Every finding on record at Aventura at Shiloh Springs

Based on record review, review of a facility investigation, review of a facility self reported incident (SRI), review of a police report, staff interview and policy review, the facility failed to ensure a resident was free from abuse. The affected one (#58) out of four residents reviewed for abuse. The facility census was 57. Findings include: Review of Resident #58's medical record revealed an admission date of 06/04/26 with diagnoses of type 2 diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease, major depressive disorder, and developmental disorder of scholastic skills. Review of the Discharge Return Not Anticipated, Minimum Data Set (MDS) completed on 06/29/26 revealed resident was cognitively intact. Further review revealed Resident #58 was independent with bed mobility, transfers, and wheelchair mobility. Resident required set-up assistance with eating and oral hygiene, and required partial assistance with toileting, bathing, dressing, and personal hygiene. Review of Resident #58's care plan dated 06/05/26 revealed the resident needs assistance with toileting with intervention to keep call light within reach, offer and honor choices, and assist with toileting needs. Further revealed a care plan dated 06/05/26 of Resident #58 having manipulative behaviors of screams and curses at staff with interventions of all staff to deal with resident consistently, provide positive feedback to resident, and include resident in plans. Review of the Health Status Note, dated 06/27/26 at 2:40 A.M. revealed Resident #58 had no foley output in the foley drainage bag. At 12:00 A.M. while this nurse was performing replacement of foley Resident #58 became irate, verbally aggressive and attempted to strike the nurse, CNA and another nurse and tried to exit the bed. Resident #58 stated he will jump out of bed and will not care to harm himself. Staff maintained a safe distance and used verbal redirection to calm Resident #58. Resident #58 falsely claimed staff were harming him and then became verbally aggressive, using racial slurs and threatening to kill another nurse. The foley catheter was not fully placed at that time. Resident #58 then exited the bed, onto his amputated legs and fell onto the floor, then attempted to strike staff again. The resident then grabbed another staff member's leg, attempting to bite and scratch. The staff member was able to break free safely. This nurse notified the physician. The physician agreed to pink slip the resident. 911 was called and assisted to help return the resident to bed. No other staff members touched the resident. Staff stood in the hallway, observing, and removed any potential harmful objects from reach. Resident #58 then allowed the nurse to complete the Foley placement. Resident #58 called 911. Police Officers arrived at 2:45 A.M. and spoke with the resident about appropriate use of emergency services. Resident verbalized understanding. Resident safety maintained. Review of Incident Report, dated 06/27/26 at 12:00 A.M. revealed while this nurse was performing replacement of foley Resident #58 became irate, verbally aggressive and attempted to strike the nurse, certified nursing assistant (CNA) and another nurse and tried to exit the bed. Resident #58 stated he will jump out of bed and will not care to harm himself. Staff maintained a safe distance and used verbal redirection to calm Resident #58. Resident #58 falsely claimed staff were harming him and then became verbally aggressive, using racial slurs and threatening to kill another nurse. The foley catheter was not fully placed at that time. After notifying the physician of the resident's behavior and risk of harm. Resident #58 then exited the bed, onto his amputated legs and fell onto the floor, then attempted to strike staff again. Resident #58 then grabbed another staff member's leg, attempting to bite and scratch. The staff member was able to break free safely. This nurse notified the physician. The physician agreed to pink slip the resident. 911 was called and assisted to help return the resident to bed. No other staff members touched the resident. Staff stood in the hallway, observing, and removed any potential harmful objects from reach. Review of a facility SRI, dated 06/27/26 at 2:10 A.M. revealed the facility reported that Resident #58 reported staff verbally and physical abused him. The facility investigated the allegation and verbal abuse was substantiated and the employees were terminated. Review of Police Report dated 06/27/26 at 2:16 A.M. revealed Resident #58 called for an officer due to he wanted his room door closed, staff took his call light and not answering his request. Police arrived at the facility at 2:44 A.M. and left at 2:48 A.M. on 06/27/26. Review of Resident #58's Witness Statement, undated revealed Resident #58's foley needed changes and staff discussed his penis and laughed, called him white trash and honky, began laughing about the size of his penis, and was rubbing his chin. He reported the nurse yanked the phone cord and call light out of the wall. The nurse removed the table and refused to return it to him. Resident #58 reported the male nurse bear hugged him from behind, with resident's arms crossed in front of him for approximately five minutes. When the male nurse let go, Resident #58 reported he fell backwards onto his back. Resident #58 reported he was trying to get up by grabbing the drawer, and staff took the drawer. Emergency Medical Services (EMS) arrived and assisted Resident #58 back to bed. Review of the Interdisciplinary Team (IDT) note created on 07/10/26 at 9:59 A.M. by Regional Director of Clinical Operations revealed on 06/29/26 at 9:59 A.M. the IDT met to discuss an allegation of verbal abuse from 06/26/26 regarding Resident #58. No injuries noted. Two nurses entered Resident #58's room to change his catheter and were verbally abusive. Stated they were laughing about the size of his penis and rubbing his chin. Resident #58 became agitated and attempted to throw his call light at the nurses. The male nurse grabbed the resident from behind and crossed the resident's' arms and held him in a bear hug for approximately five minutes. When the bear hug was released the resident fell backward onto his back. The nurses also unplugged the call light from the wall and the phone. Resident #58 got out of bed onto the floor, the nurse then removed the overbed table that the resident was using for support. While the resident was trying to get up he grabbed the drawer of the nightstand, the drawer pulled all the way open and the nurses also removed the drawer. Review of Licensed Practical Nurse (LPN) #138 employee file revealed a hire date of 04/01/26. Abuse training was completed on 04/01/26. Last day worked was 06/27/26. Employee suspended on 06/28/26. Notified on 07/07/26 of termination date of 06/27/26 for gross misconduct with a resident. Review of LPN #146 employee file revealed a hire date of 05/14/26. Abuse training was completed on 05/14/26. Last day worked was 06/27/26. Employee suspended on 06/28/26. Notified on 07/05/26 of termination date of 06/27/26 for gross misconduct with a resident. Interview on 07/10/26 at 10:32 A.M with Regional Director of Clinical Operations confirmed she did not complete the IDT note on Resident #58's abuse incident until today, 07/10/26 at 9:59 A.M and dated it as 06/29/26 at 9:59 A.M. When asked why she waited until questioned about the SRI today, on Resident #58, to document the incident today, 07/10/26, she reported she did not have time. Interview on 07/10/26 at 11:15 A.M. with Regional Director of Clinical Operations confirmed LPN #138 and #146 were suspended on 06/28/26, but did not work after their shift ended on 06/27/26. Interview also confirmed LPN #138 and #146 were terminated with a termination date of 06/27/26 due to the abuse being substantiated involving Resident #58. Interview on 07/10/26 at 11:39 A.M. with Administrator #185 confirmed on 06/28/26 around 6:12 A.M. she called the facility to check in and was made aware of the allegation of abuse to Resident #58. Interview confirmed she went to the facility to investigate the abuse allegation. Interview confirmed she interviewed Resident #58 and he reported that LPN #138 and #146 had abused him verbally and LPN #138 put him into a bear hug for five minutes, and when LPN #138 let go of Resident #58, the resident fell back into the bed. Resident #58 tried to get away from LPN #138 and #146, he hit his head on the draw of the nightstand. Interview confirmed there was a present, identified as CNA #167. When interviewed, CNA #167 reported nothing happened. CNA #167 came back and reported she did not tell the truth about the incident because she was afraid of retaliation from the nurses but decided she needed to report what happened. Administrator #185 confirmed CNA #167 completed a witness statement that aligned more with what Resident #58 had reported happened during the incident. Interview confirmed LPN #138 and #146 were terminated for abuse. Interview also confirmed CNA #167 was terminated for a false statement due to the facility felt she was just as guilty for letting the abuse occur and lying about the abuse occurring. Interview on 07/10/26 at 3:27 P.M. with Administrator #114 confirmed the facility, including the Regional Director of Clinical Operations know there is a witness statement from CNA #167 stating abuse occurred towards Resident #58 by LPN #138 and #146, but now they do not know where the witness statement located. Review of the Residents' Right To Freedom From Abuse, Neglect, Misappropriation Of Resident Property And Exploitation policy, dated 04/07/25 revealed it is the policy of the facility for residents to be free from abuse. Facility staff will not use verbal or physical abuse against any resident. This deficiency represents non-compliance investigated under Complaint Number 3072126.

Based on medical record review, observation, staff interview, and review of online resources from the Centers for Disease Control and Prevention (CDC), policy review, the facility failed to ensure appropriate infection control practices were implemented. This affected four Residents (#47, #46, #16, and #38) of four residents reviewed for infection control. The facility census was 56. Findings include: 1) Review of the medical record of Resident #47 revealed an admission date of 01/16/26. Diagnoses included osteomyelitis of vertebra, paraplegia, carrier of Carbapenem-Resistant Acinetobacter Baumanni (CRAB) (highly resistant bacteria that cause deadly multidrug resistant infections in hospitalized patients in hospitals and nursing homes) and open wound to right lower leg. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/06/26, revealed the resident had intact cognition. The resident was dependent for bed mobility and transfers. Review of the physician orders for Resident #47 dated 06/10/26, revealed the resident was ordered to in contact precautions related to wounds, an indwelling foley catheter, and history of CRAB. Orders dated 06/30/26, revealed the resident was ordered to have dressing changes to his right posterior-lateral shin and right lateral foot Review of the medical record of Resident #46 revealed an admission date of 01/23/25. Diagnoses included lack of coordination, depression, adult failure to thrive, hyperlipidemia, hereditary hemolytic anemia, and repeated falls. There was no record of Resident #46 being in any type of isolation precautions. Review of the most recent quarterly MDS assessment, revealed Resident #46 had severely impaired cognition. Review of the June 2026 active physician orders for Resident #46, revealed the resident was not ordered to be any type of isolation precautions. Observation of Residents #46 and #47's room (roommates) on 06/30/26 at 4:02 P.M., revealed a sign on the door the door indicating the need for contact precautions with a gown and gloves to be worn when entering the room. Resident #46 was seated in her wheelchair in the room and Resident #47 was resting in bed on her side of the room. Licensed Practical Nurse (LPN) #20 entered the room without donning a gown nor gloves. LPN #20 cleared off Resident #47's bedside table, which contained numerous personal items, including empty food containers and other trash. LPN #20 exited the room to gather supplies for wound care. During an interview on 06/30/26 at 4:09 P.M., LPN #20 verified Resident #47 was in contact precautions related to CRAB. LPN #20 verified she did not don a gown nor gloves upon entrance into the room. LPN #20 stated she would not apply a gown and gloves until she was ready to complete the wound treatments. LPN #20 verified the sign on the door to the resident's room indicated instructions to don a gown and gloves at the door before entering the room. Observation of wound care for Resident #47 on 06/30/26 at 4:12 P.M., LPN #20 donned a gown and gloves and entered the resident's room to begin the resident's wound treatment. LPN #20 removed the existing dressing from Resident #47's right shin and placed it in a bag on the bed. LPN #20 then used the same gloved hand and retrieved a clean gauze pad and wound wash from the bedside table, applied the wound wash on the wound, and dried it with the gauze pad. LPN #20 removed her gloves and applied new gloves without performing any hand hygiene between the glove change. LPN #20 applied alginate and a dry dressing. At 4:19 P.M., LPN #20 removed her gloves, utilized a marker to write the date on the new dressing, and applied new gloves. LPN #20 did not perform hand hygiene between the glove change. LPN #20 then applied wound wash and a dry dressing, gathered her supplies, doffed the gown and gloves, and washed her hands before leaving the room. During an interview on 06/30/26 at 4:24 P.M., LPN #20 verified she did not don clean gloves after removing the dirty dressing and before applying the wound wash and did not perform hand hygiene between glove changes. During an interview on 07/01/26 at 9:56 A.M., the Administrator verified Residents #46 and #47 were cohorted in the same room. The Administrator verified Resident #47 required contact precautions due to CRAB and Resident #46 did not require any type of isolation precautions. The Administrator verified there were rooms available within the facility which could be used instead of cohorting Residents #46 and #47 together. During an interview on 07/01/26 at 10:30 A.M., the Director of Nursing (DON) stated the staff should don a gown and gloves at the door for residents who are in contact precautions. Review from online resources from CDC (https:www.cdc.gov), revealed CRAB infections don't respond to common antibiotics and some CRAB are resistant all available antibiotics and large outbreaks have been reported in hospitals and nursing homes. CRAB spreads through direct and indirect contact with patients infected or colonized with CRAB or contaminated environmental surfaces and equipment. It is usually transmitted from person to person, often via the hands of healthcare personnel or on contaminated shared medical equipment, like intravenous (IV) poles and blood pressure machines. CRAB can cause large outbreaks in healthcare facilities. Without effective cleaning and disinfection, CRAB can persist in the environment and on medical equipment for days to weeks, even in dry conditions. CRAB can contaminate a healthcare worker's hands and clothes while they care for a patient infected or colonized (bacteria colonization means bacteria are living and multiplying on or in your body without causing disease or symptoms with CRAB or work in their environment. This puts the patients who are cared for afterwards at risk of getting CRAB. If private rooms are unavailable, residents with CRAB should only be cohorted with other patients who have already tested positive for CRAB. They should never share a room with a non-CRAB patient. Review of online resources from CDC (https://www.cdc.gov/handhygiene/providers/guideline.html) dated 01/30/20, revealed healthcare personnel should complete hand hygiene before moving from a work area of a soiled body part to a clean body site on the same patient and healthcare personnel were to perform hand hygiene in accordance with the CDC recommendations. Review of the facility policy titled, Isolation-Categories of Transmission-Based Precautions, dated 2001, revealed contact precautions are implemented for residents with known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The individual on contact precautions is placed in a private room, if possible. The staff were to wear gloves and a disposable gown when entering the room. Gloves should be changed after having contact with infective material, and hand hygiene performed after removing gloves. 2) Review of the medical record revealed Resident #38 was admitted to the facility on [DATE]. Diagnoses included unspecified asthma, immune reconstitution syndrome, and nonrheumatic mitral insufficiency. Review of the most recent MDS 3.0 assessment dated [DATE], revealed Resident #38 cognitively intact. Observation of medication administration on 06/30/26 at 9:22 A.M., by Registered Nurse (RN) #60, revealed she was preparing medications for Resident #38. RN #60 prepared all 11 of Resident #38's 9:00 A.M. medications by pushing the medications through the blister foil on medication card and placing each of the medications in her bare hand and then placing the medications into the medication cup. RN #60 administered the medications to Resident #38. RN #60 acknowledge she placed the medications in her bare hand and stated she did not do anything wrong since she used hand sanitizer prior to preparing the medications. 3) Review of the medical record of Resident #21 revealed an admission date of 02/11/26. Diagnoses included major depressive disorder, chronic obstructive pulmonary disease, type 2 diabetes mellitus, morbid obesity, congestive heart failure, GERD, bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #21 had intact cognition. Observation of medication administration on 06/30/26 at 10:40 A.M. by LPN #10, revealed she was preparing medications for Resident #21 when she dropped a dapagliflozin (for diabetes) tablet directly on top of the medication cart. LPN #10 picked up the medication with her bare hand, placed it in the medication cup then administered the medication to Resident #21. LPN #21 verified the observation and stated she should have discarded the medication table that was dropped onto the medication cart. Review of the policy titled, Administering Medications, dated 04/2019 revealed staff followed established facility infection control procedures, examples handwashing, antiseptic technique, gloves, isolation procedures, for the administration of medications, as applicable.

Based on medical record review, staff interview, and policy review, the facility failed to ensure falls were documented and investigated in a thorough manner. This affected one (#21) of three residents reviewed for safety. The facility census was 56. Findings include: Review of the medical record of Resident #21 revealed an admission date of 02/11/26. Diagnoses included major depressive disorder, chronic obstructive pulmonary disease, type 2 diabetes mellitus, morbid obesity, congestive heart failure, GERD, bipolar disorder.Review of the Morse Fall Scale dated 02/11/26, revealed Resident #21 was at a moderate risk for falls. Review of the plan of care dated 02/16/26, revealed Resident #21 was at risk for falls related to requiring assistance with ambulation and transfers. Interventions included assisting the resident with wheelchair or walker for mobility as needed. Review of the physician order for Resident #21 dated 05/29/26, revealed the resident was ordered to receive one-on-one (1:1) supervision until further notice. Review of the progress note for Resident #21 dated 05/30/26 and authored by Licensed Practical Nurse (LPN) #50, revealed the resident fell outside with her 1:1 supervision. The resident was assessed and did not have any injuries, and neurological (neuro) checks were implemented. The progress notes contained no additional details regarding how the fall occurred. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #21 had intact cognition. The resident utilized a wheelchair for mobility, was independent with bed mobility and walking short distances and required supervision for transfers. Review of the fall investigation for Resident #21 dated 06/02/26, revealed the Interdisciplinary Team (IDT) met to discuss Resident #21's fall on 05/30/26. The note indicated the resident had the potential for falls related to her diagnosis, no narcotics, was cognitively intact and able to understand safety education. The care plan was updated to reflect education on the proper use of the wheelchair. The investigation contained no details of the fall, including who was present, what happened or any witness statements. During an interview on 07/01/26 at 8:40 A.M., Certified Nursing Assistant (CNA) #30 stated on the morning of 05/30/26, she was providing 1:1 supervision to Resident #21 and took her outside to smoke. CNA #30 stated, when she was bringing Resident #21 back into the building, she pulled the resident up the ramp, backwards in her wheelchair, and the resident fell forward and out of the wheelchair. CNA #30 stated her method of handling the resident in her wheelchair was not appropriate. During an interview on 07/01/26 at 10:39 A.M., Regional Corporate Nurse (RCN) #40 verified Resident #21's fall on 05/30/26 did not contain a thorough investigation During an interview on 07/01/26 at 1:00 P.M., the Director of Nursing (DON) verified Resident #21's medical record did not contain sufficient information describing the resident's fall on 05/30/26. Review of the facility policy titled, Safety and Supervision of Residents, dated 10/2025, revealed with accident hazards are identified by the safety committee shall evaluate and analyze the cause of the hazards, The interdisciplinary care team shall analyze information obtained from assessments and observations to identify specific hazards or risks for individual or groups of residents.This deficiency is a recite to complaint survey completed 06/22/26.

Based on record review, observations, staff and resident interviews, and review of the facility's smoking policy, the facility failed to adequately assess and supervise residents identified as being supervised smokers to prevent them from smoking while oxygen was in place. This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries on 04/14/26 when Resident #43 lit a cigarette while wearing oxygen via nasal cannula and sustained burns to his face. On 05/31/25, Resident #43 again lit a cigarette while wearing oxygen and sustained additional burns to his face. This affected one (Resident #43) of three residents reviewed for accident hazards. The facility identified 28 residents (#04, #06, #08, #11, #12, #16, #22, #24, #26, #27, #28, #31, #32, #33, #36, #40, #41, #42, #43, #50, #53, #54, #57, #58, #59, #60, and #61) who smoked. The facility census was 61.On 06/10/26 at 12:58 P.M., the Administrator, Director of Nursing (DON), Regional Director of Clinical Operations (RDCO) #105, and Regional Director of Operations (RDO) #106 were notified that Immediate Jeopardy began on 04/14/26 when Resident #43, who was assessed as a non-smoker but care planned as a supervised smoker, went outside on the facility grounds with smoking materials he was allowed to keep with him and smoked while wearing oxygen. His oxygen tubing ignited, causing a small flame which burned Resident #43's face. He was ordered to receive Zinc Oxide to the burn. There was no documented assessment of Resident #43 at the time of the incident and there were no immediate interventions implemented to prevent similar incidences. On 05/31/26 at approximately 4:00 P.M., Resident #43 went outside in the parking lot with his smoking materials and smoked while wearing oxygen and again burnt his face. Resident #43 was never assessed after this incident, nor provided any treatment for his burns, the provider was never notified, the incident was not investigated by the facility nor was it documented in Resident #43's medical record. The Immediate Jeopardy was removed on 06/15/26 when the facility implemented the following corrective actions: On 06/09/26, Assistant Director of Nursing (ADON) #25 completed a skin assessment on Resident #43 and called to clarify the treatment order with Medical Director (MD) #100. Resident #43 was noted with left nostril burn measuring 1.8 centimeters (cm) by 0.8 cm. MD #100 gave an order for Silvadene cream one percent twice daily and the treatment order was entered in by ADON #25. On 06/09/26, Smoking Safety Evaluations were completed for the 28 residents with a history of smoking or who are current smokers by ADON #25. There were 22 residents assessed as independent smokers, and six residents were assessed to need supervision. There were four resident's smoking evaluations that required changes from their prior assessment: Resident #41 and Resident #40's prior evaluation was incorrectly coded as requiring supervision while smoking. The updated evaluation revealed Residents #41 and #40 were safe to smoke independently. Resident #60 was changed from able to smoke safely to being required supervision while smoking. Resident #43's prior evaluation inaccurately was coded as a non-smoker, and the updated evaluation revealed the resident was safe to smoke with supervision. On 06/09/26, Nursing Administration, (Registered Nurse [RN] #151, DON, and ADON #25) were educated by RDCS #105 on incident notification, updating facility smoking safety/skin assessment, incident reporting requirements, transcribing physician orders, documentation requirements, interventions for non-compliance and timeliness of smoking evaluations. On 06/09/26, LPN #152 (who worked on 04/14/26) and LPN #153 (who worked on 05/31/26) were educated by ADON #25 on incident notification, updating facility smoking safety/skin assessment, incident report requirements, transcribing physician orders and documentation requirements. On 06/09/26, a new Smoking Policy was implemented by RDO #106. Smoking Safety Evaluations will now be completed upon admission/re-admission, quarterly, annually, upon significant change or a change in condition and after a safety event. On 06/09/26, a new Independent Smoking Contract was implemented by RDO #106 and reviewed and signed by the six residents assessed to safely smoke independently on 06/10/26. For residents with signed independent smoking contracts and physician orders, they will be encouraged to first utilize the designated smoking area on facility property which is located through the activity room and has a key code entry to exit out to the courtyard. The residents will need to notify staff that they want to smoke and the staff will allow the residents to access the area. The residents will not have access to this area at all times due to there not being a key code entry on the outside to return inside. If residents are deemed competent to make their own decisions and have an order for leave of absence (LOA), they were re-educated on the LOA policy of notifying staff that they were leaving the building and the requirement to sign out and sign back in upon return. On 06/09/26, staff education was initiated by ADON #25, the Administrator and RDCS #105 and was completed on 06/10/26. Those not educated in person were educated via phone and the staff that did not receive the education, will be educated in person prior to working their next shift. The staff were educated on new smoking policy, behavior smoking contracts and independent smoking contracts with safety for residents with oxygen, LOA Policy and notification of resident's failure to comply with safe keeping of materials, signing out and back in, resident conduct and the facility's policy on abuse/neglect. The same items were sent to the staffing Agency Group and uploaded into the portal for shift pick-ups where agency staff must review items sent prior to working. The confirmation is sent to the building upon completion. Additionally, the staff nurses were educated on Smoking Safety Evaluation and frequency required, incident reporting, documentation of physician notification, transcription of physician orders, accuracy of assessments, non-compliance interventions, updated Smoking Guidelines and Policy. The same items were sent to the staffing Agency Group and uploaded into the portal for shift pick-ups where staff must review items sent prior to working. The confirmation is sent to the building upon completion. On 06/09/26, the 28 residents identified as being smokers had the new smoking policy and guidelines reviewed with them by the Administrator, ADON #25 and/or RDCS #105. On 06/09/26, new physician orders were obtained for the 28 smokers which included those needing supervision or assessed as safe to smoke independently and the orders were entered on 06/10/26 by RDCS #105. The responsible parties and/or guardians were notified by ADON #25. A total of seven residents (Residents #43, #23, #33, #54, #12, #41 and #50) that smoked were identified with orders for oxygen. Those seven residents had updated orders for the removal of oxygen prior to smoking entered on 06/09/26 and 06/10/26 by RDCS #105 to remove oxygen prior to smoking with the responsible parties and/or guardians notified by ADON #25. On 06/09/26, an audit of the progress notes from 04/01/26 to current was conducted for related incidents by RDCS #105. There were no further incidents identified other than the incidences on 04/14/26 and 05/31/26 involving Resident #43. On 06/09/26, an Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with Administrator, ADON #25, RDCS #105, RDO #106 MD #100, Corporate [NAME] President of Clinical Services #160, Corporate Clinical Specialist #162 and [NAME] President of Operations #164. The QAPI team discussed the Root Cause Analysis (RCA). MD #100 verbalized understanding the abatement plan being put in place and had no additional items to add. On 06/10/26, the residents deemed safe to smoke independently were issued lock boxes by the Administrator for their smoking materials that they are to lock up after completing their smoke breaks. On 06/10/26, MD #100 was notified of the Immediate Jeopardy by RDO #106. On 06/10/26, a new Smoking Behavior Contract was implemented for the 28 residents identified as smokers by RDO #106. On 06/10/26, RDCS #105 updated the care plans for the 28 residents identified as smokers which included supervision, independent and/or the need for oxygen removal prior to smoking. Beginning 06/10/26, the DON/designee began auditing the 24-hour report (report that pulls over progress notes, medication administration records (MAR), treatment administration records (TAR), incident reports and other items that require coding), LOA log notes for non-compliance, and behavior documentation five times per week for four weeks. Beginning 06/10/26, the DON/designee began auditing new/de-admissions, change in conditions, Annual and Quarterly Smoking Safety Screens three times per week for four weeks to ensure accuracy and completeness with assessments, physician orders, care plan updates/safety equipment and lock box needs. Beginning 06/11/26 Interdisciplinary Team (IDT)/QAPI meetings will be held weekly to review results of observations and monitoring activities for four weeks followed by monthly QAPI meetings on the third Wednesday of every month for three months. On 06/15/26, the Administrator and RN #166, held a follow-up care plan meeting with Resident #43 and advised the resident that due to the safety incidents on 04/14/26 and 05/31/26, the smoking safety evaluation was redone on 6/15/26 with an outcome of the resident needing supervision while smoking. Smoking materials would be placed in a designated locked cart, and the staff had to provide the smoking materials. The resident would smoke at the designated times with all other residents who required supervision by staff and there would be a 30-day period to supervise him to ensure he is practicing safe smoking practices. Due to the resident's history of non-compliance with the smoking policy and he maintained a Brief Interview Mental Status (BIMS) of 15 (indicating the resident was cognitively intact), they re-educated resident on the facility's LOA policy and if he chose to go off property he was required to alert a staff member and sign out and back in upon return. Resident #43 was informed that any non-compliance would result in a thirty (30) day intent to discharge. The Smoking Behavior Contract signed by the resident on 06/09/26 remained in effect with a re-evaluation for independent smoking status in thirty (30) days. Resident #43's physician was contacted and orders and a plan of care were updated by the RDCS #105. Although the Immediate Jeopardy was removed on 06/15/26, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include:Review of the medical record for Resident #43 revealed an admission date of 05/19/25. Diagnoses included type II diabetes mellitus (DM II), emphysema, chronic obstructive pulmonary disease (COPD), and chronic respiratory failure. Review of the physician order for Resident #43 dated 09/24/25, revealed the resident was ordered to receive oxygen at two liters per minute (lpm) per nasal cannula as needed (PRN) to maintain pulse oxygen saturation above 92 percent. Review of the Smoking Safety Screen for Resident #43 dated 02/26/26, revealed the resident was not a current smoker. Review of the care plan for Resident #43 dated 03/20/26, revealed the resident was at risk for injuries related to smoking and needed supervision when smoking and utilizing tobacco-cigarette products. Interventions included informing the resident and the family of the smoking policy, observing the resident smoking in designated areas, nursing to maintain all smoking materials in a designated area, and the resident to be supervised when smoking. Review of the physician order dated 04/14/26, revealed Resident #43 was ordered zinc oxide external cream one percent to be applied to nose twice daily for skin irritation for 10 days and monitor and report signs or symptoms of infection. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #43 had intact cognition. Review of the physician progress note dated 04/15/26 at 3:00 A.M. and authored by MD #100, revealed Resident #43 was seen for a skin burn. There was no additional documentation related to the burn, how it occurred, any interventions to prevent it from happening again or a treatment plan. During an interview on 06/08/26 at 3:05 P.M., the current Administrator stated she did not know about the smoking incident on 05/31/26 involving Resident #43 getting burned while smoking with oxygen. During an interview on 06/09/26 at 8:53 A.M., Resident #06 stated on 05/31/26 around 4:00 P.M., he was outside in the front parking lot with Resident #43. Resident #06 stated Resident #43 lit his cigarette while wearing his oxygen via nasal cannula, and Resident #43's face caught on fire around his nose and up his ears. Resident #06 stated he panicked and attempted to move his wheelchair, but the brakes were locked, so he jumped out of his wheelchair in fear Resident #43's oxygen tank was going to explode. Resident #06 stated he laid on the ground for approximately twenty minutes before staff responded.During an interview on 06/09/26 at 9:08 A.M., Resident #43 stated on 05/31/26, he was outside smoking with his oxygen on and caught himself on fire. Resident #43 stated he had burns to his nose and forgot to take his oxygen off prior to smoking. Resident #43 stated he had been putting cream on his burns that he had from previous incident in April from being burned while smoking with his oxygen on. During an observation at the time of the interview, Resident #43 had white cream around his nose. During an interview on 06/09/26 at 10:41 A.M., RN #30, who stated she was assigned to care for Resident #43 on 05/31/26, denied any knowledge of Resident #43 sustaining any burns from smoking with his oxygen on. RN #30 stated the resident told her he was burned in the past because of his oxygen being on. During an interview on 06/09/26 at 10:50 A.M., Certified Nursing Assistant (CNA) #10, who stated she was assigned to care for Resident #43 on 05/31/26, stated she heard about the incident on 05/31/26. Resident #43 asked her for ice three or four times that evening for his burn injuries. CNA #10 also stated she was never asked about the incident or asked to complete a witness statement. During an interview on 06/09/26 at 10:58 A.M., LPN #20, who stated she was assigned to care for Resident #06 on 05/31/26, said she was alerted that Resident #06 was on the ground in the parking lot. LPN #20 stated Resident #43's oxygen saturation status was checked, and she gave him a cold rag per his request. LPN #20 stated she reported the incident involving Resident #43 to RN #30.During an interview on 06/09/26 at 11:23 A.M., LPN #22, who reported she was the night shift nurse on 05/31/26, stated she was never informed during the shift-to-shift report or by Resident #43 that he had sustained burns related to smoking while using his oxygen. During an interview on 06/09/26 at 11:32 A.M., LPN #21 stated he responded to the parking lot where the incident took place on 05/31/26 involving Resident #06 and Resident #43. LPN #21 stated Resident #43 had a singed nasal cannula and burns due to smoking with oxygen in use. LPN #21 stated Resident #06 reported Resident #43's oxygen tank was on while he was started smoking, and the resident caught on fire briefly. LPN #21 stated there was a similar incident involving Resident #43 smoking with oxygen on and burning himself but was unsure when. During an interview on 06/09/26 at 2:28 P.M., RDCS #105 stated she was unaware of the burn incidents on 04/14/26 and 05/31/26 involving Resident #43. Observation of Resident #43 on 06/09/26 at 2:33 P.M. with RDCS #105, revealed the resident had burned areas to his nose and nostrils. During an interview on 06/09/26 at 2:35 P.M., alongside RDCS #105, Resident #43 stated he burned himself on 05/31/26 because he forgot to take off his oxygen when he smoked. Resident #43 reported he had been applying the cream to his nose that he was given the last time a similar incident occurred which was about a month or so ago. During an interview on 06/09/26 at 3:05 P.M., ADON #25 stated she was unaware of the burn incident on 05/31/26 involving Resident #43. ADON #25 stated she heard about a similar incident in April but was unaware of any investigation.During an interview on 06/09/26 at 3:10 P.M., MD #100 stated he was aware of a burning incident in April 2026 involving Resident #43, but he had no other details of the incident. MD #100 stated he was not made aware of the burn incident on 05/31/26 involving Resident #43. Review of the progress note for Resident #43 dated 06//09/26 written as a late entry on 06/10/26 at 9:35 P.M. and authored by RDCS #105, revealed the resident was educated on the dangers of smoking with oxygen use. The resident verbalized understanding and stated he would stop at the nurse's station prior to going to smoke.During an interview on 06/10/26 at 10:03 A.M., former Administrator #200 stated he was the Administrator during the incident on 04/14/26; however, he was unaware of Resident #43 being burned on 04/14/26. Former Administrator #200 stated his last day working in the facility was Friday 05/29/26.Review of the Smoking Safety Screen for Resident #43 dated 06/15/26 at 2:26 P.M. and authored by RDCS #105, revealed the resident was an active smoker and required supervisionDuring an interview on 06/16/26 at 2:34 P.M., RDO #106 stated Former #200's last day working was Friday 05/29/26 and the Current Administrator started on 05/30/26. RDO #106 stated she assisted with covering the facility and stated she was never informed of the incident on 5/31/26 involving Resident #43. RDO #106 stated she had no knowledge of the April 2026 incident involving Resident #43. Review of the facility policy titled, Smoking Policy - Residents, revised October 2023, revealed the facility had established and maintained safe resident smoking practices. Smoking was only permitted in designated resident smoking areas, which were located outside of the building. Oxygen use was prohibited in smoking areas. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. The residents who have independent smoking privileges were permitted to keep cigarettes, electronic-cigarettes, pipes, tobacco, and other smoking items in their possession. The residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision. This deficiency represents non-compliance investigated under Complaint Number 3035005. This deficiency is a recite to complaint survey completed 05/21/26.

Based on record review , staff interviews, and policy review, the facility failed to ensure the physician was notified when a resident experienced a change in condition. This affected one resident (#43) of three reviewed for change in condition. The facility census was 61.Findings include:Review of the medical record for Resident #43 revealed an admission date of 05/19/25. Diagnoses included type II diabetes mellitus (DM II), emphysema, chronic obstructive pulmonary disease (COPD), and chronic respiratory failure.Review of the physician order dated 09/24/25, revealed Resident #43 was ordered oxygen at two liters per minute (lpm) per nasal cannula as needed to maintain pulse oxygen saturation above 92 percent (%).Review of the most recent Smoking Safety Screening dated 02/26/26, revealed Resident #43 was not recorded as a current smoker.Review of Resident #43's care plan dated 03/20/26, revealed Resident #43 was at risk for injury related to smoking. The resident required supervision when smoking and utilized tobacco-cigarette products. Interventions included informing the resident and family of the smoking policy, observing the resident smoking in designated areas, nursing to maintain all smoking materials in designated area, and the resident to be supervised with smoking.Review of the physician order dated 04/14/26, revealed Resident #43 was ordered to receive Zinc oxide external cream one percent (%) for his nose every shift (twice daily) for skin irritation for 10 days and monitor and report signs or symptoms of infection.Review of the physician progress note dated 04/15/26 at 3:00 A.M., revealed Resident #43 was seen for skin burn. There were no additional details. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #43 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of the late entry progress note dated 06/09/26 and entered on 06/10/26 at 9:35 P.M., revealed Resident #43 was educated on the dangers of smoking with oxygen use. The resident verbalized understanding and that he would stop at the nurse's station prior to going to smoke.During an interview on 06/09/26 at 9:08 A.M., Resident #43 stated on 05/31/26, he was outside smoking with his oxygen on and caught himself on fire. Resident #43 reported he had burns to his nose from the nasal cannula catching on fire. Resident #43 stated he forgot to take his oxygen off prior to smoking. Resident #43 explained he had been putting cream on his burns that he received from similar incident when he was burned while smoking with his oxygen on.During an interview on 06/09/26 at 10:41 A.M., Registered Nurse (RN) #30 stated she was not aware Resident #43 sustained burns on 05/31/26. RN #30 stated the resident reported to her he had been burned in the past because of his oxygen being on.During an interview on 06/09/26 at 10:58 A.M., Licensed Practical Nurse (LPN) #20 stated she was alerted that Resident #06 was on the ground in the parking lot. LPN #20 reported Resident #43's oxygen saturation status was checked and gave him a cold rag per his request. LPN #20 stated she reported the incident with Resident #43 to RN #30.During an interview on 06/09/26 at 2:28 P.M., Regional Director of Clinical Services (RDCS) #105 stated she was unaware of the burn incidents on 04/14/26 and 05/31/26 involving Resident #43.Observation of Resident #43 on 06/09/26 at 2:33 P.M. with RDCS #105, revealed the resident had burned areas to bilateral nose/nostrils.During an interview on 06/09/26 at 2:35 P.M., alongside RDCS #105, Resident #43 stated he burned himself on 05/31/26 because he forgot to take off his oxygen. Resident #43 reported he had been applying the Zinc cream to his nose that he was given the last time a similar incident occurred about a month or so ago.During an interview on 06/09/26 at 3:05 P.M., Assistant Director of Nursing (ADON) #25, stated she was unaware of the 05/31/26 incident involving Resident #43 burning himself while smoking with oxygen on. ADON #25 reported she heard about the previous incident in April but was unaware of any investigation.During an interview on 06/09/26 at 3:10 P.M., Medical Director (MD) #100 stated he was unaware of the burning incident in April involving Resident #43. MD #100 stated he was not made aware of the burn incident on 05/31/26.Review of the facility policy titled, Change of Condition, revealed a significant change of condition was a decline or improvement in the resident's status that required interdisciplinary review and/or revision to the care plan. The center will notify the resident's physician and the resident's representative whenever there is a significant change in the resident's health, mental or psychosocial status.

Based on review of the medical record, staff interviews, and policy review, the facility failed to ensure the physician progress notes were written, signed and dated at the time of the visit. This affected three Residents (#33, #50, and #62) of three residents reviewed for physician visits. The facility census was 61. Findings include:1) Review of the medical record for Resident #33 revealed an admission date of 10/17/24. Diagnoses included Chronic obstructive Pulmonary Disease (COPD), bipolar disorder, depression, and type II diabetes mellitus (DM II).Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #33 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of the physician notes for Resident #33 authored by Medical Director (MD) #100, revealed she was seen on 04/01/26 and the progress note was written and signed by MD #100 on 04/19/26. The resident was seen again on 05/01/26 and the progress note was written and signed by MD #100 on 05/03/26. The resident was seen again on 05/27/26 and the note was written and signed by MD #100 on 05/29/26.During an interview on 06/11/26 at 9:49 A.M., Regional Director of Clinical Services (RDCS) #105 verified Resident #33's physician notes were not signed by MD #100 at the time of visit for 04/01/26, 05/01/26, and 05/27/26.2) Review of the medical record for Resident #50 revealed an admission date 12/08/21. Diagnoses included acute respiratory failure with hypoxia, DM II), dementia, and anxiety disorder.Review of the Medicare-Five day MDS assessment dated [DATE], revealed Resident #50 had intact cognition as evidenced by a BIMS score of 14. Review of the physician notes for Resident #50 and authored by MD #100, revealed the resident was seen on 04/01/26 and the progress note was written and signed on 04/19/26. The resident was seen on 04/08/26 and the progress note was written and signed by MD #100 on 04/14/26. The resident was seen on 05/01/26 and the progress note was written and signed by MD #100 on 05/03/26. The resident was seen on 05/08/26 and the progress note was written and signed by MD #100 on 05/11/26.During an interview on 06/11/26 at 9:49 A.M., RDCS #105 verified Resident #50's physician notes were not signed at the time of visit by MD #100 for 04/01/26, 04/08/26, 05/01/26, and 05/08/26.3) Review of the medical record for Resident #62 revealed an admission date of 04/22/25 with a discharge date of 05/06/26. Diagnoses included DM II, osteomyelitis of right ankle and foot, depression, and venous insufficiency.Review of the Annual MDS assessment dated [DATE], revealed Resident #62 had intact cognition as evidenced by a BIMS score of 15. Review of the physician notes for Resident #62 and authored by MD #100, revealed the resident was seen on 03/18/26 and the progress note was written and signed by MD #100 on 03/22/26. The resident was seen on 04/01/26 and the progress note was written and signed by MD #100 on 04/19/26. The resident was seen on 04/11/26 and the progress note was written and signed by MD #100 on 04/13/26. The resident was seen on 05/01/26 and the progress note was written and signed by MD #100 on 05/03/26.During an interview on 06/11/26 at 9:49 A.M., RDCS #105 verified Resident #62's physician notes were not signed at the time of visit by MD #100 for 03/18/26, 04/01/26, 04/11/26, and 05/01/26.Review of the facility policy titled, Charting and Documentation, dated July 2017 revealed all services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. Documentation of procedures and treatments will include care-specific details including: the date and time the procedure/treatment was provided, the assessment data and/or any unusual findings obtained during the treatment, the signature and title of the individual documenting.

Based on review of the medical record, staff interviews, and policy review, the facility failed to ensure resident's records were complete and accurately documented. This affected one (#43) of three residents reviewed for documentation. The facility census was 61.Findings include:Review of the medical record for Resident #43 revealed an admission date of 05/19/25. Diagnoses included type II diabetes mellitus (DM II), emphysema, chronic obstructive pulmonary disease (COPD), and chronic respiratory failure.Review of the nurse's progress notes for Resident #43 from 04/14/26 through 05/31/26, revealed no documentation related to the incidents 04/14/26 and 05/31/26 when the resident was burned when he was smoking with oxygen on. Review of the physician progress note dated 04/15/26 at 3:00 A.M. and authored by Medical Director (MD) #100, revealed Resident #43 was seen for skin burn.Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. During an interview on 06/09/26 at 9:08 A.M., Resident #43 stated on 05/31/26, he was outside smoking with his oxygen on and caught himself on fire. Resident #43 stated he had burns to his nose from the nasal cannula catching on fire. Resident #43 stated he forgot to take his oxygen off prior to smoking. Resident #43 explained he had been putting cream on his burns that he had from a previous incident when he was burned while smoking with his oxygen on.During an interview on 06/09/26 at 2:28 P.M., Regional Director of Clinical Services (RDCS) #105 stated she was unaware of either burn incidents involving Resident #43. RDCS #105 verified there was no documentation in the medical record for Resident #43 regarding the incidents on 04/14/26 and 05/31/26During an interview on 06/09/26 at 2:35 P.M., alongside RDCS #105, Resident #43 stated he burned himself on 05/31/26 because he forgot to take off his oxygen. Resident #43 reported he had been applying the Zinc oxide cream to his nose that he was given the last time the incident occurred about a month or so ago.During an interview on 06/09/26 at 3:05 P.M., Assistant Director of Nursing (ADON) #25 stated she was unaware of the incident on 05/31/26 when Resident #43 burned himself while smoking with oxygen on. ADON #25 stated she heard about the previous incident in April but was unaware of any investigation.During an interview on 06/09/26 at 3:10 P.M., Medical Director (MD) #100 stated he was unaware of the incident in April 2026 when Resident #43 was burned while smoking with oxygen on. MD #100 stated he was not made aware of the burn incident on 05/31/26.Review of the facility policy titled, Charting and Documentation, dated July 2017 revealed all services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record.

Based on medical record review, observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure staff provided the necessary level of supervision for safe smoking and residents smoked in the designated smoking areas. This affected two (Residents #29 and #41) of three residents reviewed for smoking safety. The facility census was 57. Findings include:1. Review of the medical record revealed Resident #29 had an admissions date of 03/20/26. Diagnoses including displaced fracture of fifth cervical vertebra, hallucinations, bipolar disorder, panic disorder, and muscle weakness.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact. The smoking assessment dated [DATE] revealed Resident #29 was a smoker and did not require supervision when smoking. Review of the care plan revealed Resident #29 was at risk for side effects/injury from smoking. Interventions included Resident #29 will smoke in designated areas. Review of the Leave of Absence sign out sheet revealed Resident #29 signed himself out of the facility on 05/21/26 at 8:00 A.M.Observation on 05/21/26 at 8:10 A.M. revealed Resident #29 was under the overhang door located near the front entrance, that was an unused door. He had a cigarette he was lighting with his lighter. No staff were observed outside.Interview on 05/21/26 at 8:11 A.M. with Resident # 29 verified he was smoking in front of the facility. Interview on 05/21/26 at 8:12 A.M. with the Administrator and Receptionist #76 revealed Resident #29 has smoked in front of the facility before. The Administrator stated Resident #29 has been educated to not smoke in front of the facility. Receptionist #76 verified Resident #29 was smoking in front of the facility and she would ask him to come inside. Interview on 05/21/26 at 9:31 A.M. with the Administrator verified the residents were expected to go off of facility property when they sign themselves out to smoke. 2. Review of the medical record for Resident #41 revealed an admission date of 09/26/25. Diagnoses included type II diabetes mellitus without complication, chronic obstructive pulmonary disease, and tobacco use. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact. The smoking assessment dated [DATE] revealed Resident #41 was a smoker and required supervision. Review of the care plan revealed Resident #41 was at risk for injury related to smoking. Interventions included the resident would be supervised with smoking. Observation on 05/19/26 at 10:30 A.M. revealed Resident #41 was smoking in the smoking area by herself. Interview on 05/19/26 at 10:35 A.M. with the Director of Nursing (DON) revealed residents have designated smoking times and there should be a staff member supervising them. The DON verified Resident #41 was in the smoking area actively smoking and was not visible to any staff. Interview on 05/19/26 at 10:37 A.M. with Activities Aide #40 verified Resident #41 was in the smoking area actively smoking and she was unable to the resident because the view was obstructed by a tree.Review of the facility policy titled Smoking Policy - Resident dated October 2023 revealed smoking is only allowed in designated smoking areas. Any resident with smoking privileges requires monitoring shall have the direct supervision of a staff member at all times while smoking. This deficiency represents non-compliance investigated under Complaint Number 3007829.

Based on observations, staff interviews, Long-Term Care Ombudsman interview, and policy review, the facility failed to maintain the residents' floors and medical equipment in a clean manner. This affected two residents (Residents #38 and #40). The facility census was 57. Findings include:Observation and interview on 05/19/26 at 10:28 A.M. revealed Certified Nursing Assistant (CNA) #79 was performing care for Resident #40 in her room. Resident #40's floor was wet and had just been mopped. The floor had specks of unknown black dirt laying on wet cream floor. Under Resident #40's bed, there was heavy dirt, which included hair, and a speck of unknown dirt against wall and floor. There were large spots of enteral feed spilled on the floor and tube feed pole. In the center of Resident #40's floor, there were four tan stains measuring around four to five inches in irregular circular size, like the color of the enteral feed. CNA #79 said enteral feed gets spilled and gets stuck on the floor. CNA #79 verified Resident #40's floor had some dirt and areas on floor were unclean.Observation and interview on 05/19/26 at 10:40 A.M. with Housekeeping Aid (HA) #47 revealed Resident #38's room had just been mopped and swept. HA #47 verified there was scattered black unknown dirt on the floor. HA #47 verified the wall edges had an unknown black substance, and dirt could be moved by moving your shoe around the floor. HA #47 verified the floor in Resident #38's room was not swept good. Observation and interview on 05/19/26 at 10:42 A.M. with HA #47 revealed she just cleaned Resident #40's floor had just been swept and mopped. HA #47 verified there was still dirt scattered on the floor. HA #47 verified enteral feed was spilled and dried under the tube feed pole, and there were four tan stains in center of the floor in Resident #40's room. HA #47 verified she never mopped or swept under Resident #40's bed, because her broom or mop handle would bang up against the bottom of Resident #40's bed. Interview on 05/21/26 at 1:15 P.M. with Long-Term Care Ombudsman (LTCO) #300 stated the residents had complained about rooms being clean. Review of the facility policy titled Housekeeping Department dated 09/07/24 revealed that the facility provided a clean and healthy environment for all residents, visitors, and staff members. General cleaning included dusting, bathrooms, and floors. The facility was to clean behind and underneath nightstands, dressers, and beds every other day. Check walls for spills, doors, and handrails.This deficiency represents non-compliance investigated under Complaint Number 3006175.

Based on medical record review, resident interview, staff interview, physician interview, and policy review, the facility failed to ensure physician orders were transcribed accurately. This affected one (Resident #08) of four residents reviewed for physician orders. The facility census was 60.Findings include:Review of the medical record of Resident #08 revealed an admission date of 11/20/25. Diagnoses included syncope and collapse, asthma, diabetes, cocaine abuse in remission, drug-induced subacute dyskinesia, bradycardia, anxiety, depression, and post traumatic stress disorder (PTSD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #08 had intact cognition. The resident was assessed as exhibiting verbal behavioral symptoms directed towards others and rejection of care one to three days during the assessment period. The resident was independent with bed mobility, required setup/cleanup assistance with eating, supervision with transfers, and partial/moderate assistance with toileting and bathing.Review of physician orders revealed an order dated 01/28/26, which stated, May not go on leave of absence (LOA). Further review of the medical record revealed Resident #08 went on a LOA with her family on 03/01/26.Review of a progress note dated 01/28/26 and authored by the Assistant Director of Nursing (ADON) #26 revealed a new order was received and the resident was not to go on LOA while under care at the facility related to finding empty bottles of narcotics that had recently been filled by other pharmacies. Interview on 04/02/26 at 10:35 A.M., Resident #08 stated she became aware of an order written for no LOA when she was being loaded onto a transport van to go to get food and was told by staff she was not allowed to leave the facility. Interview on 04/02/26 at 1:46 P.M., the ADON #26 stated she put the order in following a phone conversation between the Administrator and Physician #200. The ADON #26 stated she was able to hear the physician's voice on the phone, however she did not hear specifically what the orders were. ADON #26 verified she should only take orders directly from a physician and further verified she did not clarify the order directly with the physician. ADON #26 stated she became aware of the order not matching what the physician had said when the Ombudsman came to the facility on [DATE] and questioned the order. Interview on 04/02/26 at 10:21 A.M., Physician #200 stated he gave a verbal order for the resident to only have LOA with supervision. Physician #200 denied giving an order for the resident to not be allowed LOA.Review of the facility policy titled, Verbal Orders, dated 02/2014, revealed the individual receiving the verbal order will read the order back to the practitioner to ensure the information is clearly understood and correctly transcribed. This deficiency represents non-compliance investigated under Complaint Number 2809324.

Based on record review and staff interview, the facility failed to submit the Payroll Based Journal (PBJ) staffing information to Centers for Medicare and Medicaid Services (CMS) as required. This had the potential to affect all 55 residents residing in the facility. The facility census was 55. Findings include: Review of the PBJ Staffing Data Report [NAME] Report 1705D FY Quarter 3 2025 (April 1 - June 30) dated 12/26/25 revealed the facility failed to submit staffing data for the quarter. Interview with Corporate Human Resources (CHR #300) on 01/08/26 at 2:25 P.M. verified corporate received an alert notifying them of late submission for one of the quarters of fiscal year 2025.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure resident care plans were accurate to reflect the residents needs. This affected three (#2, #3, and #65) of 21 residents reviewed in the sample. The census is 55. Findings include: 1.Review of Resident #2's medical record revealed and admission dated of 12/04/25. Diagnoses listed included bacteremia, hypertension, cellulitis, type two diabetes mellitus, and osteomyelitis. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact. Further review of Resident #2's medical record revealed he was admitted with a urinary catheter (Foley) on 12/04/25 and the Foley remained in place until 01/06/26. Review of physician orders revealed Resident #2 had been ordered the narcotic pain medication oxycodone since admission [DATE]. Review of Resident #2 care plan dated initiated 12/204/25 revealed no focus, goals, or interventions related to a Foley or narcotic medication use. Interview with the Director of Nursing (DON) on 01/08/26 at 8:42 A.M. confirmed Resident #2's care plan did not have no focus, goals, or interventions related to a Foley or narcotic medication use. 2. Review of the medical record for Resident #03 revealed an admission date of 09/17/25 with medical diagnoses of intracranial hemorrhage, left hemiparesis, end stage renal disease (ESRD), and dependence on dialysis. Review of the medical record for Resident #03 revealed a quarterly MDS assessment, dated 12/18/25, which indicated Resident #03 was cognitively intact and required partial/moderate staff assistance with toilet hygiene and showers, and supervision with transfers. The MDS indicated Resident #03 was independent with bed mobility and Resident #03 received dialysis. Review of the medical record for Resident #03 revealed a physician order for dialysis on Monday/Wednesday/Friday at a dialysis center with a chair time at 11:45 A.M. Review of the medical record for Resident #03 revealed no documentation to support the facility developed a comprehensive person-centered dialysis care plan. 3. Review of the medical record for Resident #65 revealed an admission date of 10/03/25 with medical diagnoses of wedge compression fracture of lumbar vertebra, asthma, and convulsions. Review of the medical record for Resident #65 revealed an admission MDS assessment, dated 10/07/25, which indicated Resident #65 was cognitively intact and required partial/moderate staff assistance with bathing and toilet hygiene, substantial/maximum staff assistance with transfers, and supervision with eating. Review of the medical record for Resident #65 revealed a physician order dated 10/06/25 for docusate sodium 100 milligram (mg) one capsule by mouth two times per day for constipation, orders dated 10/07/25 for MiraLAX 17 gram per scoop, give one scoop by mouth daily for constipation and enema rectal to insert one applicator rectally one time only for constipation, and an order dated 10/08/25 for Colace one tablet by mouth daily for constipation. Review of the medical record for Resident #65 revealed no documentation to support the facility completed a comprehensive person-centered care plan for constipation. Interview on 01/08/26 at 8:34 A.M. with Director of Nursing (DON) confirmed the medical record for Resident #03 did not have a dialysis care plan. DON also confirmed Resident #65 had received many medications for constipation and was at risk for constipation. DON confirmed the medical record for Resident #65 did have a constipation care plan. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, stated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs would be developed and implemented for each resident. The policy stated the care plan would describe services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being.

Based on medical record review, staff and resident interviews, review of information from Medscape and review of information from the National Library of Medicine, the facility failed to ensure bowel movements were monitored for residents at risk of constipation. This affected one (#2) out of two residents reviewed for constipation. The census was 55. Findings include: Review of Resident #2's medical record revealed and admission dated of 12/04/25. Diagnoses listed included bacteremia, hypertension, cellulitis, type two diabetes mellitus, and osteomyelitis. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact. Review of physician orders revealed an order dated 12/11/25 for oxycodone hydrochloride (narcotic pain medication) oral tablet 5 milligrams (mg) by mouth four times a day for pain. Further review of Resident #2's medical record revealed no documentation of bowel movements being monitored. There was not any documentation of Resident #2's last bowel movement. Interview with Resident #2 on 01/05/26 at 9:37 A.M. revealed it had been 10 days since he had a bowel movement. Resident #2 believed he had been given something to help but did not believe it was working. Interview with the Administrator on 01/07/26 at 10:10 A.M. confirmed there was no documentation of Resident #2 bowel movement being monitored. Review of Medscape revealed oxycodone hydrochloride may cause constipation. Review of information from the National Library of Medicine at https://medlineplus.gov/ency/patientinstructions/000120.htm revealed Constipation is when you do not pass stool as often as you normally do. Your stool may become hard and dry, and it can be difficult to pass. And under the section, When to contact a medical professional, Contact your provider if you have not had a bowel movement in 3 days. This deficiency represent non-compliance investigated under Complaint Number 2642439.

Based on medical record review, observations and staff and resident interviews, the facility failed to ensure a resident's indwelling urinary catheter (Foley) was attempted to be removed as ordered. This affected one (#2) of one reviewed for Foley catheter care. The census was 55. Findings include: Review of Resident #2's medical record revealed and admission dated of 12/04/25. Diagnoses listed included bacteremia, hypertension, cellulitis, type two diabetes mellitus, and osteomyelitis. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact. Review of physician orders revealed an order dated 12/30/25 to clamp Foley times four hours then release times 15 minutes, repeat times 24 hours then discontinue Foley. If no voiding may straight catheter every four to six hours and as needed. If post void residual is greater than 500 milliliters times two times replace foley. Further review Resident #2's medical record revealed no documentation of Resident #2's Foley being removed or being attempted to be removed on 12/20/26. Review of progress notes revealed Resident #2 Foley was removed on 01/06/25 per order. Resident #2 was sent to the emergency room (ER) for elevated temperature, elevated pulse rate, and decreased blood pressure. Observation and interview with Resident #2 on 01/05/26 at 12:15 P.M. revealed Resident #2 had an indwelling Foley catheter in place. Resident #2 stated the nurse told him the Foley didn't look right. Interview with the Administrator and the Director of Nursing (DON) on 01/06/25 at 2:25 P.M. confirmed there was no documentation of Resident #2's Foley being removed or attempted to be removed. The DON stated she thought Resident #2's Foley was removed and put back in but confirmed no documentation. This deficiency represents non-compliance investigated under Complaint Number 2650877 and Complaint Number 2650899.

Based on medical record review, observations, staff interview, and review of facility policy, the facility failed to ensure staff cared for a resident's tracheostomy appropriately. This affected one (#10) of one residents reviewed for tracheostomy care. The census was 55. Findings include: Review of Resident #10's medical record revealed an admission date of 01/21/25. Diagnoses listed included chronic obstructive pulmonary disease, coronary artery disease, anxiety disorder, hemiplegia, encephalopathy, and psychotic disturbance. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was rarely understood by staff and received tracheostomy (trach) care. Review of Resident #10's medical record revealed the resident had a trach which was being cared for by nursing staff. Resident #10's tracheostomy care being completed by Licensed Practical Nurse (LPN) #201 was observed on 01/07/25 at 2:05 P.M. LPN #201 removed gloves used during feeding tube care. LPN #201 did not sanitize or wash hands after removing gloves. LPN #201 then opened a tracheostomy care pack that contained sterile gloves, a sterile suction catheter, and sterile box container used for sterile water. LPN #201 did not down any gown or facemask. LPN #201 then unfolded the sterile box and poured sterile water into it. LPN #201 donned sterile gloves and attached the sterile suction catheter to the suction tubing. Wearing sterile gloves, LPN #201 then turned on the suction machine. Both of LPN #201's hands touched the suction machine. LPN #201 then removed Resident #10's inner trach canula with her left hand and discarded it. LPN #201 then used her left hand to guide the suction catheter into Resident #10's trach and suctioned three times, each time clearing the tubing with sterile water. LPN #201 then put in place Resident #10's inner canula using he same sterile gloves used for suctioning. LPN #201 did not change any gloves during the procedure and did not keep any hand sterile. Interview with LPN #201 on 01/12/26 at 2:20 P.M. confirmed she did not down a gown or facemask while performing Resident #10's trach care. LPN #201 confirmed she did not wash or sanitize her hands between gloves changes and also use sterile gloves while touching non-sterile items during the procedure.Review of the facility policy titled Tracheostomy Care dated October 2023 revealed General Guidelines included:1. Aseptic technique must be used:a. during cleaning and sterilization of reusable tracheostomy tubes;b. during all dressing changes until the tracheostomy wound has granulated (healed); andc. during tracheostomy tube changes, either reusable or disposable.2. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures.3. A mask and eyewear must be worn if splashes, spattering, or spraying of blood or body fluids is likely to occur when performing this procedure.4. Tracheostomy tubes should be changed as ordered and as needed (at least monthly).5. Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies.6. A replacement tracheostomy tube must be available at the bedside at all times.7. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times.

Based on medical record review, staff interview, interview with dialysis staff, review of dialysis treatment logs, and policy review, the facility failed to ensure pre and post dialysis evaluations were completed, failed to ensure communication with dialysis center was consistently done, failed to ensure the medical record contained documentation related to missed dialysis treatments, and failed to ensure the physician was notified of missed dialysis treatments. This affected the one (#03) of one residents reviewed for dialysis services. The facility census was 55. Findings include: Review of the medical record for Resident #03 revealed an admission date of 09/17/25 with medical diagnoses of intracranial hemorrhage, left hemiparesis, end stage renal disease (ESRD), and dependence on dialysis. Review of the medical record for Resident #03 revealed a quarterly Minimum Data Set (MDS) assessment, dated 12/18/25, which indicated Resident #03 was cognitively intact and required partial/moderate staff assistance with toilet hygiene and showers, and supervision with transfers. The MDS indicated Resident #03 was independent with bed mobility and Resident #03 received dialysis. Review of the medical record for Resident #03 revealed a physician order for dialysis on Monday/Wednesday/Friday at a dialysis center with a chair time at 11:45 A.M. Review of the December 2025 Treatment Administration Record (TAR) indicated Resident #03 received dialysis as scheduled except on 12/08/25, 12/21/25, and 12/23/25. Review of the dialysis center treatment logs for December 2025 revealed Resident #03 refused dialysis on 12/01/25, 12/05/25, 12/29/25, and 12/31/25. Further review of the dialysis treatment logs, revealed Resident #03 missed treatments on 12/03/25, did not receive full dialysis treatment on 12/10/25, 12/15/25, 12/17/25, 12/21/25, and 12/23/25, and the dialysis treatments on 12//22/25 and 12/24/25 were rescheduled. Review of the medical record for Resident #03 revealed no documentation to indicate why Resident #03 had not received dialysis on 12/21/25 or 12/23/25. Further review of the medical record for Resident #03 revealed no documentation to support the facility notified the physician of missed dialysis treatments or the facility completed pre and post dialysis treatment evaluations. Review of the medical record for Resident #03 revealed a dialysis communication form, dated 12/19/25, which stated Resident #03 did not receive a full dialysis treatment. Review of the medical record revealed no other communication forms for December or January 2025 had been completed by the facility. Interview on 01/06/26 at 11:33 A.M. with Dialysis Nurse #320 stated Resident #03 had a history of refusing treatments or not completing a full dialysis treatment. Dialysis Nurse #320 stated Resident #03 last dialysis treatment in December 2025 was on 12/23/25. Dialysis Nurse #320 stated Resident #03 refused her dialysis on 12/31/25 and the nurse informed the facility that Resident #03 would need to get stat potassium levels completed at the hospital before she returned to dialysis. Dialysis Nurse #320 confirmed Resident #03 had not been to the dialysis center since 12/31/25. Interview on 01/08/26 at 8:34 A.M. with the Director of Nursing (DON) confirmed Resident #03's medical record did not have documentation to support the facility staff completed pre/post dialysis evaluations after each treatment, did not have documentation to support the facility communicated with the dialysis center regarding Resident #03's treatments, or that the facility notified the physician of the missed treatments. DON also confirmed the facility had not completed the stat potassium levels as requested by the dialysis center on 12/31/25. DON also confirmed Resident #03's medical record did not have documentation related to missed treatments or partial treatments. Review of the facility policy titled, Hemodialysis Catheters, revised June 2025 stated the nurse should document in the resident's medical record every shift the location of the catheter, condition of dressing, if dialysis was done during shift, any part of report from the dialysis nurse post-dialysis given and observations post dialysis.

Based on medical record review, observation, staff interviews, and review of facility policy, the facility failed to ensure medications were not left at a resident's bedside. This affected one (#50) out of 55 residents observed during the initial pool. The census was 55. Findings include: Review of Resident #50's medical record revealed an admission date of 09/18/25. Diagnoses listed include atrial fibrillation, heart failure, hypertension, malnutrition, and post-traumatic stress disorder. Review of a quarterly Minimum data Set (MDS) dated [DATE] revealed Resident #50 was cognitively intact. Further review of Resident #50's medical record revealed the nursing staff were to administer the residents medication and there was no assessment, order or care plan for the resident to self-administer medications. Observation on 01/05/26 at 11:22 A.M. revealed several pills in a medication cup and a bottle of Flonase (nasal spray) on a bedside table in Resident #50's room. Interview and observation with Licensed Practical Nurse (LPN) #275 on 01/05/26 at 11:25 A.M. confirmed 14 pills in a medication cup and a bottle of Flonase on Resident #50's bedside table. LPN #275 denied leaving the medications on the bedside and was unsure when they were left there. Resident #50 stated he believed they were left there from the morning. Review of the facility's policy titled Medication Labeling and Storage dated revised February 2023 revealed medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.

Based on medical record reviews, staff interviews, and policy review, the facility failed to ensure laboratory (labs) values were obtained as per physician orders. This affected three (#02, #03, and #09) residents out of five residents reviewed for lab services. The facility census was 55. Findings include: 1. Review of the medical record for Resident #03 revealed an admission date of 09/17/25 with medical diagnoses of intracranial hemorrhage, left hemiparesis, end stage renal disease (ESRD), and dependence on dialysis. Review of the medical record for Resident #03 revealed a quarterly Minimum Data Set (MDS) assessment, dated 12/18/25, which indicated Resident #03 was cognitively intact and required partial/moderate staff assistance with toilet hygiene and showers, and supervision with transfers. The MDS indicated Resident #03 was independent with bed mobility and Resident #03 received dialysis. Review of the medical record for Resident #03 revealed a physician order dated 09/29/25 for complete blood count (CBC) and basic metabolic panel (CMP) to be done weekly and faxed to the dialysis center every Monday. Review of the medical record for Resident #03 revealed on 12/22/25 Resident #03 refused CBC and BMP to be done. Review of the medical record revealed no documentation to support the facility obtained or attempted to obtain the CBC and BMP any other dates in December 2025. 2. Review of the medical record for Resident #09 revealed an admission date of 10/17/24 with medical diagnoses of chronic obstructive pulmonary disease (COPD), bipolar disorder, diabetes mellitus, and hypertension. Review of the medical record for Resident #09 revealed a quarterly MDS assessment, dated 12/28/25, which indicated Resident #09 was cognitively intact and required partial/moderate staff assistance with toilet hygiene, showers, and set-up assistance with eating and transfers. Review of the medical record for Resident #09 revealed a physician order dated 10/06/25 for CBC and BMP to be done weekly. Review of the medical record for Resident #09 revealed no documentation to support the facility obtained or attempted to obtain the labs as ordered in November 2025 except on 11/20/25. 3. Review of Resident #02's medical record revealed and admission dated 12/04/25. Diagnoses listed included bacteremia, hypertension, cellulitis, type two diabetes mellitus, and osteomyelitis. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #02 was cognitively intact. Review of progress notes dated 12/30/25 at 4:57 P.M. reviewed laboratory values were reviewed with nurse practitioner (NP) and a new order for a Stat (urgent) chest X-radiation (X-ray) and complete blood count (CBC) on the next laboratory day. Review of physician orders revealed an order dated 12/30/25 for CBC to be drawn next lab day. Review of laboratory results revealed the specimen was obtained on 12/31/25 and noted to be clotted. The results were reported on 01/01/26. Further review of Resident #02's medical record revealed no documentation of the CBC being attempted to be re-drawn or of Resident #02's physician being notified. Resident #02 was discharged to the emergency room (ER) on 01/06/25. Interview on 01/08/26 at 8:40 A.M. with Director of Nursing (DON) confirmed the medical records for Residents #03, #09 and #02 did not contain documentation to support the facility obtained labs as per physician orders. Review of the facilities policy titled Lab and Diagnostic Test Results - Clinical Protocol dated revised November 2018 revealed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs, staff will process test requisitions and arrange for tests, laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure staff implemented enhance barrier precautions (EBP). This affected one (#10) of five reviewed for transmission-based precautions (TBP). The census was 55. Findings include: Review of Resident #10's medical record revealed an admission date of 01/21/25. Diagnoses listed included chronic obstructive pulmonary disease, coronary artery disease, anxiety disorder, hemiplegia, encephalopathy, and psychotic disturbance. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was rarely understood by staff and received tracheostomy care. Review of physician orders revealed an order date 09/24/25 for EBP due to the presence of a tracheostomy and feeding tube. Observation of Resident #10's trach care and medication administration per feeding tube on 01/07/2026 2:05 P.M. revealed Licensed Practical Nurse (LPN) #201 did not don a gown when providing care. LPN #201 accessed Resident #10's to administer medications and completed his trach care including deep suctioning. LPN #201 did not down a facemask when performing deep suctioning. Interview with LPN #201 on 01/12/26 at 2:20 P.M. confirmed she did not don a gown during Resident #10's care and that there was a sign posted on the entrance to Resident #10's room informing of staff of EBP. Review of the facility's policy titled Enhanced Barrier Precautions dated December 2024 revealed Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Personal protective equipment (PPE) is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: dressing; bathing/showering; providing hygiene or grooming; changing briefs or assisting with toileting; transferring; providing bed mobility; changing linens; prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (e.g., in the shower room, therapy gym, or during restorative care); device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and wound care (any skin opening requiring a dressing).

Based on observation, resident interview, staff interview and review of facility policy, the facility failed to ensure residents were supervised while smoking and further failed to ensure residents smoked in designated areas per facility policy. Additionally, the facility failed to ensure residents utilized non-combustible containers to extinguish smoking materials. This affected two (#21 and #07) of two residents reviewed for smoking. The facility identified 15 (#07, #08, #13, #15, #16, #20, #21, #24, #26, #32, #34, #43, #48, #49, and #50) residents who smoked. The facility census was 50.Findings include:1. Review of the medical record for Resident #21 revealed an admission date of 02/13/24 with medical diagnoses of chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), and tobacco use.Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/11/25, revealed Resident #21 was cognitively intact and was independent with all activities of daily living (ADLs).Review of the current plan of care revealed Resident #21 was at risk for injury related to smoking. Interventions included nursing staff to maintain all smoking materials in the designated area and the resident was to be a supervised smoker.Review of the Smoking Safety Screen, dated 06/10/25, revealed Resident #21 was a smoker and preferred to smoke in the morning, afternoon, evenings, and nights. The screen indicated Resident #21 required supervision when smoking and the resident was aware that staff needed to store his lighter and cigarettes.Observation on 09/03/25 at 7:45 A.M. revealed Resident #21 exited the facility through the main entrance door, propelled himself in his wheelchair approximately three feet from the entrance, removed a cigarette and lighter from his pocket, lit a cigarette and proceeded to smoke. Further observation revealed a no smoking sign was posted on a pole near the entrance door. No facility staff were observed providing supervision for Resident #21. Concurrent interview with Resident #21 confirmed he was smoking on the sidewalk in front of the facility's main entrance.Interview on 09/03/25 at 7:50 A.M. with Housekeeper (HSK) #228 confirmed Resident #21 was smoking unsupervised, approximately three feet from the facility's main entrance door. HSK #228 stated residents who required supervision with smoking were to smoke in the designated smoking area at designated times. Interview on 09/03/25 at 8:25 A.M. with Resident #21 revealed the nursing staff kept his smoking supplies at the nurses' station and that he was provided with a cigarette and his lighter by staff to smoke this morning.2. Review of the medical record for Resident #07 revealed an admission date of 06/17/25 with medical diagnoses of COPD, cellulitis to right lower extremity, hypertension (HTN) and anxiety.Review of an admission MDS assessment, dated 06/22/25, revealed Resident #07 was cognitively intact and required supervision with toilet hygiene, bathing, and transfers and was independent with bed mobility. The MDS indicated Resident #07 used tobacco products.Review of the Smoking Safety Screen, dated 06/17/25, revealed Resident #07 preferred to smoke in the morning, afternoon, evenings, and nights and the resident could light his own cigarette. The screen indicated Resident #07 was aware the facility needed to store his lighter and cigarettes and he was safe to smoke without direct supervision.Observation on 09/03/25 at 7:48 A.M. revealed Resident #07 was sitting in his wheelchair in the visitor parking lot smoking a cigarette. Concurrent interview with Resident #07 confirmed he was smoking on the facility property and was aware that he was supposed to go off the facility property to smoke. Resident #07 stated the nursing staff kept his smoking supplies at the nurses' station.Interview on 09/03/25 at 7:50 A.M. with HSK #228 confirmed Resident #07 was smoking in the facility parking lot. HSK #228 stated residents who did not require supervision while smoking were required to smoke off of the facility property.3. Observation on 09/03/25 at 7:50 A.M. revealed multiple cigarette butts were on the ground along the sidewalk to the front entrance and in the parking lot, as well as in the mulch at the front entrance. Concurrent interview with HSK #228 verified the cigarette butts located on the ground in the facility parking lot, sidewalk, and in the mulch. Interview on 09/03/25 at 10:00 A.M. Licensed Practical Nurse (LPN) #249 revealed the designated smoking area for the residents was located on a patio off of the activity room. LPN #249 stated some residents would sign themselves out on leave of absence (LOA) and go off the facility property to smoke. LPN #249 confirmed residents were to smoke in the designated smoking area unless they were off facility property. Concurrent observation of the designated smoking area revealed several discarded cigarette butts in the mulch and in the grass. Further interview with LPN #249 confirmed an appropriate non-combustible container was available for the disposal of smoking materials; however, multiple cigarette butts were in the mulch and the grass area of the smoking area. Review of the facility policy titled, Smoking, revised 02/18/22, revealed the facility would establish and maintain safe resident smoking practices. The policy stated that prior to, or upon admission, residents would be informed of any limitation on smoking, including designated smoking areas, and the extent to which the facility could accommodate their smoking or non-smoking preferences. Further review revealed that residents with restricted smoking privileges requiring monitoring should have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. Smoke breaks would only be held under supervision and/or during assigned smoking break times.The deficiency was based on incidental findings discovered during the course of the complaint investigation.

Based on record review, observation, staff interview, review of the facility policy, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin and failed to timely identify the resident's pressure ulcers until they reached an advanced stage. This resulted in Actual Harm to Residents #32, #39, and #42 who developed pressure ulcers while in the facility which were not identified until they had reached an advanced stage. Resident #42 was not assessed for the risk of pressure ulcer until after the resident developed four pressure ulcers (a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed) to the right thigh, a stage III pressure ulcer to the superior coccyx, an unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) to the inferior coccyx, and a stage III pressure ulcer to the left trochanter.) Resident #32 was at risk for pressure ulcers and developed a stage III pressure ulcer to the right heel. Resident #39 was at risk for pressure ulcers and developed a deep pressure tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue) to the right heel. This affected three (Residents #32, #39, and #42) of three residents reviewed for pressure ulcers. The facility identified three residents with pressure ulcers. The facility census was 41. Findings include: 1. Review of the closed medical record for Resident #42 revealed an admitted [DATE] with diagnoses including chronic embolism and thrombosis of veins, chronic obstructive pulmonary disease (COPD), hypertension (HTN), anxiety disorder, depression, seizures, neuromuscular dysfunction of the bladder, and a body mass index (BMI) > 70. Resident #42 was discharged to the hospital on 10/14/23. Review of the admitting nurse progress note for Resident #42 dated 09/18/23 revealed it did not include a description or assessment of the condition of the resident's skin. Review of the medical record for Resident #42 revealed it did not include an admission nursing assessment and it did not include weekly skin assessments from 09/18/23 to 10/02/23. Review of the care plan for Resident #42 initiated 09/19/23 revealed the care plan did not include resident's risk for development of impaired skin integrity. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was cognitively intact and required extensive assistance of one to two staff with activities of daily living (ADLs.) Resident #42 was coded negative for the presence of pressure ulcers upon admission to the facility. Review of the wound physician notes dated 10/03/23 revealed Resident #42 developed four pressure ulcers in the facility all of which were first noted on 10/03/23. Resident #42 had a stage III pressure ulcer to the right posterior thigh which measured 3.7 centimeters (cm) in length by 1.2 cm in width by 0.1 cm in depth; a stage III pressure ulcer to the superior coccyx which measured 1.0 cm in length by 0.7 cm in width by 0.1 cm in depth; an unstageable pressure ulcer to the inferior coccyx which measured 2.3 cm in length by 1.1 cm in width with 80 percent (%) slough tissue obscuring the wound bed; and a stage III pressure ulcer to the left trochanter which measured 0.6 cm in length by 1.4 cm in width by 0.2 cm in depth. There was a treatment ordered to cleanse the wounds with normal saline, apply alginate to the wound beds and cover with dry clean dressing once daily. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #42 was at risk for the development of pressure ulcers. Interview on 10/17/23 at 12:50 P.M. with Licensed Practical Nurse (LPN) #230 confirmed the nurses were supposed to conduct weekly skin assessments for all residents and document the results in the electronic medical record. LPN #230 further confirmed Resident #42 was admitted on [DATE] and did not have skin checks completed from 09/18/23 to 10/02/23. LPN #230 confirmed Resident #42 was noted to have developed four pressure ulcers in the facility on 10/03/23. Interview on 10/18/23 at 4:34 P.M. with the Administrator and Regional Nurse (RN) #395 confirmed Resident #42 was admitted to the facility on [DATE] and her record did not include an admission nursing assessment or weekly checks of the resident's skin until 10/03/23. On 10/03/23, Resident #42 was noted to have four pressure ulcers: a stage III pressure ulcer to the right thigh, a stage III pressure ulcer to the superior coccyx, an unstageable pressure ulcer to the inferior coccyx, and a stage III pressure ulcer to the left trochanter. The Administrator and RN #395 confirmed Resident #42's pressure ulcers were not identified until they had reached an advanced stage, and the facility conducted a pressure ulcer risk assessment on 10/04/23 after the pressure ulcers had already been identified which showed the resident was at risk for the development of pressure ulcers. 2. Review of the medical record for Resident #39 revealed an admitted [DATE] with diagnoses including malignant neoplasm of the prostate, diabetes mellitus (DM). hyperlipidemia, cerebrovascular disease, major depressive disorder, hypertension (HTN), and psychosis. Review of the care plan dated 03/17/21 revealed Resident #39 had the potential for impaired skin integrity related to edema, incontinence, and reduced bed mobility. Interventions included the following: apply cushion to wheelchair, assist the resident with turning and repositioning on routine rounds and as needed, assist with toileting needs and incontinence care, elevate heels when in bed, pressure reduction mattress to bed, and provide for routine skin care. Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #39 was at risk for the development of pressure ulcers. Review of the weekly skin check dated 06/29/23 revealed Resident #39 had no new skin issues. There were no weekly skin checks for Resident #29 from 06/30/23 to 07/11/23. Review of the nursing progress note dated 07/11/23 revealed Resident #39 was noted to have a deep tissue injury (DTI) to his right heel which measured 5.0 cm in length by 4.5 cm in width. Review of the wound physician progress note dated 07/11/23 revealed Resident #39 had a deep tissue pressure injury (DPTI) to the right heel which measured 5.0 cm in length by 4.5 cm in width. The treatment order was to use a barrier wipe to the area every shift and as needed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADLs.) Observation on 10/18/23 at 11:37 A.M. revealed Resident #39 was resting in bed on a low air loss mattress with his heels floated on pillows. A dime-sized pressure ulcer was noted to the resident's right heel. Interview on 10/18/23 at 4:34 P.M. with the Administrator and Regional Nurse (RN) #395 confirmed Resident #39 had developed a DTPI to his right heel which was first identified on 07/11/23. The last skin check documented for Resident #39 occurred on 06/29/23 and showed no new open areas. The Administrator and Regional Nurse (RN) #395 confirmed the pressure ulcer for Resident #39 was not identified until it had reached an advanced stage. 3. Review of the medical record for Resident #32 revealed an admitted [DATE] with diagnoses including diabetes mellitus (DM), moderate protein calorie malnutrition, gastrostomy tube, and Alzheimer's disease. Review of the weekly skin check dated 08/24/23 revealed Resident #32 had no new open skin areas. Review of the medical record for Resident #32 revealed there were no skin checks recorded from 08/25/23 to 10/02/23. Review of the care plan dated 08/25/23 revealed Resident #32 was at risk for the development of skin breakdown. Interventions included the following: educate the resident/representative about proper skin care to prevent skin breakdown, educate resident/representative on importance of keeping skin clean and moisturized, encourage the resident to frequently shift weight, encourage the use of lifting devices while in bed, evaluate skin for areas of blanching or redness, evaluate ulcer characteristics, monitor bony prominences for redness, notify family of new onset finding, and provide skin care per facility guidelines. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADLs). Review of the wound physician note dated 10/03/23 revealed Resident #32 developed a facility-acquired stage III pressure ulcer to his right heel on 10/03/23 which measured 1.0 cm in length by 1.8 cm in width by 0.1 cm in depth. The wound treatment ordered was to cleanse the wound with normal saline, apply alginate, and cover with dry clean dressing once daily and as needed. Review of the wound physician note dated 10/17/23 revealed Resident #32's stage III pressure ulcer to the right heel measured 0.5 cm in length by 0.9 cm in width by 0.1 cm in depth. The wound treatment was changed to cleanse the wound with normal saline, apply barrier wipe, and leave open to air once daily. Observation of wound care on 10/18/23 at 11:41 A.M. for Resident #32 completed by LPN #230, revealed the resident was resting on a low air loss mattress. Resident #32 had a pressure ulcer to his right heel which was the size of pencil eraser in diameter. Interview with LPN #230 on 10/18/23 at 11:49 A.M. confirmed Resident #32 developed a stage III pressure ulcer to his right heel, which was first identified on 10/03/23. LPN #230 stated the wound had decreased in size since it was identified. Interview on 10/18/23 at 4:34 P.M. with the Administrator and RN #395 confirmed Resident #32 had developed a stage III pressure to his right heel which was first identified on 10/03/23. The last skin check documented for Resident #32 occurred on 08/24/23 and showed no new open areas. The Administrator and RN #395 confirmed the pressure ulcer for Resident #32 was not identified until it had reached an advanced stage. The Administrator confirmed the facility did not have a policy regarding skin assessment or prevention of skin breakdown. Review of the facility's undated policy titled Skin Wound Care Protocol revealed the facility had a protocol for wound care and treatment for each stage of ulcer development. Review of the NPUAP guidelines dated 2014 pages 70-71 at (https://npiap.com/general/custom.asp?page=2014Guidelines) revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominence. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosity, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents non-compliance investigated under Complaint Numbers OH00147361, OH00146921, and OH00146879.

Based on medical record review, observation, resident, staff and pharmacist interview, review of the narcotic count sheet, review of a pharmacy e-mail correspondence and policy review, the facility failed to ensure a resident with a chronic debilitating condition received as needed narcotic pain medication. This resulted in Actual Harm, when staff failed to ensure Resident #10 received as needed (PRN) narcotic pain medication when he reported a sharp stabbing pain at a level nine out of 10 on a pain scale from one to 10 with 10 being the worst pain. The narcotic pain medication was not administered until approximately 16 hours later. This affected one resident (#10) of three residents reviewed for pain. The facility identified 22 residents (#02, #04, #07, #10, #11, #12, #18, #22, #23, #24, #29, #31, #32, #36, #37, #42, #43, #45, #47, #48, #49 and #51) who received pain medication. The census was 49. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission assessment dated [DATE] revealed Resident #10 had intact cognition. The resident required limited assistance for bed mobility and transfers, he used a cane and a wheelchair. There was no pain assessment completed. Review of the baseline care plan dated 04/01/22 revealed Resident #10's pain would be controlled and would not interfere with functional abilities. Review of physician orders dated 04/04/22 revealed Resident #10 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the narcotic count sheet dated 04/02/22 revealed the last dose of [MEDICATION(S)] was given to Resident #10 on 04/04/22 at 6:00 P.M. Review of the progress note dated 04/05/22 at 2:24 A.M. revealed the nurse had been trying for hours to obtain authorization to pull Resident #10's pain medication from the emergency box (E-box). The prescription was faxed multiple times and every time the pharmacy called back, they stated the information was missing on the form; however, the form was completed correctly. The nurse also was on hold for over 45 minutes on the telephone and unfortunately was unable to obtain the request for the pain medication. Review of an e-mail correspondence from the facility pharmacy dated 04/05/22 revealed the order faxed from the facility to the pharmacy and on the upper left-hand corner there was a stamp dated 04/05/22 to pull one [MEDICATION(S)]/APAP ([MEDICATION(S)]) 7.5/325 mg per Licensed Practical Nurse (LPN) #156. On the lower left-hand corner of the order revealed another stamp that had authorized to pull the medication. Verification of what these boxes meant on the order was received from Pharmacist #155 via e-mail on 04/06/22 at 5:50 P.M. and revealed the upper left top box was the [MEDICATION(S)] pull authorization on 04/05/22 after 5:00 P.M. and the bottom left was the pull authorization on 04/05/22 at 9:30 A.M. Review of a Physical Therapy (PT) progress note dated 04/05/22 at 1:14 P.M. revealed Resident #10 reported pending transfer to another facility with ongoing pain which the resident indicated he wanted to wait to start PT until he transferred to the next facility and reiterated his pain was exacerbated by movement and intended to limit movement here at the facility. Interview and observation with Resident #10 on 04/05/22 at 3:00 P.M., revealed he had [CONDITION(S)] disc disease, and it has affected three vertebras in his neck and three in his lower back. He said he had a pinched nerve, and they did a procedure on him before coming to the facility and that made it worse. He stated everything at the facility had been going downhill because he wasn't able to participate in therapy due to his pain which he identified as a nine out of 10 described as a sharp and stabbing pain, and he wasn't able to sleep at night. Resident #10 stated the nursing staff were unable to obtain his pain medications to give to him. He said he asked for medication and the nurse said, I will be back and they don't come back. He said the last dose of pain medication he received was on 04/04/22 at 6:00 P.M. He stated he spoke to the nurse, and she said the doctor did something wrong with his script and the facility was trying to get it fixed. During the conversation when the resident turned in the bed, he would wince. Interview with the Pharmacist General Manager (PGM) #155 on 04/06/22 at 8:48 A.M. revealed the pharmacy had not received a new script until 04/05/22 at 12:38 A.M. and this would have gone out on 04/05/22 to the facility. He said there were two authorizations to pull the [MEDICATION(S)] approved at 9:30 A.M. and at 5:30 P.M. from the E-box. Interview with Licensed Practical Nurse (LPN) #156 on 04/06/22 at 10:17 A.M., revealed when she came in on 04/05/22 the pain medication for Resident #10 was not in the facility. She stated when the physician filled out the order on 04/04/22 the year was not on the script and the pharmacy would not take it and sent it back. She said it was after 9:30 A.M. before the physician came in and put the year on the script and then she faxed it back to the pharmacy. She stated she was an agency nurse and said she had to find out what the procedure was for taking medications out of the E-box and could not obtain Resident #10's pain medication until 4:36 P.M. She verified there was a delay in getting the pain medications. Interview with the Director of Nursing (DON) on 04/06/22 at 11:30 A.M., revealed the pain medications ran out on the evening of 04/04/22. She stated Resident #10 was alert and oriented and could ask for his medications when he needed them. She stated it was not the nurses' responsibility to reorder the pain medications ahead of time, they would be ordered when the next nurse discovered the medications were out. Interview with PT #103 on 04/06/22 at 12:19 P.M., revealed when he saw Resident #10 to perform an evaluation, the resident was lying in bed and said he was in pain. He stated when the resident moved or gets out of the bed, the pain was exacerbated, and the resident did not want to do the evaluation or therapy. He said the resident was interested in leaving this facility and going to another one and did not want to get started with therapy here and then start all over again at another facility. He denied he reached out to the physician to report the resident not wanting to participate in therapy because of his pain. He revealed there were some challenges with the Resident #10's pain medication. Interview with LPN #61 on 04/06/22 at 1:24 P.M., revealed she worked the morning of 04/05/22 and tried to get the pain medication ([MEDICATION(S)]) for Resident #10 from about 10:00 P.M. to 2:00 A.M. She stated the medication ran out on 04/04/22 at 6:00 P.M. when the nurse, before her, gave the resident the last one. She found a prescription in the hard chart dated 04/04/22 for the [MEDICATION(S)] and faxed it to the pharmacy. She stated the pharmacy sent it back to her because there wasn't a year posted on the script. She denied she tried to call the physician because she could not read the name so she put a note in the doctor's box that would be seen in a few hours of her leaving her shift when the physician came into the facility. She said the nurse who took the last one on 04/04/22 at 6:00 P.M. should have sent the script that was in the chart dated 04/04/22 to the pharmacy and then there would not have been such a problem. She said she made a bad judgement call when not calling the physician and verified she was unable to obtain the pain medication. Review of the facility policy titled Pain Management dated 12/01/11 revealed the facility had a wide commitment to the resident's comfort by recognizing and assessing the resident for pain. The goal of the pain management program was to achieve a consistent level of comfort for the resident while maintaining as much physical function as possible. This deficiency substantiates Complaint Number OH 331.

Based on observations, medical record review, policy review, resident interview, Insurance Provider Representative interview and staff interviews, the facility failed to ensure a resident was provided an orderly discharge to meet the mental health and safety of the resident. This resulted in actual psychosocial harm of the resident as evidence by the resident displaying physical signs of red face, being out of breath, crying and verbally stating she was being kicked out. This affected one (#10) of three residents reviewed for discharge planning. The current census is 59. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and was a one person set up and assist for Activities of Daily Living (ADLs). Review of Resident #10's care plans dated 04/2017 revealed a focus for impaired vision related to [CONDITION(S)]. Interventions included provided glasses to resident and announce care provided. A discharge care plan revealed the resident does not anticipate a discharge from a level of long- term care. Review of Resident #10's discharge notice dated 07/30/21 revealed the resident was being discharged from the facility on 08/30/21 due to the facility was unable to provide care and services to meet the resident's needs. No discharge facility location was documented on the discharge notice. Per the discharge the resident was not to be transferred earlier than 08/30/21 unless both the resident and the facility agreed to an earlier discharge date . Observation and interview on 08/17/21 at 10:30 A.M., with Resident #10 was conducted in the courtyard of the facility with other residents. Resident #10 appeared visually upset, the resident's face was red, she was tearful and out of breath, as the resident explained she was being kicked out of the facility for smoking marijuana. Resident #10 stated she was informed earlier in the morning she was being discharged . Resident #10 stated she did not know when or where she was being discharged . The resident stated she was mentally exhausted at this point and tired of fighting to stay in her home. During the time of interview, Resident #13 approached the surveyor and Resident #10. Resident #13 stated the staff were packing the resident's belongings in her room. Resident #10 began to get upset and cry. When asked who told him Resident #10 was being discharged , Resident #13 refused to say what staff member told him she was being discharged . Interview on 08/17/21 at 10:44 A.M., with Licensed Practical Nurse (LPN) #200 revealed Resident #10 was scheduled to be discharged to another facility 08/17/21 at 3:00 P.M. The nurse did not say which facility the resident was being discharged too. Interview on 08/17/21 at 10:50 A.M., with Human Resource Manager (HRM) #1, verified Resident #10 was being discharged from the facility due to violating the drug policy regarding smoking marijuana on facility grounds. HRM #1 stated he was unaware if Resident #10 knew the discharge facility or the date and time of the discharge. Interview and observation on 08/17/21 at 11:50 A.M., with Resident #10 revealed the resident was in her room with Housekeeper #300 packing her belongings. Housekeeper #300 stated the resident was being discharged that morning. The housekeeper was instructed to pack all the resident's belongings into boxes and take them to the transport vehicle currently waiting at the front of the facility. Resident #10 stated she was not going to go in the transport vehicle, and she was refusing discharge. The resident was tearful and upset during the interview and the observation. Resident #10 continued to state she was being kicked out of the facility against her will. Resident #10 stated the Administrator told her if she did not leave today in the transport vehicle, she would be charged daily for all her services and she did not have any money to pay the facility, she felt she was being coerced by the Administrator stating she could not stay if she could not pay. Per Resident #10, she was only notified this day, 08/17/21, where she would be discharged to and the new facility was a place she did not want to go to because she had heard it was a bad facility and going there was causing her anxiety. Observations on 08/17/21 at 11:55 A.M. revealed a transport vehicle waiting outside of the facility. Interview on 08/17/21 from 12:00 P.M. to 12:15 P.M., with the Administrator, Social Service Activity Director (SSAD), and the Regional Nurse, revealed Resident #10 was being discharged earlier than the date on the notice. The Administrator stated due to Resident #10's insurance being transferred to the other facility the resident's stay would not be paid for by insurance if she chose to refuse the discharge. The Administrator verified the information for the discharge including the insurance information was being provided by the SSAD. The SSAD stated she had made the determination for the discharge as the facility was unable to care for Resident #10 due to her continuously using marijuana on facility grounds. SSAD verified the discharge notice did not have a destination and the form stated the resident would not be discharged prior to 08/30/21 unless the resident agreed to the discharge. The Regional Nurse stated the reason for discharge was inappropriate and should be to ensure resident safety not failure to provide needed care and services. The Regional Nurse stated the discharge would not be taking place on 08/17/21 until the resident had been issued a new notice for which she would be read what the notice stated and understood the discharge cause. Interview on 08/17/21 at 12:19 P.M., with Resident #10's Insurance Provider Representative (IPR) #11 revealed the facility had put in a request for authorization of payment to another facility on 08/16/21. Per IPR #11, Resident #10 was being covered in any facility she was residing. IPR #11 stated she was not scheduled to be discharged for another 13 days on 08/30/21, so the early discharge was confusing and appeared to be without just cause. IPR #11 stated the insurance company would continue to pay for Resident #10's stay at the facility if the resident chose to refuse the discharge and stay at her current residence. In addition, IPR #11 stated she has spoken with SSAD and the Administrator on 08/16/21 and on 08/17/21 and instructed them the resident's stay will be covered if the resident decided to stay until 08/30/21. Observation on 08/17/21 at 4:50 P.M., of Resident #10 revealed the resident and Housekeeper #300 were unpacking the resident's belongings. Resident #10 stated she was told by the Administrator she would be allowed to stay in the facility. The resident stated she was stressed due to the facility's attempt to discharge her before she was ready. Resident #10 stated she was unable to read the discharge notice due to her [CONDITION(S)] and could not understand the notice when SSAD had told her to sign the discharge notice on 07/30/21. Per Resident #10 she felt this early discharge was in retribution of her telling staff she felt SSAD was 'flirting' with male residents. Resident #10 stated she reported SSAD to the Administrator on 08/17/21 when she was told she would have to leave the facility. Interview on 08/18/21 at 2:00 P.M., with the Administrator and the Director of Nursing (DON) revealed Resident #10 was still being discharged from the facility with a new date as 09/17/21, for the cause of safety for the resident and other residents who reside in the facility. Per the Administrator, Resident #10 had the notice read to her and she agreed to sign the new discharge notice. Per the DON and the Administrator, Resident #10 did not make any accusations regarding SSAD flirting with any male residents. The DON and Administrator denied any allegations of inappropriate conduct from SSAD from any other residents or staff. Review of facility policy titled Discharging the Resident, dated 12/2016, revealed the facility was required to consult the resident about the discharge, explain the reason for the discharge, and give the location of the new facility. Per the policy if the resident exercises her right to refuse the discharge the resident will not be discharged until the appeal is resolved. The date and time and location will be documented on the discharge notice. This deficiency substantiated Complaint Number OH 740.

Based medical record review, staff interview, and review of information from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to implement pressure ulcer preventative measurements resulting in the development of avoidable pressure ulcers and the facility failed to complete pressure ulcer treatments as ordered. This resulted in Actual Harm when the resident developed three avoidable unstageable pressure ulcers to the lower extremities. This affected one (#66) out of three residents reviewed for pressure ulcers. The census was 62. Findings include: Review of Resident #66's closed medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #66 was assessed as being cognitively intact, frequently incontinent of bowel and bladder, and having one stage two pressure ulcer in a Minimum Data Set (MDS) assessment dated [DATE]. Resident #66 required two person physical assistance from staff for bed mobility and transfers. Resident #66 was discharged on [DATE]. Review of Resident #66's care plan dated as initiated 11/01/20 revealed there was no focus listed for skin integrity and no interventions were listed for the prevention of pressure ulcers. Further review of Resident #66's closed medical record revealed no documentation of any preventive measures to prevent lower extremity pressure ulcers. The only preventative order was a pressure reduction mattress ordered on [DATE]. Review of Resident #66's Braden assessment dated [DATE] revealed the resident was assessed as being a moderate risk for pressure ulcers development. Further review revealed there were no Braden assessment was documented before 11/13/20. Wound Care Nurse Practitioner (WCNP) notes dated 11/18/20, 11/23/20, 12/02/20, and 12/09/20 were reviewed. Date of first wound consult was noted as 11/18/20. In WCNP notes dated 11/18/20 documented two new lower extremity pressure ulcers (#1 and #2) were identified for Resident #66, all being noted as in-house acquired and acute. Wound #1 was to right lateral malleolus (ankle). Wound #1 was identified as an in-house acquired unstageable pressure ulcer. Wound #1 measured 1.5 centimeters (cm) by (x) 1.5 cm x 0.1 cm with moderate serosanginous exudate, 80 percent (%) slough-eschar, and 20% granulation tissue. A treatment of [REDACTED]. Wound #2 was to the plantar of right heel. Wound #2 was identified as an in-house acquired suspected deep tissue injury (STDI) unstageable pressure ulcer. Wound #2 measured 1.0 cm x 0.8 cm x zero cm with 100% necrotic tissue eschar. No exudate was present. A treatment of [REDACTED]. Both wounds (#1 and #2) require offloading for optimal healing. Recommend every two hours turn/repositioning. Further review of physician orders [REDACTED]. Review of physician orders [REDACTED]. Order was discontinued 12/09/20. A physician order [REDACTED]. A new pressure ulcer was identified in WCNP notes dated 12/09/20. Wound #6 an unstageable pressure ulcer to the left posterior heel. Wound #6 measured 1.5 cm x 1.5 cm x 0.1 cm with 100% slough-eschar. The site was noted as requiring aggressive offloading. A physician order [REDACTED]. Offload heels with heel boots or pillows at all times. Review of treatment administration records (TAR) for November 2020 and December 2020 revealed the Santyl treatment to the right lateral ankle ordered on [DATE] was not documented as being completed on 11/20/20, 11/23/20, 11/27/20, 11/30/20, 12/03/20, 12/07/20, 12/08/20, and 12/14/20. Further review of the TAR revealed the treatment of [REDACTED]. Interview with the Administrator on 01/28/21 at 7:35 A.M. confirmed lack of preventative measures to reduce the risk of lower extremity pressure ulcers development for Resident #66. The Administrator confirmed Resident #66's care plan lacked any focus or interventions for risk of skin impairment or the risk of pressure ulcer development. The Administrator confirmed Resident #66's right heel, right ankle, and left heel wounds were in-house acquired, the areas were unstageable and interventions had not been in place to prevent them. The Administrator also confirmed pressure ulcer treatments were not completed as ordered. Review of NPIAP website (https://npiap.com/) revealed an unstageable pressure injury is defined as and obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. A deep tissue pressure injury (DTPI) is defined as persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury. Further review revealed to ensure that the residents heels are free from the bed. Recommended using heel offloading devices or [MEDICATION NAME] foam dressings on individuals at high-risk for heel ulcers. This deficiency substantiates Complaint Number OH 735.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a closed medical record, review of the facility investigation, review of the death certificate, interviews with facility staff and review of the facility policy, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) for one resident (Resident #35) when the resident was found unresponsive, without a pulse or respirations, and was identified as a Full Code status. This resulted in Immediate Jeopardy and life-threatening harm when Resident #35 did not receive CPR and expired at the facility. This affected one (Resident #35) of two residents reviewed for Full Code status and death. Only one other resident who was identified as a Full Code status expired at the facility in the past five months. The facility identified a total of 31 current residents who were designated as having a Full code status. The facility census was 41. On [DATE] at 6:00 P.M., the Administrator was notified Immediate Jeopardy began on [DATE] at 5:00 A.M. when Resident #35 was found unresponsive by State tested Nursing Assistant (STNA) #21, who then notified Licensed Practical Nurse (LPN) #11 that the resident was unresponsive. LPN #11 did not initiate CPR on Resident #35 who had a Full Code status. LPN #11 did not document any assessment or care of the resident. LPN #11 called the physician, who gave a verbal order to release the body to the local Coroner's office. At the time there was not a Registered Nurse (RN) in the building. An RN did come in at 7:00 A.M. The only other nurse in the building was LPN #66. The Immediate Jeopardy was removed, and the deficiency was corrected on [DATE] when the facility implemented the following corrective actions: · On [DATE], LPN#11 was terminated and ineligible for rehire related to behavior. Her termination was not a result of not performing CPR on Resident #35. · On [DATE] at 12:03 P.M., after Residents #35's insurance company investigated the resident's death, the Administrator implemented a facility investigation into the resident's death. · The events below occurred on [DATE] between 12:32 P.M. and 4:05 P.M. Exact times of each item was not captured individually. Staff assisting to complete the investigation included: Administrator, the previous Director of Nursing (DON), Assistant Director of Nursing (ADON) #10, Medical Records (MR) #40, Minimum Data Set (MDS) Coordinator #30, Human Resources-Business Office Manager (BOM) #50, Regional Director of Clinical Compliance (RDCC) #60, Vice President of Clinical Services (VPCS) #70, and Chief Director of Senior Care Development/Owner (CD) #80. · On [DATE], the Administrator reviewed the [DATE] Quality Assurance and Performance Improvement (QAPI) minutes to determine if Resident #35's death had previously been reviewed or if there was any information related to the death. There was no documentation related to Resident #35's death in the QAPI [DATE] minutes. · On [DATE] at 1:24 P.M., the Administrator contacted the local fire department to see when nine-one-one (911) was called in regards to Resident #35. Per the local fire department there were no calls from the facility on [DATE]. · On [DATE], the Administrator instructed the previous DON to implement individual education to all nurses and to call nurses who were not currently working to come in to complete the education. On [DATE], the previous DON and ADON #10 educated all Registered Nurses (RN) and LPNs related to CPR and the expectations of notification of resident's death to include the Administrator, DON, physician and family members. · On [DATE], MDS Coordinator #30 and MR #40 conducted a whole house audit and chart reviews on all current residents to ensure the code status in the electronic chart, care plan and paper chart matched in all three areas. All charts reviewed were found to have the correct code status in all three areas. · On [DATE], the Administrator reviewed all deaths of residents with Full Code status, that had occurred in the facility since [DATE]. There were no previous deaths of residents with a Full Code status from [DATE] through [DATE]. · On [DATE], the Administrator implemented notification of all resident's death should be made to the Administrator. Also, any resident death would be reviewed during morning clinical review. Residents deaths would also be reviewed during monthly and quarterly · QAPI review unless the resident was under the care of hospice or had a valid Do Not Resuscitate (DNR) order. · On [DATE] at 4:05 P.M., an email was sent to the corporate team verifying interviews were conducted with staff working that night. Two staff who were no longer employed did not respond to requests for an interview. Verified lack of calling 911 for Emergency Medical Services (EMS), review of resident ' s chart, education in progress, and audits completed. · On [DATE] into [DATE], the Administrator reviewed all deaths of residents with Ohio DNR Comfort Care orders who died in the facility from [DATE] through [DATE]. There were no negative findings. · On [DATE], the Administrator conducted a QAPI meeting to discuss the issue and to implement the monitoring plan to include verification of code status daily on new admissions. Code status on all residents was to be audited weekly for four weeks and then monthly. T he audits are to continue every month. · On [DATE], the Administrator conducted a mandatory all staff meeting to review accurate and complete documentation expectations. · On [DATE], the facility provided CPR training by the local Fire Department to nursing staff whose certification was due to expire in late 2020 and 2021. · On [DATE], Resident #100, who was a Full Code, expired at the facility. His medical record was reviewed and there were no concerns related to the lack of CPR. This was the only death in the facility of a resident who had a Full Code status. · On [DATE], interviews were conducted with four staff members regarding CPR and notification including RN's #77 and #88 and LPN's #66 and #99. These interviews revealed they were in-serviced on code status and were knowledgeable of the location of code status. They were also aware of who needed notified when there was a death in the facility. Findings include: Review of the closed record for Resident #35 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #35's physician order dated [DATE] revealed Full Code status. Review of Resident #35's progress note dated [DATE] at 7:50 A.M. revealed the physician ordered to discharge Resident #35's body to the local Coroner's office. Further review of Resident #35's medical record revealed no documentation regarding finding the resident unresponsive or of any assessment completed by nursing staff. Review of the facility's investigation of Resident #35's death dated [DATE] revealed on [DATE] during the 5:00 A.M. rounds, STNA #21 found Resident #35 lying in bed, unresponsive. STNA #21 alerted LPN #11. CPR was not initiated even though the resident did not have a pulse or respirations and had a Full Code status. Review of the electronic charting on the resident's Medication Administration Record [REDACTED].M. Review of Resident #35's Death Certificate signed on [DATE] by the local County Coroner revealed the cause of death was an immediate result of Acute Cardiopulmonary Arrest. Review of a statement dated [DATE] from STNA #44 revealed she was asked to assist with after death care of Resident #35. STNA #44 stated she did not see any sign that CPR was performed. STNA #44 stated there was no crash cart inside, outside or near the room. Interview on [DATE] at 10:23 A.M. with the Administrator revealed on [DATE] she became aware of Resident #35's death as a result of a Medicaid investigation. The Administrator revealed her hire date to the facility was [DATE]. The Administrator confirmed the result of the investigation on [DATE] verified Resident #35 was a Full Code status and CPR was not initiated by LPN #11. The Administrator revealed STNA #21 found Resident #35 unresponsive on [DATE] during 5:00 A.M. routine rounds. STNA #21 alerted LPN #11 who went into the room to check the resident. The Administrator confirmed Emergency Medical Services was not contacted. The Administrator reported there were multiple unsuccessful attempts to reach LPN #11 on [DATE]. During an interview on [DATE] at 5:12 P.M. with STNA #21 she confirmed taking care of Resident #35 on [DATE]. STNA #21 revealed she checked on Resident #35 during the routine 3:00 A.M. check and the resident was breathing. STNA #21 confirmed she checked Resident #35 on the 5:00 A.M. rounds and he was cold, unresponsive and his eyes were open. STNA #21 stated she alerted LPN #11 immediately. STNA #21 revealed seeing the nurse rubbing the resident's chest hard. STNA #21 denied seeing LPN #11 initiate CPR. Telephone interview on [DATE] at 12:10 P.M. with LPN #11 revealed she remembered going into Resident #35's room after being notified by STNA #21 that the resident was unresponsive. LPN #11 stated the resident was cold and his eyes were open. LPN #11 stated she had never pulled out a crash cart for someone who was already gone. LPN #11 could not remember if the resident was a Full Code or if the resident had a DNR order. LPN #11 confirmed knowledge of how to locate the resident's code status in the electronic charting or in the paper chart. LPN #11 stated she asked another nurse (LPN #66) about initiating CPR. LPN #11 confirmed she did not initiate CPR. LPN #11 was questioned about appropriate documentation following the death of a resident. LPN #11 indicated any change in condition including the appearance of the resident should be documented. A telephone interview on [DATE] at 12:45 P.M. with LPN #66 was attempted. A voice message was left requesting a return call. Review of the facility policy entitled Emergency Procedure-Cardiopulmonary Resuscitation, dated 2001 and revised [DATE], revealed guidelines to include: If an individual (resident, visitor or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/Basic Life Support (BLS) shall initiate CPR unless it is known that a DNR order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death such as rigor mortis. This deficiency substantiated Complaint Number OH 486.

Based on medical record review, observations, staff interview, policy review and review of information from Medscape, the facility failed to timely and appropriately treat a resident who was positive for a urinary tract infection [MEDICAL CONDITION] and assess a resident when their was a change of condition. This resulted in actual harm when Resident #40's urinary tract infection was not timely and/or appropriately treated and the resident was subsequently hospitalized for [REDACTED].#40) out of two residents reviewed for hospitalization . Additionally, the facility failed to ensure a physician ordered bone stimulation device was applied as ordered and the resident's physician was notified when ordered medical equipment was not functioning properly. This affected one (#56) of five reviewed for implementing physician orders. Facility census was 58. Findings include: Review of Resident #40 medical record revealed the resident was admitted to the facility on [DATE] was recently readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of most recent minimum data set ((MDS) dated [DATE] revealed the resident has a brief interview of mental status score of 15 indicating the resident is cognitively intact. The resident had verbal behaviors daily but no other behaviors, hallucinations or delusions. The resident requires limited assist for eating and locomotion and extensive for all the other activities of daily living. The resident is coded frequently incontinent of bowel and bladder. Review of progress notes revealed on the noted dated 08/28/18 at 7:04 P.M. indicated the resident has been in bed with complaints of not feeling well for three days, the resident also has complaints of lethargy and toileting on herself. The note indicates there is a pending urinalysis laboratory test and that the resident refused Tylenol. Review of the progress note dated 08/29/18 at 3:53 P.M. revealed the note was a late entry for 08/26/18 and on that date the resident came to nurse stating she had blood in her urine. The progress note states the nurse collected urine for culture. Review of the progress note dated 08/29/18 at 5:55 P.M. revealed the resident had abdominal pain and a temperature of 99 degrees Fahrenheit (F). The note was an administration note that correlated to medication administration. Review of the progress note written 08/29/18 at 10:27 P.M. revealed the urinalysis results were back and reported to the physician with new order for [MEDICATION NAME] (Antibiotic) 100 milligrams (mg) twice a day for five days and the resident was notified Further review of a physician orders [REDACTED]. Review of progress note on 09/01/18 at 3:32 P.M. revealed at the 8:00 A.M. and 12:00 P.M. medication pass the resident is easy to awaken but keeps her eyes closed during medication administration. The resident is noted to have difficulty consuming medications and is noted to be alert time one (to self only). The note revealed the on coming nurse was notified of the resident's condition but was silent to the physician being notified of the acute change in the resident's condition. Review of the laboratory urine culture and sensitivity revealed the urine was colleted and test initiated on 08/27/18 and the laboratory test was complete and sent to the facility on [DATE] at 1:00 P.M. Review of the urine analysis culture and sensitivity revealed the urine was collected on 08/27/18 and the test was completed on 08/30/18 at 1:00 P.M. the results of the laboratory test revealed the resident had positive results for the bacterium of Escherichia Coli (E-Coli) and Proteus Mirabilis. The sensitivity indicated the antibiotic [MEDICATION NAME] that was prescribed was only effective in treating the E-Coli, and was not effective in treating Proteus Mirabilis. Resident was seen by the nurse practitioner on 08/30/18 at 5:15 P.M. and the progress note from that visit indicated the staff was to continue with the administration of [MEDICATION NAME] for the resident and when the urine culture and sensitivity was available it would be reviewed and the plan of care would be adjusted as needed. Review of Resident #40 Medication Administration Record [REDACTED].M. Review of the emergency Box (Ebox), an emergency supply of medications stored at the facility used for newly ordered medications so there is no delay in treatment, medication availability list revealed the box contains four [MEDICATION NAME] 100 mg pills. Review of the progress note dated 09/01/18 at 8:27 P.M. revealed the nurse went into the resident room to administer medications and the resident was slumped over to her right side and was very lethargic. The resident is noted to not respond when her name was called. The nurse noted the resident vial signs were taken and the resident's blood pressure was 186/85 millimeters of mercury (mm/hg), temperature was 102.7 degrees F. The nurse had another nurse come to the room and monitor the resident while she went to call the physician to report the findings. The nurse notified the physician, nurse practitioner, director of nursing and the unit manager. The progress note indicated the physician was ok with sending the resident out to the hospital. The nurse documented responsible party notifications were made. Review of hospital documentation for Resident #40 revealed the resident was hospitalized and treated for [REDACTED]. During an interview on 11/14/18 at 2:40 P.M. with the Regional Consultant Registered Nurse #805 confirmed if a resident receives an order for [REDACTED].#805 verified Resident #40 had a delay in treatment and should have had [MEDICATION NAME] initiated on 08/29/18 at 10:00 P.M. when the order was received. Regional Consultant Registered Nurse #805 confirmed the laboratory result for the urine analysis culture and sensitivity was completed and back to the facility on [DATE] at 1:00 P.M. Regional Consultant Registered Nurse #805 confirmed the nurse practitioner saw Resident #4 on 08/30/18 at 5:00 P.M. according to the progress note which indicated to continue [MEDICATION NAME]. Regional Consultant Registered Nurse #805 further confirmed when the laboratory test is complete it should reviewed and the plan of care adjusted if necessary. Regional Consultant Registered Nurse #805 verified the laboratory test results were back at the time the nurse practitioner made the visit; however, when reading the nurse practitioner's note it was revealed the nurse practitioner was not aware of the laboratory results being back at the facility nor that the resident had not had her medication initiated on the day it was ordered. During the interview, Regional Consultant Registered Nurse #805 confirmed the resident was admitted and treated at the hospital for urinary tract infection. Regional Consultant Registered Nurse #805 further confirmed Resident #40 not only had a delay of initiation of antibiotic treatment at the facility, and it was also a delay in reporting a change of condition when it was noted on 09/01/18 at 8:00 A.M. when the resident was noted to be lethargic, only alert to self and having difficulty taking medications the nurse did not notify the physician but documented she notified the oncoming shift. Review of the policy titled Change in a Resident's Condition or Status dated (MONTH) 2011 documented the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and or status (e.g. changes in level of care, billing/payments, resident rights, etc.). Under Policy Interpretation and Implementation 1. the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician On-Call Physician when there has been: a significant change in the resident's physical/emotional/ mental condition. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff of by implementing standard disease-related clinical intervention (is not self- limiting), b. Impacts more than one area of the resident's health status and/or c. Requires interdisciplinary review and/or review to the care plan. Review of information from Medscape revealed a positive urine culture is based on the growth of bacteria at a high number of colony forming units (CFUs). Urine culture results should be interpreted in conjunction with clinical symptoms of UTI, such as dysuria, urinary frequency, suprapubic pain, flank pain, and fever. 2. Review of Resident #56's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #56 was assessed as belong severely cognitively impaired on a Minimum Data Set (MDS) assessment dated [DATE]. Review of physician orders [REDACTED]. Review of (MONTH) (YEAR) and (MONTH) (YEAR) progress notes revealed that Resident #56's bone stimulator was documented as not functioning properly on 10/13/18, 10/18/18, 10/19/18, 10/22/18, 10/24/18, 11/01/18, 11/02/18, 11/06/18, 11/07/18 and 11/11/18. Review of medication administration records (MAR) for (MONTH) (YEAR) and (MONTH) (YEAR) revealed Resident #56's bone stimulator had been administered 15 times out of a possible 45 times. Resident #56 was documented as refusing treatments and other, see progress notes. Further review of progress notes for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the only record of physician notification of Resident #56's bone stimulator not working properly was on 10/13/18 when a voicemail message was left at the orthopedic office. There was no record of any follow-up communication. Resident #56's bone stimulator was observed on 11/14/18 at 3:46 P.M. Regional Consultant Registered Nurse Regional Consultant Registered Nurse #805 tried to turn on the bone stimulator. A message alarm came up on the bone stimulator's screen, no more treatments was displayed. The bone stimulator would not start a treatment. Regional Consultant Registered Nurse #805 confirmed that Resident #56's bone stimulator would not work or start a treatment. Regional Consultant Registered Nurse #805 confirmed on 11/15/18 at 10:09 A.M. that Resident #56's bone stimulator had been documented as not functioning properly on the above mentioned dates. Regional Consultant Registered Nurse #805 confirmed the facility staff should have addressed Resident #56's malfunctioning bone stimulator. Regional Consultant Registered Nurse #805 confirmed Resident #56's physician had not been notified when the bone stimulator was not working properly or when he refused the treatment.