirrhotic metabolic dysfunction with moderate to advanced liver scarring and documented as related to alcohol abuse.Review of an email dated 07/21/26 at 11:45 A.M. from the pharmacy to the Administrator revealed that Resmetirom was unable to be obtained and supplied by the pharmacy.Review of the July 2026 Medication Administration Record (MAR) revealed that Resmetirom was not dispensed to Resident #50 on 07/22/26, 07/23/26, 07/24/26, 07/25/26, 07/27/26, and 07/28/26. On each of these dates, the medication was coded as 9, indicating it was not administered.Review of the care plan dated 08/03/26 revealed that Resident #50 was not care planned for cirrhosis of the liver or for medication administration related to this condition.Review of the Medicare 5-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11/15 indicating Resident #50 had moderate cognitive impairment.Review of the August 2026 MAR revealed that Resmetirom was not dispensed to Resident #50 on 08/04/26 through 08/13/26, as well as on 08/15/26, 08/17/26, and 08/19/26.Review of the progress notes from admission through 08/19/26 revealed that the physician was not notified that Resmetirom was not dispensed to Resident #50 and was unavailable to the facility.On 08/19/26 at 8:40 A.M., an observation of medication administration for Resident #50 revealed that Resmetirom was not dispensed. Licensed Practical Nurse (LPN) #592 confirmed the medication had not been dispensed at the time of the observation and stated she believed the facility was waiting for insurance approval.On 08/20/26 at 4:45 P.M., an interview with the Director of Nursing (DON) confirmed that Resmetirom had not been administered to Resident #50 since admission or readmission. The DON also verified that the physician had not been notified of the medication's unavailability and was only later informed that the medication had not been administered. The DON stated she was not aware that the medication was unavailable from the pharmacy.A review of the undated facility policy titled Status Change in Resident Condition-Notification revealed that the licensed nurse is required to notify the resident's attending physician for direction when the resident misses two or more consecutive medication doses due to refusal, physician ordered hold parameters, or medication unavailability.This deficiency represents non-compliance investigated under Complaint Numbers 3134582 and 3042906.

Based on medical record review, staff interview, and facility policy review, the facility failed to accurately document resident health information in the medical record by including surgical wound assessments. This affected one resident (Resident #128) of four residents reviewed for accurate documentation. The facility census was 104.Findings include: Review of the closed medical record for Resident #128 revealed an admission date of 12/30/25 and discharge to the hospital on [DATE]. His diagnoses revealed fusion of the cervical spine, diabetes, and spinal stenosis. Review of former Resident #128's December 2025 and January 2026 Physician Orders and Treatment Administration Records (TARs) revealed an order dated 12/31/25 to check his skin related to his cervical collar use every shift and as needed and notify the physician of any changes in skin integrity. This was documented in the TAR as being completed as ordered. He also had an order dated 01/03/26 to remove the staples to his cervical incision on 01/09/26 and this was signed off as completed by former Licensed Practical Nurse (LPN) #901. Review of former Resident #128's admission Packet dated 12/30/25 and completed by former LPN #640 revealed his skin was not intact as he had areas to his sacrum and bilateral Achilles (heels). There was no documentation on his admission assessment regarding his cervical surgical incision with staples. Review of care plan dated 12/30/25 revealed former Resident #128 had an alteration in musculoskeletal status secondary to status post cervical (C2) to thoracic (T1) fusion and C3 to C7 laminectomy (a surgical procedure to relieve pressure on your nerves by removing the arched back piece of your vertebrae) on 12/26/25. Interventions included cervical collar prior to transferring and when out of bed, skin assessment per policy, and skin checks related to cervical collar use every shift and as needed. Review of nursing notes from 12/30/25 to 01/25/26 revealed there was no documentation regarding former Resident #128's cervical surgical incision including measurements and description of his wound. Review of nursing note dated 12/31/25 at 1:24 P.M. completed by former LPN #644 revealed the facility spoke with Surgeon #900 regarding follow-up appointments. Per Surgeon #900's office, former Resident #128 did not need to come back to see Surgeon #900 on 01/09/26 if the facility could remove the staples. A follow-up appointment was scheduled for 01/26/26 at 10:30 A.M. The facility was to obtain cervical x-rays prior to the appointment on 01/26/26 and a cervical collar was to be worn at all times prior to transferring and when out of bed. Surgeon #900 recommended skin checks every shift related to cervical collar use. Review of the Wound Nurse Practitioner (NP) #629's progress notes dated 01/01/26, 01/08/26, 01/15/26 and 01/22/26 revealed Wound NP #629 was in and evaluated former Resident #128's pressure areas to his sacrum and deep tissue injuries to his bilateral heels. There was no assessment documented regarding his surgical incision to his cervical area. Review of the Skin Grid Non-Pressure forms dated from 12/30/25 to 01/26/26 revealed there were no skin assessments completed regarding former Resident #128's surgical wound. Review of the Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed former Resident #128's cognition was intact and he had a surgical wound. Review of nursing notes dated 01/26/26 at 2:26 P.M. completed by former LPN #642 revealed former Resident #128 had bleeding and drainage from his neck and spine. The wound measured 9.0 centimeters (cm) length, 1.0 cm width and 2.0 cm depth. Review of the Skin Grid Non-Pressure form dated 01/26/26 completed by former LPN #642 revealed former Resident #128 had a surgical wound to the back of the head that measured 9.0 cm length, 1.0 cm width and 2.0 cm depth. There was moderate drainage and the wound was from recent spinal surgery. Review of the care plan dated 01/26/26 revealed former Resident #128 had an open area to the post-surgical site of the cervical neck. The area was closed, well-approximated with staples removed and it had reopened. Interventions included completing skin documentation per policy, monitoring for signs of infection, and skin assessments per facility policy. Interview on 08/25/26 at 11:02 A.M. and 11:52 A.M. with Director of Nursing (DON) verified former Resident #128 was admitted with a cervical surgical incision that was closed with staples and there was no documentation of the incision including measurements and its description. She verified the staples were removed on 01/09/26 as it was signed off by former LPN #901 in the TAR but that there was no documentation per the nursing notes regarding the measurements or a description of the surgical area after removal of the staples. She verified throughout his stay at the facility from 12/30/25 until 01/25/26 there was no documentation of his surgical wound that included measurements and/or its description. She confirmed on 01/26/26 was the first time there was documentation of his cervical surgical wound that revealed it measured 9.0 cm length, 1.0 cm width and 2.0 cm depth and the wound had moderate drainage from his recent spinal surgery. She stated that on admission the nurse should have measured and documented the description of the wound as well as the wound nurse should have assessed the surgical wound and completed a weekly Skin Grid Non-Pressure form that included measurements and description of the wound. Interview on 08/25/26 at 11:58 A.M. with former LPN #642 revealed she was on duty on 01/26/26 when she noticed former Resident #128's wound incision had dehisced (split open). She did not see any signs of infection and had contacted NP #643 who had ordered him to go to the hospital for evaluation. Interview on 08/25/26 at 12:16 P.M. with Respiratory Therapist #626 revealed former Resident #128 was also a family member and that he had seen his surgical wound almost daily as he was in the room assisting with respiratory needs as the nurses assessed his surgical area underneath his cervical collar. He revealed the surgical incision was approximately 8.0 inches in length from the base of his head to his upper spine and had staples that appeared well approximated. The staples were removed as ordered and the incision appeared to be healing well with no signs of infection. The first day the wound displayed a change in condition was on 01/26/26 when the incision split open and he was sent to the hospital. Review of undated facility policy labeled, Documentation, revealed the resident's clinical record was to be a concise account of treatment, care, response of care, signs, symptoms and progress of the resident's condition. There was nothing in the policy regarding documentation of skin including surgical incisions. This deficiency represents non-compliance investigated under Complaint Numbers 2729716 and 2732059.

Based on record review and interview the facility failed to revise Resident #7's care plan in response to new interventions to prevent resident to resident incidents. This affected one (Resident #7) of four residents reviewed for care plans. The facility census was 99. Findings include:Review of the medical record for Resident #7 revealed an admission date of 11/15/22 with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, chronic viral hepatitis (liver disease), mild dementia, and type two diabetes.Review of the closed medical record for Resident #13 revealed an admission date of 01/30/24 with diagnoses including cerebral palsy, osteogenesis imperfecta, diabetes mellitus type two, major depressive disorder, need for assistance with personal care, convulsions, and aortic stenosis. Resident #13 discharged from the facility on 02/02/26 to another facility. Review of a nursing note dated 09/27/25 revealed Resident #7 was involved in an incident with Resident #13 in Resident #13's room. The staff intervention included Resident #7 was given verbal instruction by staff to not enter Resident #13's room and staff demonstrated an alternate route to the back of the facility for the smoking and activity area. Resident #7 was agreeable to those interventions. This alternate route would allow Resident #7 to avoid passing by Resident #13's room. Review of the self-reported incident dated 12/07/25 revealed Resident #7 was involved in a second incident with Resident #13. Resident #7 was found in Resident #13's room and staff reminded him that he could not be in there and needed to leave.Review of the care plan for Resident #7, review date 12/23/25, revealed Resident #7 had an alteration in cognitive function secondary to dementia related to medication and cognitive deficits. Interventions included assisting with decision making problems, monitor for change in condition, monitor for changes in cognition, and offer verbal reminders and cues as necessary. There were no revisions made to the care plan to reflect the resident-to-resident incidents on 09/27/25 and 12/07/25 and interventions related to Resident #7 not entering Resident #13's room or taking an alternate route to the back of the facility to avoid passing by Resident #13's room.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 was cognitively intact, did not exhibit behavior symptoms or rejection of care, was independent with transfers, could self-propel in his wheelchair and required set up to moderate assistance for activities of daily living. An interview on 02/26/26 at 3:19 P.M. with the Director of Nursing (DON) verified there were two incidents between Resident #7 and Resident #13 in Resident #13's room, and Resident #7 was educated about not entering Resident #13's room and using an alternative route to the back of the building so he would not go by Resident #13 room. The DON verified those interventions were not added to the care plan for Resident #7.

Based on observation, record review, interview, and review of facility policy, the facility failed to ensure the resident received adequate supervision including maintaining a hazard free environment to prevent injury to Resident #30. This affected one resident (#30) out of three residents reviewed for accident hazards. The facility census was 101.Review of the medical record for Resident #30 revealed an admission date of 01/04/2010 with diagnoses including type two diabetes mellitus with hyperglycemia and diabetic neuropathy. Review of the minimum data set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #30 had intact cognition. Resident #30 required dependent assistance with showers. Review of the physician orders for September 2025 revealed an order for left foot third and fourth toe cleanse with normal saline (NS), apply mupirocin two percent (%) ointment, apply gauze, wrap with kerlix every other day (QOD), every dayshift, every other day for wound care and Doxycycline Hyclate 100 milligram (MG) give one (1) tablet by mouth (PO) two times a day (BID) for foot infection for 10 days. Review of the progress note dated 09/05/25 revealed Certified Nursing Assistant (CNA) #309 informed Licensed Practical Nurse (LPN) #300 while transporting Resident #30 out of the shower area in the shower room, Resident #30's third and fourth toe got caught on an uneven tiled area that was loose and missing tiles. CNA #309 stopped movement to get assistance while staying with the resident. Both feet were assessed by the nurse with the third and fourth digit toenails noted to be lifted, partial removal to both, and moderate amount of bloody drainage noted to areas. No visible open areas noted after cleansing with normal saline (NS) and dressing applied. Nurse Practitioner (NP) #401 updated while in the facility to evaluate with new orders to give Keflex (an antibiotic) 500 milligram (MG) three times a day (TID) for seven (7) days as prophylactic with podiatry consult and follow up. All notifications were made. An interview on 09/16/25 at 9:26 A.M. with Resident #30 confirmed she was showering on 09/05/25 and when leaving the shower her left foot toes got caught on the loose and missing tiles in the shower room on the 200 hall. Resident #30 reported she was seen by NP #401 and Podiatrist and started on an antibiotic and wound treatment. An observation on 09/16/25 at 10:31 A.M. of the shower room on the 200 hall revealed multiple areas of tile had been repaired. An interview on 09/16/25 at 10:31 A.M. with the Administrator confirmed the missing loose tile in the 200 shower room had been repaired. An interview on 09/16/25 at 10:48 A.M. with Maintenance #243 confirmed the shower room on 200 hall had loose and missing tile. Maintenance #243 reported he patched it up/repaired the missing and loose tiles in the shower room. An interview on 09/18/25 at 9:57 A.M. with Licensed Practical Nurse (LPN) #300 confirmed there was loose and missing tile in the 200 shower room and Resident #30 got her third and fourth toe on her left foot stuck on it resulting in an injury requiring treatment at the facility. An interview on 09/22/25 at 8:05 A.M. with CNA #309 confirmed Resident #30 got her third and fourth toe on her left foot caught in the loose and missing tile in the 200 shower room. Review of facility policy, Maintenance Repairs/Work Orders, dated 08/2016, revealed the policy was to ensure that facility environment, equipment and overall life safety was maintained to assist in prevention of breakdown. Review of facility policy, Safe and Homelike Environment, undated, revealed facility will provide a safe, clean, comfortable and homelike environment. Housekeeping and maintenance services will be provided to maintain a sanitary, orderly, and comfortable environment This deficiency represents non-compliance investigated under Complaint Number 2615515.

Based on record review, interviews and review of the facility shower schedules, the facility failed to provide showers as scheduled to Residents #23, #25, #31, and #53. This affected four (Residents #23, #25, #31, and #53) of seven residents reviewed for showers. The facility census was 99. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 07/05/25. Diagnoses included type two diabetes mellitus, acute respiratory failure, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had intact cognition. Resident #23 required moderate to extensive assistance for all activities of daily living. Review of the care plan dated 05/27/25 revealed Resident #23 required assistance with activities of daily living secondary to decreased mobility, generalized muscle weakness, and shortness of breath. Interventions included for staff to provide assistance with daily hygiene and showering per facility policy. Review of the facility shower schedule revealed Resident #23 was scheduled showers every Wednesday and Friday. Review of the shower sheets and shower documentation for Resident #23 for May 2025 revealed she did not have documentation of receiving a shower or refusal or shower on 05/16/25. 2. Review of the medical record for Resident #25 revealed an admission date of 01/04/10. Diagnoses included motor neuron disease, type two diabetes mellitus, and chronic obstructive pulmonary disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #25 had intact cognition. Resident #25 required extensive assistance to complete dependence on staff for all activities of daily living. Review of the care plan dated 05/29/25 revealed Resident #25 required activities of daily living assistance secondary to impaired mobility and generalized muscle weakness. Interventions included that Resident #25 was totally dependent on staff for showers, and for staff to assist with daily hygiene needs. Review of the shower schedule revealed she was to have showers every Monday, Wednesday, and Friday. Review of the shower sheets for Resident #25 for May 2025 revealed she did not have documentation of receiving a shower or refusal or shower on 05/09/25 or 05/26/25. Interview on 06/03/25 at 8:23 A.M. with Resident #25 reported she is not getting three showers a week like she is scheduled. She reported she is lucky if she gets two a week. 3. Review of the medical record for Resident #31 revealed an admission date of 03/28/25. Diagnoses included malignant neoplasm of the cerebrum with metastasis, epilepsy, and hypertension. Review of the care plan dated 03/28/25 revealed Resident #31 required assistance from staff for activities of daily living. Interventions included that staff would assist with daily hygiene and showers as per facility policy. Review of the admission MDS assessment dated [DATE] revealed Resident #31 had moderate cognitive impairment. Resident #31 required set-up to moderate assistance for all activities of daily living. Review of the shower schedule revealed he was to be showered on Sundays and Thursdays. Resident #31 did not receive showers on 05/01/25, 05/04/25, 05/11/25, 05/15/25, and 05/18/25 with no documented evidence of refusals. 4. Review of the medical record for Resident #53 revealed an admission date of 08/26/24. Diagnoses included Huntington's disease and dysphagia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #53 had moderate cognitive impairment. Resident #53 required extensive assistance to total dependence on staff for all activities of daily living. Review of the care plan dated 05/26/25 revealed Resident #53 required assistance from staff for activities of daily living. Interventions included that staff would assist with daily hygiene and showers as per facility policy. Review of the shower sheets for May 2025 revealed she was ordered showers every Monday, Wednesday, and Friday. Review of the shower sheets for May 2025 for Resident #53 revealed she did not have documentation of receiving a shower or refusal or shower on 05/09/25. Interview on 06/04/25 at 9:48 A.M. with the Administrator confirmed that showers have been an issue in the facility and verified the missing showers for Residents #23, #25, #31, and #53. The Administrator reported they changed the system with showers in February 2025 with getting rid of the shower aide, and the facility has struggled since. This deficiency represents non-compliance investigated under Complaint Number OH00166091.

Based on record review, interview and facility policy review, the facility failed to adequately control Resident #38's pain when his as needed pain medication was not administered timely on 05/31/25. This affected one (Resident #38) of three residents reviewed for pain management. The facility census was 99. Findings include: Review of the medical record for Resident #38 revealed an admission date of 05/29/25. Diagnoses included sepsis, fracture of the left pubis, and wedge compression fracture of the third lumbar vertebra. Review of the physician's order dated 05/29/25 revealed an order to administer oxycodone (opioid pain medication) 10 milligrams (mg) by mouth every four hours as needed for pain. Review of the admission assessment dated [DATE] revealed Resident #38 had intact cognition and was aware of person, place, and time. Resident #38 reported he had severe pain. Review of the care plan dated 05/29/25 revealed Resident #38 was at risk for alteration in comfort secondary to bacteremia infection, closed compression fractures, and left-sided inferior pubic ramus closed fracture. Interventions included administering medications as ordered and monitoring for effectiveness and interventions. Review of the Medication Administration Record (MAR) for 05/31/25 revealed Resident #38 received his oxycodone at 4:02 A.M. and did not receive his next dose until 10:49 A.M. Interview on 06/03/25 at 8:43 A.M. with Resident #38 reported he keeps notes on everything. Review of the progress notes on 05/31/25 revealed he activated his call button from 8:30 A.M. to 9:30 A.M. His call light still had not been answered, so he called the main phone line reporting he wanted pain medication because it was due at 8:30 A.M., and he needed it. Resident #38 reported the nurse did not administer his pain medication until around 11:00 A.M. when she finally answered the call light. Interview on 06/04/25 at 9:36 A.M. with Licensed Practical Nurse (LPN) #502 revealed that she did care for Resident #38 on 05/31/25. It was her first day caring for him. She reported she was told in report that he wanted his pain medications every four hours but was not told what time his next dose was due. She confirmed she did not answer the call light until 10:40 A.M. and administered his pain medications then. LPN #502 reported that morning was busy, but the facility did have enough staff. LPN #502 also reported that she now is getting to know Resident #38 and is in his room every four hours if he hits the call light or not. Review of the undated facility policy labeled Pain Management revealed the healthcare facility recognizes the need to identify pain and its underlying cause, as able, that will allow for a prompt response to pain. This deficiency is an incidental finding identified during the complaint investigation.

Based on record review, interview, review of facility investigation and policy review, the facility failed to ensure Resident #53 received the ordered food texture resulting in her choking and requiring the Heimlich maneuver. This affected one (Resident #53) out of three residents removed for modified food texture and had the potential to affect 18 additional (Residents #5, #13, #20, #26, #30, #43, #47, #48, #55, #56, #71, #76, #78, #82, #86, #95, #100, and #101) identified by the facility as requiring a modified diet texture. The facility census was 99. Findings include: Review of the medical record for Resident #53 revealed an admission date of 08/26/24. Diagnoses included Huntington's disease and dysphagia. Review of the physician's order dated 08/26/24 revealed Resident #53 required regular diet with mechanical soft texture, and thin liquids. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had moderate cognitive impairment. Resident #53 required extensive assistance for all activities of daily living and set up and cueing for eating. Review of the nursing progress note dated 05/13/25 at 5:30 P.M. revealed Resident #53 was eating in the dining room at 3:18 P.M. during an activity program and began choking on a piece of sausage. Initially, Resident #53 was able to talk but with continued coughing her airway became increasingly obstructed. The Heimlich procedure was done with five thrusts, and Resident #53 was able to cough out the food. She was assessed and vital signs were taken with no concerns for wheezing or shortness of breath. The physician was notified and a new order for vital signs every four hours for 24 hours was obtained. Review of the care plan dated 05/26/25 revealed Resident #53 required a mechanically altered diet. Interventions included to monitor consistency of diet served, and honor food preferences if able. Interview on 06/04/25 at 10:32 A.M. with Resident #66 revealed she had no concerns and reported she felt safe in the facility. Resident #66 reported she was there for the incident with Resident #53. Resident #66 pointed to Contracted Behavioral Health Aide #506 and reported that she gave her a bratwurst, and Resident #53 was not supposed to have it. Resident #66 confirmed that Resident #53 began choking, and the nurse had to do the Heimlich maneuver to get it out. Resident #66 reported it was scary to watch. Interview on 06/04/25 at 10:38 A.M. with Contracted Behavioral Health Aide #506 confirmed she did give Resident #53 the bratwurst, and she did choke on it and require the Heimlich maneuver. Contracted Behavioral Health Aide #506 reported that the facility keeps a logbook in the activity and lunchroom that states every resident's diet, and they were to check the book before giving any food to the residents. She reported that it was her second day at the facility, and she did not check. Interview on 06/04/25 at 10:45 A.M. with Resident #53 confirmed she did eat the bratwurst and choked. She reported the nurse gave her the Heimlich maneuver, and she did not get hurt or have any problems after. Resident #53 reported she feels happy in the facility and had no concerns with her care. Review of the undated facility policy labeled Assisting a Resident with Feeding stated the staff member will verify the type of diet, consistency, and/or need for thickened liquids or devices with feeding prior to initiating feeding. This deficiency represents non-compliance investigated under Complaint Number OH00166091.

Based on observation, interview and review of facility policy, the facility failed to maintain a clean and homelike environment. This affected four residents (#13, #35, #74 and #257) of ten residents reviewed for environmental concerns and had the potential to affect all 106 residents residing in the facility. Findings include: Observation on 04/28/25 at 10:27 A.M. of Residents #13 and #35's room revealed a large amount of dirt accumulation on the floor including underneath both beds. There were multiple pieces of paper and plastic, pieces of used medical equipment such as what appears to be an intravenous cap and a used individual serving coffee creamer cup. There was no trash bag in the trash can. Interview at the time of the observation with Housekeeping Surveyor (HS) #3910 verified the findings and indicated being new to the job and having made changes to address some of the issues. Housekeepers were not available after 5:00 P.M., so nursing assistants were supposed to assist with any visible issues until a housekeeper returned the following day but admitted the dirt accumulation in Residents #13 and #35's room appeared to be over more than one day. Observation and interview on 04/28/25 at 10:56 A.M. of Residents #74 and #257's room revealed a large amount of dirt accumulation on the floor and bathroom floor including underneath both beds. There were multiple pieces of plastic and paper and dried spills throughout. Numerous areas of the floors and around the bathroom toilet were darkened from dirt build-up. Resident #257 complained of the floor being overly dirty and of housekeeping not cleaning on a routine basis. Interview at the time of the observation with Registered Nurse (RN) #3340 verified the findings and indicated there should be a housekeeper coming around to address it. Observation and interview on 04/28/25 at 11:06 A.M. with HS #3910 of Residents #74 and #257's room confirmed the dirty floors and indicated it had accumulated over more than one day. Resident #74's overbed table had large amounts of dried spills on the tabletop and table legs. HS #3910 verified the overbed table was not cleaned after use on a routine basis. Review of facility policy, Housekeeping Policy/Procedure, dated 12/28/13, revealed the facility will be maintained and cleaned to meet a home like environment for residents. This deficiency represents non-compliance investigated under Complaint Number OH00163856 and Complaint Number OH00163679.

Based on observation, interview, record review, review of photographs provided by Resident #27's fiancee/power of attorney (POA) and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of pressure ulcers and timely identify new pressure ulcers, including timely incontinence care and turning and repositioning. This affected two residents (#27 and #109) of two residents reviewed for pressure ulcers. The facility census was 106. Actual Harm occurred on 12/19/24 when Resident #27, who had a history of a pressure ulcer, quadriplegic and in a persistent vegetative state, was dependent on staff assistance for all activities of daily living (ADL) including toileting, hygiene, showers, dressing, transfers, and rolling left and right in bed, was found to have an in-house acquired Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) to his sacrum that contained 30 percent slough/necrosis (dead tissue). The facility failed to provide documented evidence of effective, comprehensive, and adequate interventions being in place to prevent the development of this pressure ulcer and to ensure the pressure ulcer was identified before being found at a Stage III. Actual Harm occurred on 01/16/25 when Resident #109, who was dependent on staff for all ADL care including toileting, hygiene, showers, dressing, and rolling left and right in bed, was found to have an in-house acquired unstageable (full thickness tissue loss in which the actual depth of the ulcer was obscured by slough/ dead skin) pressure ulcer to his left lateral foot that contained 100 percent dry eschar firmly adhered. The facility failed to provide documented evidence of effective, comprehensive, and adequate interventions being in place to prevent the development of this pressure ulcer and to ensure the pressure ulcer was identified before being found at unstageable. Findings include: 1. Review of the medical record for Resident #27 revealed an admitted [DATE] with diagnoses including anoxic brain damage, chronic respiratory failure, quadriplegia, and persistent vegetative state. Review of the care plan dated 12/05/24 revealed Resident #27 was dependent on staff with ADL due to anoxic brain damage, persistent vegetative state quadriplegia. Interventions included turning and repositioning every two hours, staff to provide incontinence care with routine rounds, and staff to provide all care as he was dependent and does not participate in any aspect of his ADL. Review of the care plan dated 12/05/24 revealed Resident #27 was at risk for impaired skin integrity secondary to bowel and bladder incontinence and impaired mobility, and he required total staff dependence for all his care needs. Interventions included elevating heels off mattress, inspecting skin during routine daily care, lift sheet on chair/bed for positioning, lotion to skin as needed, incontinence care after each incontinent episode, pressure reduction mattress to bed, and treatments as ordered. Review of the CHS Admission Packet V13.1 dated 12/05/24 and completed by Wound Nurse/Licensed Practical Nurse (LPN) #209 and LPN #287 revealed on admission Resident #27 was in a comatose state and his skin was warm, dry and within normal limits. He had a left buttock open area, but no description was noted in the assessment. There was no skin integrity issues noted to his sacral area. (There was no further reference to any area on his left buttock in the medical record). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had impaired cognition. He was dependent on staff for all ADL, including rolling left and right, toileting hygiene, personal hygiene, transfers, and showers. He was always incontinent with bowel and bladder and was at risk for developing pressure ulcers but had no unhealed pressure ulcers on admission. Review of the Braden Scale for Predicting Pressure Sore Risk dated 12/12/24 and completed by Wound Nurse/LPN #209 revealed Resident #27 was at very high risk for the development of pressure ulcers as he was completely limited with sensory perception, very moist, bedfast, completely immobile, and had a problem with friction and shearing. Review of the Skin Grid Pressure 3.0-V2 dated 12/19/24 and completed by Wound Nurse/LPN #209 revealed on 12/18/24, Resident #27 was identified to have a new Stage III pressure ulcer to his sacrum area that measured of 5.5-centimeter (cm) length by 6.1 cm width by 0.3 cm depth. The assessment described the area as: several open areas across the sacrum among scar tissue from a previously healed pressure wound. There was thin slough with granulating tissue with scattered areas of moist tissue at wound edges. The wound had moderate drainage. Review of the nursing note dated 12/19/24 at 3:00 P.M. and completed by Wound Nurse/LPN #209 revealed she noticed a new Stage III pressure injury to Resident #27's sacrum area with scar tissue surrounding the wound indicating he had a previous pressure area to this area. The nursing note revealed she ordered an air mattress and to off-load the pressure with wedges. Review of the care plan dated 12/19/24 revealed Resident #27 had actual impaired skin integrity as he had a Stage III pressure ulcer to his sacrum which the family had reported he had a wound there a few years ago. Interventions included wound care per physician orders, referring to a wound physician, low air loss mattress on the bed, and ensure Resident #27 was turned and repositioned per orders. Review of Wound Nurse Practitioner (NP) #318's progress note dated 12/19/24 revealed this was the first time she consulted for Resident #27 and noted Resident #27 to have a Stage III pressure ulcer to his sacrum area that measured 5.5 cm length by 6.1 cm by 0.3 cm depth. The wound contained 30 percent slough. She revealed even though there was slough/eschar present it did not obscure the extent of tissue loss; therefore, it was acceptable to classify this wound as a Stage III. She noted several open areas across his sacrum among scar tissue related to previously healed pressure wound. The note revealed that the family had reported he had a previous wound to his sacrum a few years ago that healed. (There was no documentation in her progress note regarding the wound being unavoidable). Review of the facility form labeled Unavoidable Pressure Injury dated 12/19/24 revealed Resident #27's pressure ulcer was unavoidable because the resident had impaired mobility, bowel incontinence, quadriplegia and had a prior history of pressure ulcer in the same location. The physician signature line had NP #317's printed name. Review of the undated pictures taken by Resident #27's fiancee/ POA revealed three pictures: 1. A picture of a blue incontinence brief heavily saturated in urine with dark yellow and brown urine in it. The picture appeared that Resident #27 had urinated multiple times in the brief. 2. A picture with the white washable incontinence pad that had a large brown urine ring underneath Resident #27's buttocks. 3. A picture of linen with brown, yellow discoloration appearing from urine. Resident #27's fiancee/ POA stated she had taken the pictures 12/22/24 at 6:18 P.M. Review of text message from Resident #27's fiancee/ POA to Director of Nursing (DON) dated 12/23/24 at 8:50 A.M. revealed my concerns are still there after I spoke with you my fiancee lays there in pee and the changing supposed to be every two hours but guess what I'm there for hours at a time without him getting changed. I pulled a nasty diaper off him with a chuck also soaked to the core through and about ten pounds the night before and yesterday. Review of the Skin Grid Pressure 3.0-V2 dated 01/16/25 and completed by Wound Nurse/LPN #209 revealed Resident #27 continued to have a Stage III pressure area to his sacrum area that measured 0.9 cm length by 0.6 cm width by 0.3 cm depth. The area improved with dark pink granulating tissue present and moderate drainage. Interview on 01/21/25 at 9:41 A.M. with LPN #221 revealed there had been issues with incontinence care getting done. She revealed there was a problem last night as when she came in there were multiple rooms where resident's incontinence briefs excessively filled with urine indicating the residents were not changed. She revealed the urine had leaked out of the incontinence briefs onto the bed linens requiring several full linen bed changes. She revealed many of the linen changes had brown rings. Interview on 01/21/25 at 10:08 A.M. and 01/22/25 at 4:49 P.M. with Resident #27's fiancee/ POA revealed Resident #27 was admitted to the facility with intact skin. She was upset as she came in almost daily and frequently found him with saturated incontinence briefs, and dried brown urine-soaked linens indicating he was not being changed timely as well as when she was in the facility for long periods of time, he was not being turned and repositioned every two hours as he needed to be. She revealed she took multiple pictures of the incontinence briefs and linens and showed the pictures and brought up her concerns to the DON. She revealed Resident #27 then developed a large pressure ulcer to his sacrum which she believed never should have happened if he was being changed and turned as he needed. She verified the pictures of the saturated blue incontinence brief, washable incontinence pad with large brown ring underneath Resident #27's buttocks were soaked with urine and the linen with brown, yellow discoloration appearing from urine were taken on 12/22/24 at 6:18 P.M. Interview on 1/21/25 at 11:21 A.M. and 3:20 P.M. with Wound Nurse/LPN #209 verified Resident #27's pressure ulcer to his sacrum was first identified at Stage III and contained 30 percent slough tissue. She was unable to provide a reason why the wound was not identified before it was Stage III. She revealed she did not see him daily and was not at the facility 24 hours a day, so she was unable to say if he was being provided with timely incontinence care and/or turned and repositioned every two hours but believed that he was. Interview on 01/21/25 at 2:22 P.M. and 2:44 P.M. with the DON verified Resident #27's fiancee/ POA showed her pictures as well as communicated her concern to her that Resident #27 was not getting turned and repositioned or changed timely. She was shown the pictures and verified the blue incontinence brief was heavily saturated in urine with yellow and brown urine in it. She verified the picture appeared he was not changed in a timely manner. She stated, I do not really have an explanation of why but that was why the facility proceeded to go to a condom catheter (a urine collection device that fits like a condom over the penis and has a tube to drain the urine). She then verified the pictures with the white washable incontinence pad that had a large brown ring underneath Resident #27's buttocks and the linen with brown, yellow discoloration appearing from urine. She again stated she had no explanation and again stated that was why the facility went with a condom catheter. Interview on 01/22/25 at 9:42 A.M. with NP #317 regarding the facility form labeled Unavoidable Pressure Injury dated 12/19/24 revealed Resident #27's pressure ulcer was unavoidable because the resident had impaired mobility, bowel incontinence, quadriplegia and had a prior history of pressure ulcer in the same location. The physician signature line had NP #317's printed name. She stated she had never seen this form prior and verified she had not filled out this form and never discussed Resident #27's wound with the facility. She did not get involved with the wounds because the facility had a wound company that came in and handled the wounds at the facility. Observation of wound care on 01/22/25 at 9:58 A.M. revealed Assistant Director of Nursing (ADON)/Registered Nurse (RN) #309 changed Resident #27's wound dressing to his sacrum area according to the physician order. She described the wound bed as red with minimal drainage and no signs of infection. Interview on 01/22/25 at 10:45 A.M. with DON revealed she was not aware Wound Nurse/LPN #209 had printed NP #317's name on the form in the area of physician's signature. She verified she had spoken with NP #317 who also confirmed to her that she had not signed the form and/or had any discussion with the facility regarding Resident #27's wound status. She revealed she felt it was a mistake but could not speak about why this was done at this time as currently Wound Nurse/LPN #209 was on suspension. 2. Review of the closed medical record for Resident #109 revealed an admitted [DATE], and he was discharged to the hospital on 01/19/25. His diagnoses included acute and chronic respiratory failure with hypoxia, dependence on a respiratory ventilator, and hemiplegia and hemiparesis following cerebrovascular disease effecting his left dominant side. Review of the CHS Admission Packet V13.1 dated 12/11/24 and completed by Wound Nurse/LPN #209 and LPN #287 revealed Resident #109 was disoriented, nonverbal, and had severe cognitive impairment. He had a deep tissue injury (DTI) (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.) to his coccyx, left buttock and right buttock and a pressure ulcer to his left hip region. There was no skin impairment identified to his bilateral lower feet. Review of the care plan dated 12/11/24 revealed Resident #109 was admitted with impaired skin integrity/pressure ulcers. He was unable to reposition himself. Interventions included elevating heels off the mattress, inspecting skin during routine daily care, lotion to skin as needed, pillows for positioning, skin assessments as ordered, turn and reposition as ordered, and pressure reduction devices if ordered. Review of the care plan dated 12/12/24 revealed Resident #109 required staff assistance for his ADL related to ventilator and tracheostomy dependent. Interventions were identified as staff to assist with daily hygiene, and staff to adjust care as needed to meet resident's needs. Review of the admission MDS assessment dated [DATE] revealed Resident #109 was dependent on staff to roll him left and right, toileting hygiene, personal hygiene, and showers. Review of the Braden Scale for Predicting Pressure Sore Risk dated 12/19/24 revealed Resident #109 was at high risk for developing pressure ulcers because he was very limited to sensory perception, very moist, bedfast, very limited to mobility, and had a problem with friction and shear. Review of the previous Skin Grid Pressure 3.0-V2 dated 12/12/24, 12/19/24, 12/26/24, 01/02/25, and 01/09/24 revealed no documented evidence of any identified concerns to Resident #109's left lateral foot. Review of the Skin Grid Pressure 3.0-V2 dated 01/16/25 and completed by Wound Nurse/LPN #209 revealed Resident #109 had an unstageable pressure ulcer to his left lateral foot that measured 2.5 cm in length by 2.0 cm width by depth was unable to be determined. The assessment described the wound as having firmly adhered dry eschar. Review of the nursing note dated 01/16/25 at 9:51 A.M. and completed by Wound Nurse/LPN #209 revealed she contacted Resident #109's daughter for permission for Resident #109 to see Wound NP #318. Resident #109's daughter agreed. There was no other documentation in the nursing notes regarding Resident #109's pressure ulcer to his left lateral foot. Review of Wound NP #318's progress note dated 01/16/25 revealed this was Wound NP #318's initial consultation. Resident #109 had an unstageable left lateral foot pressure ulcer that was measured 2.5 cm length by 2.0 cm width by depth was unable to be determined. The wound was described to have 100 percent dry firmly adhered eschar. She that this wound was present on admission. Review of the January 2025 physician order revealed Resident #109 had an order dated 01/17/25 to cleanse the left lateral foot with normal saline, apply Skin Prep (forms a protective barrier) and leave open to air every day-on-day shift. Interview on 01/22/25 at 10:45 A.M. with the DON verified Resident #109's left lateral pressure ulcer to his foot was facility acquired as it was first identified as an unstageable pressure ulcer on 01/16/25 per the documentation, and that it contained 100 percent dry, firmly adhered eschar. She revealed she could not explain why it was found as unstageable and not at an earlier stage, especially since Resident #109 was dependent on staff for all ADL. Interview on 01/22/25 at 1:20 P.M. with Wound NP #318 revealed the first time she consulted for Resident #109 was on 01/16/25. She verified she documented on her progress note that Resident #109's unstageable pressure to the left lateral foot was present on admission and stated that was what Wound Nurse/LPN #209 told her. She verified she did not realize the first documentation of this area was on 01/16/25. She verified when she initially saw the wound to the left lateral foot on -1/16/25, it was unstageable with 100 percent dry eschar. Review of the undated facility policy labeled, Pressure Ulcer Prevention and Risk Identification revealed the facility would assess each resident for risk of pressure ulcer development in an effort to establish measures to prevent the development of pressure ulcers within the facility. A pressure ulcer risk assessment for each resident would be completed upon admission and weekly times four weeks and preventative measures would be implemented based on the resident's assessed need and risk score. The policy revealed a care plan would be developed and updated routinely with identified skin risk and/or actual wound development. Interventions would be implemented as indicated by the physician and as determined by the interdisciplinary team. This deficiency represents non-compliance investigated under Complaint Number OH00161212.

Based on interview, observation, record review and policy review, the facility failed to ensure appropriate interventions were implemented to prevent the development of a pressure ulcer for Resident #69. Actual Harm occurred on 12/23/20 when Resident #69 who required two person assist with bed mobility and was totally dependent with two person assist with transfers was found to have his over the bed table wedged against his right knee resulting in an unstageable pressure ulcer (full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar) when first observed by Registered Nurse (RN)/Wound Nurse #611. This affected one resident (Resident #69) of three residents reviewed for pressure ulcers. The facility census was 100. Findings include: Review of the medical record for Resident #69 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care dated 09/24/20 for Resident #69 revealed he was at risk for impaired skin integrity related to weakness, impaired mobility, and already an exiting pressure ulcer. Interventions included inspect skin during routine care, pad and protect skin as needed, pillows for positioning, pressure reduction devices as ordered, skin assessments as ordered and turn and reposition as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #69 had impaired cognition. He required the assistance of two people with bed mobility and was totally dependent with the assistance of two people for transfers. He was unable to ambulate. He was at risk for the development of pressure ulcers and had one stage III pressure ulcer to the sacrum on admission. Review of the quarterly Braden scale skin assessment dated [DATE] revealed Resident #69 was at moderate risk for developing a pressure area as his sensory perception was slightly limited, he was occasionally moist, his mobility was very limited, and he had a problem with friction and shear requiring maximum assistance in moving. Review of plan of care dated 12/23/20 revealed Resident #69 had a right knee pressure wound that was unstageable with slough and/or eschar (dead skin that usually was black). Interventions included turn and reposition per plan of care, and place the tray table on the left side of the resident only. Review of the form labeled, Skin and Wound Evaluation V5.0 dated 12/23/20 and completed by RN/Wound Nurse #611 revealed Resident #69 had increased pain to his right knee. Resident #69's right lower extremity was underneath his tray table in his room. Upon removal of the tray table, Resident #69 was noted to have a pressure ulcer area caused from extended contact with his bedside table. Resident #69's pressure ulcer was unstageable as the area had slough in the base of the wound. He had scant serosanguineous drainage (thin like water usually light red or pink tinged) to the over the bed table underside. The unstageable pressure ulcer to Resident #69's right knee measured of 3.8 centimeters (cm) in length by 3.6 cm in width. The wound base was covered with 60 percent (%) slough tissue with a light amount of serosanguineous drainage. He had intermittent pain to the area, and pain medication was in place as needed with positive effect. Review of the nursing note dated 12/23/20 at 4:30 P.M. authored by RN/Wound Nurse #611 revealed he was completing weekly wound tracking and assessment for Resident #69. Resident #69 had increased pain to the right knee, and his right lower extremity was underneath the bedside tray table in his room. Resident #69 was observed to have a pressure area to his right knee due to extended contact with the bedside tray table. RN/Wound #611 revealed the pressure ulcer was unstageable related to slough being present. The nurse practitioner was notified, and a treatment order was received. Review of the physician's orders [REDACTED].#69 had an order to cleanse his right knee with normal saline, apply Santyl (topical medication used to debride dead tissue from wound base) to slough aspect only, apply collagen and cover with house foam daily. Review of the form labeled, Skin and Wound Evaluation V5.0 dated 01/26/21 and completed per RN/Wound Nurse #611 revealed Resident #69's unstageable pressure ulcer to his right knee continued. The pressure ulcer measured 3.8 cm in length by 3.1 cm in width. The wound base had 30% slough with a moderate amount of serosanguineous drainage. He had pain during the dressing change, and as need pain medication was effective. Interview on 01/27/21 at 11:51 A.M. with State tested Nurse Aide (STNA) #602 revealed there were times in the past month when she was unable to provide incontinence care or turn and reposition a resident every two hours because there was not enough staff. Interview on 01/27/21 at 4:04 P.M. with agency STNA #612 revealed she came to the facility routinely. She revealed there were times there was only two aides on a unit, and when this occurred the residents' care was delayed as she was unable to turn and reposition the residents that required to be turned every two hours because there was not enough staff. Interview on 01/27/21 at 4:08 P.M. with Resident #69 was attempted, but he had impaired cognition and could not revealed how the wound to his knee occurred. Interview on 01/28/21 at 2:26 P.M. with RN/Wound Nurse #611 revealed on 12/23/20 he was completing his weekly wound assessments, and Resident #69 was complaining of pain to his right knee. He assessed and found his right knee wedged against the bedside tray table which caused an unstageable pressure ulcer to his right knee. He revealed the wound base contained 60% yellow slough when he found the pressure ulcer. He revealed there was no excuse, and he felt Resident #69 was not monitored or turned and repositioned as he should have been. He revealed to cause an unstageable pressure ulcer of that size, he felt Resident #69 had his right knee wedged for a prolonged time. He stated, definitely over four hours if not longer as I know I was shocked to see how bad it was. Observation of the dressing change on 01/28/21 at 2:29 P.M. for Resident #69 completed by RN/Wound Nurse #611 and Licensed Practical Nurse (LPN)/ Restorative Nurse #604 revealed Resident #69 had an unstageable pressure ulcer to his right knee. RN/Wound Nurse #611 described the wound as having a moderate amount of [MEDICAL CONDITION] (drainage with a mixture of blood and pus either green, yellow, brown, or white in color) drainage with 40 percent slough to the wound bed. He completed the treatment as ordered. Interview on 01/28/21 at 4:21 P.M. with the Director of Nursing verified Resident #69's pressure ulcer to the right knee was found as unstageable with slough present in the wound base which was caused by his right knee being lodged against the bedside tray table. Review of undated facility policy labeled, Pressure Ulcer Prevention Intervention revealed the purpose of the protocol was to implement preventative skin measures for all residents based on the levels and areas of risk. The facility was to ensure the residents skin was assessed and monitored on a routine basis. The resident at risk for skin breakdown were to be repositioned routine as established in their plan of care. The facility was to avoid positioning the resident on medical devices or objects that may cause pressure. Interventions for minimal to moderate at risk residents included to encourage the resident to change position every two hours and as needed in sitting position, while in bed, or as directed by the resident's plan of care. This deficiency substantiates Complaint Numbers OH 193 and OH 205.

Based on medical record review, review of a video tape of the incident and interview, the facility failed to ensure foot rests were in place and adequate assistance and supervision were provided during a wheel chair transport. This resulted in actual harm for Resident #24 who fell from a wheel chair, sustained lacerations to his forhead and nose that required sutures and was admitted to the hospital for back pain. This deficient practice affected one (#24) of four residents reviewed for falls. The total facility census was 125. Findings include: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with a most recent readmission of 07/02/13. Resident #24 had [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) assessments dated 10/02/12 and 05/20/13 revealed Resident #24 had moderate cognitive impairment and was totally dependent upon the assistance of one person for wheel chair mobility on and off the unit. Review of the fall risk assessment dated [DATE] revealed a score 13.0 which represented a moderate risk for a fall. The risk factors identified for Resident #24 included impaired decision making, dementia, impaired vision, required assistance with activities of daily living (ADLs) and use of a wheel chair for mobility. Review of the plan of care for fall risk with a last reviewed date of 06/09/13 revealed Resident #24 was at risk for falls related to impaired balance, impaired cognition and use of psychotherapeutic medication. Interventions included to provide a safe environment for the resident and also to anticipate and meet the resident's needs to decrease fall risk. Review of the plan of care for activities of daily living with a last reviewed date of 06/28/13 revealed Resident #24 required total assistance with wheelchair locomotion. The goal was for the resident to be safe with supervised functional mobility. On 07/19/13 at 9:08 A.M., an interview and review of the facility's fall investigation with the Director of Nursing (DON) revealed on 06/30/13 at 7:15 A.M., Resident #24 was pushed in his wheelchair from his room to the dining room by State tested Nurse Aide (STNA#1). According to STNA #1's statement, Resident #24 put his feet down while STNA #1 was pushing him and he fell out of the wheelchair and onto the floor. STNA #1 called for help. There were no other witnesses to the fall. An immediate assessment of the resident revealed bleeding from a laceration of the forehead that measured 0.5 centimeters long and an "X-shaped" laceration of the nose that measured at 0.4 centimeters long. The fall investigation revealed the resident's family, physician and the DON were notified immediately. Resident #24 was sent to the hospital and was admitted for a complaint of back pain. The resident had a Cat Scan of the head and X-ray of the back and the results showed no negative findings. However, the lacerations to the nose and the forehead (between the eyebrows) required sutures. On 06/30/13, STNA#1 received "one on one" education instructing when Resident #24 returned from the hospital, he should have both feet on foot rests during transport in the wheelchair at all times. On 07/10/13 at 10:00 A.M., the DON and Chief of Operations (COO) asked this surveyor to go to the DON's office where a video of the resident's fall could be seen as recorded that day by a camera in the hall. The video showed STNA #1 coming out of Resident #24's room, pushing the resident in a wheel chair. There were no foot rests on the wheel chair and the residents feet were out in front of him, very close to the floor. The resident suddenly fell forward, however, at that precise moment, the camera only showed the resident from the chest up. The DON and COO agreed they had to rely on STNA #1's statement indicating the resident simply put his feet down on the floor, causing him to fall forward out of the wheel chair. The DON verified the resident had dementia she could not be sure he would, or could keep his feet up without foot rests. On 07/10/13 at 11:25 A.M., the DON verified Resident #24 was totally dependent upon staff for wheel chair locomotion and he was cognitively impaired. The DON verified the facility staff could not assume the resident could be relied upon to hold his own feet up during wheel chair transport.

Based on medical record review, review of the hospital emergency department record, the ambulance run report, the facility's Notification of Changes policy, staff and attending physician interviews, the facility failed to provide adequate care when symptoms of decline in physical condition occurred and/or transferred residents timely to the hospital for treatment. This resulted in Immediate Jeopardy for one of three sampled residents, Resident #145 who exhibited severe respiratory distress, [MEDICAL CONDITION] and subsequently died . On [DATE] at 10:00 A.M., the administrator, the director of nursing (DON), the corporate nurse and the facility's attorney were notified that Immediate Jeopardy began on [DATE] at 3:31 P.M. when Resident #145 was identified by Respiratory Therapist (RT) #3 with high pitched wheezing and rhonchi throughout her lungs and swelling of both hands and elbows. On [DATE] at 4:50 P.M. Licensed Practical Nurse (LPN) #4 notified the physician of Resident #145's shortness of breath with oxygen and pain. The physician was not notified again of the resident ' s deteriorating condition. The resident was found on [DATE] at 8:15 P.M. without any vital signs. The Immediate Jeopardy was removed on [DATE] when the DON inserviced all 40 licensed nurses on the facility's current policy on Notification of Changes ([DATE]) and no current residents exhibited any symptoms warranting immediate physician intervention and emergent care at that time. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on [DATE] when the facility implemented the following corrective actions: ? On [DATE] review of the Notification of Changes Policy revealed it addressed ongoing assessment of the resident's status and notification of the physician and responsible party when a resident had a decline in condition; ensuring all conversations with the family and physician were documented; and honoring the responsible party's wishes to send a resident to the hospital. ? On [DATE] the medical records of four residents (Residents #148, #149, #150 and #66) were reviewed who had declines in physical status. Appropriate assessments and notification of physician and responsible parties were verified. Resident #66 was transferred to the hospital timely for emergency care. ? On [DATE] interview with LPN #22 at 12:05 P.M. revealed she would assess a resident who had a decline in condition, notify the physician and family and document all the events. The resident would be transferred to the hospital according to physician order, resident ' s desire (if able) and responsible party's wishes. LPN #22 indicated the same process would be appropriate for a full code and Do Not Resuscitate (DNR) status. ? On [DATE] interview with LPN #21 at 12:10 P.M. revealed he would assess a resident who had a decline in condition, initiate appropriate interventions as ordered, notify the physician and family. The physician and family would decide if the resident should be transferred to the hospital. Code status would not be a factor. ? On [DATE] interview with LPN #19 at 12:15 P.M. revealed she would assess the resident, notify the physician and family. LPN #19 would transfer the resident to the hospital per physician order [REDACTED]. Findings include: Resident #145 was readmitted to the facility on [DATE] after a left above the knee amputation. The resident had additional [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. The physician ' s admission orders [REDACTED]. The social service assessment dated [DATE] identified the resident ' s discharge plan was to return home. The physician's orders [REDACTED]. On [DATE] results of a chest x-ray revealed the resident had lower lobe pneumonia or atelectasis. The laboratory results dated [DATE] indicated the resident's prothombin time ([MEDICATION NAME]) was 47 (normal range 11.8 and 14.0) and the International Normalized Ratio (INR) was 4.7 (recommended therapeutic range for [MEDICAL CONDITION] 2XXX,[DATE].0). On [DATE] the physician ordered the [MEDICATION NAME] held on [DATE], [DATE] and [DATE]. Review of the progress notes dated [DATE] at 1:50 A.M. by LPN #6 indicated Resident #145 was alert and oriented to herself, but confused to the facility, date and time. Nasal oxygen was on and she had no shortness of breath. Review of the progress note dated [DATE] at 3:31 P.M. by RT #3 revealed Resident #145's breath sounds had high pitched wheezing and rhonchi throughout. RT #3 identified the resident had been medicated with [MEDICATION NAME] and aerosol treatments. The oxygen saturation was 93 percent with oxygen. Some swelling was noticed in both hands and elbows. The note indicated the resident would be monitored closely. There were no further progress notes by RT #3 in the medical record. Review of the nursing progress note on [DATE] at 4:50 P.M. by LPN #4 revealed Resident #145 complained of shortness of breath. An aerosol treatment was administered and the resident's oxygen saturation was 94 percent with oxygen in place. The progress note indicated the physician was notified and ordered [MEDICATION NAME] to be given every day instead of every other day and the aerosol treatments to be given routinely four times a day. The family was voicing concerns regarding the resident's condition and the nurse reassured them numerous times that the physician would continue to be updated and the staff would follow his orders. Swelling was noted to the right arm. Review of the nursing progress note dated [DATE] at 7:55 P.M. by LPN #4 revealed the resident had improvement in the swelling of the right arm. Routine aerosols were effective. Review of the nursing progress note dated [DATE] at 8:15 P.M.by LPN #12 revealed the resident was found with no vital signs and cardiopulmonary resuscitation (CPR) was started. At 8:20 P.M. the ambulance, the family and the physician were called. The ambulance arrived at 8:25 P.M., CPR was continued and the resident was transported to the hospital. Review of the [DATE] progress notes in Resident #145's medical record revealed no documentation that the physician was contacted with any status update after LPN #4's 4:50 P.M. notification. Resident #145's medical record contained no vital signs documented on [DATE], no oxygen saturation checked after the entry by LPN #4 at 4:50 P.M. and no assessment of breath sounds after the 3:31 P.M. entry on [DATE] by RT #3. Review of the ambulance run report dated [DATE] revealed the resident did not have any vital signs at the facility and during the transport to the hospital. Review of the emergency department medical records dated [DATE] revealed nurses notes indicated Resident #145 arrived at the hospital at 8:54 P.M. and was pronounced dead at 9:08 P.M. The emergency room physician documentation dated [DATE] revealed the ambulance personnel intubated the resident and followed protocol. The resident was found with a flat line Echocardiogram (EKG) and arrived at the hospital about 15 minutes later with an EKG that remained a straight line. The physician discussed the events with the family. The emergency department physician indicated in his progress notes the differential [DIAGNOSES REDACTED]. An interview with STNA #1 on [DATE] at 4:50 P.M. revealed on [DATE] he assisted STNA #2 with changing the resident's gown and linens because of Resident #145's excessive sweating. The resident was short of breath during the changing process so they tried to change her as quickly as possible. An interview with RT #3 on [DATE] at 2:40 P.M. verified that she documented on [DATE] at 3:31 P.M. that the resident's breath sounds had high pitched wheezing and rhonchi throughout. The resident's oxygen saturation on 3 liters of oxygen was 93 percent. RT #3 stated the resident only had swelling of the right hand and elbow, not in the "hands and elbows" as she had documented. RT #3 verified she had documented "will monitor closely" but never saw the resident after the 3:31 P.M. observation. RT #3 left the facility at 5:00 P.M. An interview with LPN #4 on [DATE] at 3:20 P.M. revealed [DATE] was the first time she took care of Resident #145. LPN #4 verified she had not documented any vital signs for Resident #145 on [DATE]. She verified the documentation indicated the resident had complained of shortness of breath and had received aerosol treatments at 10:00 A.M. and 2:00 P.M. LPN #4 verified there was no documentation of auscultation of any breath sounds or any aerosol treatments given after 2:00 P.M. There was no documentation of the resident's excessive sweating or difficulty breathing during repositioning. She verified she only spoke with the physician once sometime between 3:30 P.M. and 4:50 P.M. She verified the physician changed the [MEDICATION NAME] to every day instead of every other day, which the resident had already received in the morning therefore she was not given another dose. The physician changed the aerosol treatments to routine instead of as needed, which the resident had already received at 10:00 A.M. and 2:00 P.M. from the as needed order. LPN #4 stated the resident had a moist cough. LPN #4 stated the resident's family member continued to approach her about Resident #145's condition for about five hours. The family member continued to question if the physician was aware of the swelling in the resident's right arm. The family member did request the resident transfered to the hospital, but LPN #4 asked the daughter to wait to see if the aerosols would help the resident. The family member continued to question why the resident was not being transferred to the hospital. LPN #4 verified she did not update the physician after 4:50 P.M. on [DATE]. LPN #4 stated she did not know what the family member wanted from her since the swelling had decreased. LPN #4 stated she called the DON to talk with the family member. LPN #4 stated she did not know why she should have to make the decision to send the resident to the hospital. She stated she was very conflicted when making the decision to send residents to the hospital because in the past staff had been told by administration (unnamed) that the facility was skilled and able to do many of the same things as the hospital. An interview with the DON on [DATE] at 5:45 P.M. revealed LPN #4 called her at about 4:30 P.M. on [DATE], and she went into Resident #145's room at approximately 4:45 P.M. and remained about five minutes. DON reported the resident stated she was "okay". The family member stated she did not know what to do about sending the resident to the hospital and she wanted the physician to decide. The DON stated she was under the impression that LPN #4 was going to call the physician again. An interview with STNA #2 on [DATE] at 6:30 P.M. revealed on [DATE] Resident #145 did not eat much lunch and complained of coccyx pain. STNA #2 and STNA #1 changed the resident frequently because of excessive sweating. She stated the resident became short of breath and anxious when the head of the bed had to be lowered to change her gown and the linens. STNA #2 stated they changed her as quickly as possible and returned the head of the bed to the highest position. The resident was wearing oxygen via nasal cannula. The resident had a very moist cough. The resident was very anxious due to the excessive sweating, the pain and the daughter being upset. At 6:30 P.M. LPN #4 entered the room and gave the resident medication. The resident's family member asked the nurse why the resident was not being sent to the hospital. The family member told the nurse that obviously there was something wrong with the resident. STNA #2 reported LPN #4 told the family member that the resident's vital signs and oxygen saturations were okay and there was no reason to send the resident to the hospital. LPN #4 told the family member she was waiting to hear from the physician and there was no immediate reason to send the resident to the hospital. The family member stated she could not stay at the facility that night and wanted to know what was happening to her mother. STNA #2 reported Resident #145 was audibly wheezing, holding onto both side rails tightly, she was pale and still sweating. The resident appeared very tense. An interview on [DATE] at 12:30 P.M. with the attending physician (DR) #5, who was also the medical director, revealed he did not recall being called and updated regarding Resident #145's change in condition. He did acknowledge he was notified when the resident was coded. This deficiency substantiates Complaint Number OH 747.