Every finding on record at Avenue at North Ridgeville

Based on medical record review, resident interview, staff interview, and policy review the facility failed to ensure medications were available and administered to residents per physician order. This affected two residents (#14, #50) of three residents reviewed for medication administration. The facility census was 101. Findings include:1. Review of Resident #14's medical record revealed an admission date of 04/03/23. Diagnoses included sepsis, thrombocytopenia, and cardiomegaly. Review of Resident #14's Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition.Review of Resident #14's most recent care plan revealed she was to be administered Xarelto (blood thinner) for anticoagulant therapy due to congestive heart failure and atrial fibrillation. Review of Resident #14's physician order dated 07/22/26 revealed Xarelto 15 milligrams (mg) was to be administered by mouth in the evening for congestive heart failure.Review of Resident #14's Medication Administration Record (MAR) dated 07/29/26 revealed the evening dose of Xarelto was marked 9 by the nurse. This indicated to see the resident's progress notes.Review of Resident #14's progress note dated 07/29/26 at 4:58 P.M. revealed Xarelto oral tablet 15 mg was not received by the pharmacy. The pharmacy was notified and verified the pharmacy would send tonight. The resident and nurse practitioner were aware. Review of Resident #14's progress note dated 07/29/26 at 6:09 P.M. revealed hospice was notified that the Xarelto failed to be given. A voicemail was left for the resident's sister pending return communication.Interview with the Director of Nursing (DON) on 08/03/26 at 4:15 P.M. verified Resident #14 failed to receive the physician ordered Xarelto on 07/29/26 due to the medication being on order from the pharmacy.Interview with Resident #14 on 08/04/26 at 2:50 P.M. verified she missed a dose of the physician ordered Xarelto the previous week.2. Review of Resident #50's medical record revealed an admission date of 06/19/26. Diagnoses included hypokalemia, congestive heart failure, venous insufficiency, and chronic obstructive pulmonary disease.Review of Resident #50's 5-day MDS dated [DATE] revealed the resident had an intact cognition and was dependent on staff for all care.Review of Resident #50's physician order dated 07/14/26 for potassium oral packet 40 milliequivalents (mEq). Give 40 mEq by mouth at bedtime for hypokalemia.Review of Resident #50's MAR dated 07/18/26, 07/29/26, and 07/30/26 revealed the nurse documented a 9, meaning to see progress notes.Review of Resident #50's progress note dated 07/18/26 at 9:00 P.M. and 07/29/26 at 10:07 P.M. revealed the ordered 40 mEQ potassium oral packet was not available in the medication cart. Review of Resident #50's progress notes dated 07/30/26 found no documentation related to the missing dose of potassium 40 mEq. Review of Resident #50's laboratory results found the resident had no potassium levels taken after the missing doses.Interview with the DON on 08/03/26 at 4:15 P.M. verified Resident #50 failed to be administered the 40 mEq of potassium on 07/18/26, 07/29/26, 07/30/26 as it was unavailable due to the pharmacy sending inadequate amounts. Review of the facility policy titled Standard Medication Administration Times, revised 03/2023, revealed the facilities of progressive quality care strive to provide a consistent medication schedule for nursing and pharmacy and ensure safe and timely medication administration to all residents. This deficiency represents non-compliance investigated under Complaint Number 3074343.

Based on observation, medical record review, resident interview, staff interview, and policy review the facility failed to ensure dependent residents received proper grooming. This affected one (#77) of three residents reviewed for activities of daily living. The facility census was 101. Findings include:Review of Resident #77's medical record revealed an admission date of 05/29/23. Diagnoses included quadriplegia and contractures to the right hand.Review of Resident #77's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognition and was dependent on staff for all activities of daily living.Review of Resident #77's most recent care plan revealed the resident was dependent on staff for care and preferred to be shaved daily.Observation of Resident #77 on 08/03/26 at 10:50 A.M. revealed the resident was dressed for the day sitting in his room in his tilt and space wheelchair. The resident had approximately one quarter inch of beard growth on his face.Interview with Resident #77 on 08/03/26 at 10:50 A.M. revealed he wished to be shaved daily due to the beard itching his face. Resident #77 also stated that he disliked having facial hair. The resident stated he had not been shaved in five days.Interview with Certified Nursing Assistant (CNA) #225 on 08/03/26 at 2:25 P.M. verified Resident #77 failed to be shaved daily because of a lack of time. CNA #225 stated staff have no time to shave residents.Review of the facility staffing tool dated 06/28/26 through 07/04/26 revealed the staffing met minimum standards. Review of the facility policy titled Activities of Daily Living, dated March 2023, revealed a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.This deficiency represents non-compliance investigated under Complaint Number 3074343.

Based on medical record review, staff interviews, review of hospital paperwork, review of Emergency Medical Service (EMS) run report, and review of facility policy, the facility failed to ensure timely care and services following Resident #105's change in condition and failed to implement Resident #4's skin treatments as ordered. Actual harm occurred on 05/30/26 when Resident #105, who had a history of stroke and mild cognitive impairment, was observed to have a change in his cognitive and physical status without prompt assessment and response to Resident #105's change in condition. Facility staff noted possible slurred speech earlier on 05/30/26, but the resident was not assessed or treated until a left facial droop was identified at 11:00 A.M. Resident #105 was hospitalized with an acute stroke experiencing severe dysphagia requiring nothing by mouth (NPO) status and a nasogastric (NG) tube placement, loss of alertness and orientation, and new neurological deficits. This affected two residents (Resident #4 and Resident #105) of three residents reviewed for quality of care. The facility census was 89.Findings include: 1. Review of the medical record for Resident #105 revealed he was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to embolism of left middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and Parkinson's disease. Review of the care plan dated 03/15/25 revealed Resident #105 had a cognitive and activities of daily living (ADL) self-care performance deficit related to general weakness, hemiplegia, and history of cerebrovascular accident with interventions that included assistance of two staff members for ADLs and monitor for changes in behavior and cognitive status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #105 had a Brief Interview for Mental Status (BIMS) score of 10 that indicated he was alert and oriented with cognitive impairment with no signs of delirium, inattention, disorganized thinking or altered level of consciousness. Review of the MDS assessment revealed Resident #105 was dependent on staff for activities of daily living (ADLs). Review of the skilled nursing note assessment dated [DATE] revealed Resident #105 was alert and oriented to person, place, and time with some forgetfulness. Resident #105 was working with physical therapy for unsteady gait and balance and was able to feed himself with reliable hand grasp and supervision and was able to stand and pivot with standby guidance and verbal cues. Review of the late entry progress note dated 05/30/26 at 7:09 A.M. but entered on 06/02/26 at 7:54 A.M. (3 days later) by Licensed Practical Nurse (LPN) #924, revealed Resident #105 was able to be directed with statements of confusion, was at baseline, with diminished adventitious lung sounds (Unexpected, abnormal sounds superimposed over the breathing which are categorized by how they sound such as crackles, wheezing, and/or rhonchi. This typically indicates restricted airflow, fluid buildup, or trapped air in the lungs) without shortness of breath but repeated coughing. Resident #105 was not observed out of bed. Review of the progress note dated 05/30/26 at 12:11 P.M. revealed Resident #105 was sent to the Emergency Department (ED) for evaluation at 11:55 A.M. Review of the progress note dated 05/30/26 at 1:15 P.M. entered by Registered Nurse (RN) #827, revealed she was called in by Certified Nurse Assistant (CNA) #878 to assess Resident #105 due to a change that she noticed in confusion at 7:09 A.M. RN #827 observed Resident #105 sitting up in bed with his arms extended at his side. RN #827 noted no visible abnormalities in Resident #105's appearance; however, he seemed confused but at baseline. Resident #105 was able to state his name, his location, and was able to report he had previously been at the hospital for two days. RN #827 asked Resident #105 if he was experiencing any signs or symptoms related to urinary tract infection. Resident #105 denied urgency, frequency, burning sensation, and pain while voiding. RN #827 verified that Resident #105 was feeling a little tired. RN #827 noted that Resident #105 had been coughing when CNA #878 attempted to feed him and that was the reason, she initially informed RN #827. RN #827 revealed Resident #105's vital signs were within normal limits with regular arrythmias, lungs diminished throughout, and bowel sounds present in all four quadrants with no palpable pain or tenderness noted. RN #827 went into Residet #105's room at approximately 8:25 A.M. to administer medications and he was able to take them as usual without coughing and able to hold a double handed cup with cranberry juice with no tremors when handed to his left hand; however, Resident #105 was weak and needed assistance to place the cup back on the table. Resident #105 answered questions again appropriately with no facial droop noted. RN #827 went back into the room to administer Bactrim that was pulled from the emergency medication kit (E-Kit) approximately 15 minutes later. Resident #105 was still observed to notably tired but had no facial droop. Resident #105's call light was answered but uncertain of time. Prior to entering Resident #105's room, other staff informed RN #827 that he consistently used his call light, and other staff had been in and out of his room but reported no facial droop to the left side of his face. The squad was called and arrived at approximately 11:45 A.M. and Residet #105 was observed being assessed. Resident #105's Power of Attorney (POA) requested he get out of bed and showered without mentioning facial droop and continued to insist staff get him up despite observed right-sided weakness. Review of the progress note dated 05/30/26 at 1:35 P.M. revealed the Certified Nurse Practitioner (CNP) on call was notified Resident #105 was sent out. Review of the progress note dated 05/30/26 at 7:01 P.M. revealed Resident #105 was in the emergency room (ER) and noted the resident had a stroke. Review of the progress note dated 05/30/26 at 10:13 P.M. revealed Resident #105 was admitted to the hospital. Review of a handwritten witness statement by CNA #907, undated, revealed a scratched-out sentence that read I tried helping Resident #105 get up for his shower. Further review of the witness statement revealed CNA #907 helped Resident #105 get in the shower as his daughter insisted on him getting one. Resident #105 appeared weak but was able to get him in the shower. CNA #907 went to make Resident #105's bed afterwards. Once CNA #907 finished, she grabbed clean clothes and went inside the bathroom to help CNA #878 get Resident #105 dressed. Resident #105 was not up straight and was tilting to his right. Resident #105's daughter came in after and took a picture of him and called the ER. Review of the handwritten witness statement by CNA #878, dated 05/30/26, revealed during her morning rounds, she observed Resident #105 appearing weak, fatigued, and having difficulty eating breakfast, including choking episodes. CNA #878 immediately notified RN #827 of her concerns. CNA #878 revealed RN #827 assessed Resident #105 and reported normal vital signs. CNA #878 revealed she changed Resident #105 and at that point, he stated he would like to rest. CNA #878 revealed RN #827 stated Resident #105 typically was tired in the mornings and to let him rest and get him up closer to lunchtime. CNA #878 revealed once Resident #105's daughter arrived, she explained that she had concerns regarding his weakness and fatigue and at that time the daughter insisted he be showered and dressed. CNA #878 revealed Resident #105's daughter forced his clothes off and told her and CNA #907 they couldn't transfer him and proceeded to do it herself. CNA #878 revealed she expressed concern that she felt it was not best for him to be showered. CNA #878 revealed throughout the shower, Resident #105 continued to remain weak, unsteady and leaning heavily. CNA #878 revealed she continuously had to support Resident #105 and stabilize the shower chair to prevent him from falling. CNA #878 revealed she observed throughout the morning Resident #105 to be significantly weaker than usual and was concerned about his safety. Review of the handwritten witness statement by RN #815, dated 05/30/26, revealed CNA #878 approached her about concerns regarding Resident #105. CNA #878 informed RN #815 that Resident #105 kept pressing his call light but was unable to state what he wanted. CNA #878 revealed she tried to feed Resident #105 when he began choking a little. RN #815 revealed Resident #105's call light was sensitive to touch, and he had confusion sometimes and was currently being treated for a urinary tract infection. RN #815 informed CNA #878 that Resident #105 sometimes was sleepy in the morning and didn't finish his breakfast. CNA #878 reported Resident #105 declined to get out of bed and was told to try again before lunch. RN #815 revealed she went into Resident #105's room and observed him sitting upright in bed in front of his breakfast tray and did not observe any abnormalities. RN #815 revealed RN #827 informed her Resident #105's vitals were within normal limits. RN #815 revealed she observed Resident #105's call light on, time unknown, and entered his room and observed him sitting upright in bed wanting to get out of bed. RN #827 informed CNA #878 and shortly after, CNA #878 informed her that Resident #105's daughter was in the room wanting him to get up and showered. RN #815 revealed shortly after, CNA #878 approached her and reported Resident #105's daughter was calling 911 to send him to the hospital. RN #815 revealed she approached Resident #105's daughter and asked if she wanted to send him to the hospital and she yelled Yes, his face is drooping. Why didn't you call me? RN #815 revealed she informed Resident #105's daughter that she would call 911. RN #815 revealed she called 911 and let Resident #105's daughter know and observed her to be on the phone crying saying, They did nothing, they just let him lay here. RN #815 revealed she informed Resident #105's daughter that staff had been in the room helping him eat, checking his vital signs and answering his call light. Review of the vitals summary dated 05/30/26 revealed Resident #105 had one blood pressure reading (138/57mmHg), one oxygen saturation reading (94%), one temperature reading (97.7 degrees Fahrenheit) and one pulse oximetry reading (60 bpm) documented at 1:54 A.M. and another blood pressure reading (129/57mmHg), oxygen saturation readings (96%), temperature reading (97.1 degrees Fahrenheit), a pulse oximetry reading (60 bpm) and only one set of respirations (18 breaths/min) documented at 8:23 A.M. Review of the vital summary revealed Resident #105 only had one set of vitals taken after the first onset of symptoms were identified (7:09 A.M.) and no other assessments were documented from 7:00 A.M. to 11:00 A.M until his transfer to the hospital. Review of the call light audit report dated 05/30/26 revealed the following for Resident #105:-Call light activated at 12:49 A.M. and answered at 12:49 A.M.-Call light activated at 12:49 A.M. and answered at 12:50 A.M.-Call light activated at 5:14 A.M. and answered at 5:15 A.M.-Call light activated at 5:16 A.M. and answered at 5:18 A.M.-Call light activated at 7:26 A.M. and answered at 7:41 A.M.-Call light activated at 7:45 A.M. and answered at 7:46 A.M.-Call light activated at 8:02 A.M. and answered at 8:04 A.M.-Call light activated at 8:35 A.M. and answered at 8:46 A.M.-Call light activated at 8:46 A.M. and answered at 8:47 A.M.-Call light activated at 8:50 A.M. and answered at 8:53 A.M.-Call light activated at 8:59 A.M. and answered at 9:05 A.M.-Call light activated at 10:03 A.M. and answered at 10:23 A.M.-Call light activated at 10:50 A.M. and answered at 10:59 A.M.-Call light activated at 11:03 A.M. and answered at 11:13 A.M.-Call light activated at 11:17 A.M. and answered at 11:25 A.M.-Call light activated at 11:40 A.M. and answered at 11:50 A.M. Review of the prehospital care report summary dated 05/30/26 by the Fire Department revealed they received a call and were dispatched to the facility at 11:44 A.M., arrived on scene at 11:49 A.M., made contact with Resident #105 at 11:51 A.M., and left the scene at 12:01 P.M. on 05/30/26. Further review of the report summary revealed they received a call for Resident #105 experiencing left-sided drooping and garbled speech. Upon arrival, Resident #105 had notable left-sided facial droop while lying in bed. Resident #105's family member revealed he was last seen normal the previous day, 05/29/26 at approximately 1:00 P.M., talking and acting normally, after visiting with him. Staff reported Resident #105 had a decrease in his mental status that morning at 9:00 A.M. Review of the report summary revealed Resident #105 had a history of stroke, was able to speak and understand some questions, and noted to have left-sided facial droop, slurred speech and appeared confused. Resident #105 was transported to the hospital without incident. Review of Resident #105's hospital patient health summary progress note dated 05/30/26 revealed he arrived at the ED presenting with slurred speech, aphasia, and left facial droop. Resident #105, per Emergency Medical Services (EMS) per Resident #105's family member, was last known well at 6:00 P.M. on 05/29/26 after a visit at the facility. Resident #105's facial droop was observed on 05/30/26 at approximately 11:00 A.M., when staff went to bathe him. Facility staff revealed Resident #105 may have had slurred speech that morning, but EMS was not activated until after his facial droop was observed. Review of the document revealed Resident #105, as a result of a stroke, was now consuming no food, beverages, or oral medications (NPO) by mouth, was placed on a NG tube for medications, intravenous hydration, had severe oropharyngeal dysphagia with plans for Percutaneous Endoscopic Gastrostomy (PEG) tube placement, was no longer alert and oriented with partial facial paralysis and a drifting right leg. Interview on 06/24/26 at 9:27 A.M. with RN #815 revealed she was the supervising nurse at the time Resident #105 had a change in condition. RN #815 revealed CNA #878 told them to go see Resident #105 due to him acting differently and coughing when eating his breakfast. RN #815 revealed Resident #105 was sitting up in bed, and she had not observed anything strange. RN #815 revealed she proceeded to put Resident #105's glasses on him and asked him a few questions but nothing out of the ordinary. RN #815 revealed Resident #105 was typically alert and oriented and sometimes forgetful. RN #815 revealed it was Resident #105's shower day and after he was showered, Resident #105's daughter said she was calling 911 due to him being unable to form words and his face drooping. RN #815 revealed she could not elaborate on his change in condition, as she was not the nurse that was doing assessments; however, she was informed that Resident #105 was able to take his medications, drink his potassium without issues and his vitals were within normal limits. RN #815 confirmed and verified the above findings at the time of the interview. Interview on 06/24/26 at 11:28 A.M. with LPN #924 revealed she was not in the facility on 05/30/26 and initially did not recognize the progress note she had written. LPN #924, after reviewing the progress note, revealed she had backdated the note to reflect Resident #105's current status and skilled notes were automatically generated to input a synopsis of resident's overall health and care. LPN #924 revealed Resident #105 was a long-term resident, required at least one staff member for ADLs and was able to feed himself. LPN #924 revealed if a resident had a change in his mental status or observed something abnormal, she would notify the physician to determine the next steps regarding resident's care. LPN #924 confirmed and verified her assessment was inaccurate due to her not physically being present in the facility and utilizing secondhand accounts from other staff members. Interview on 06/24/26 at 11:37 A.M. with Resident #105's daughter revealed after the resident's shower on 05/30/26 he had gargled speech and left-side facial drooping, that had been identified by CNA #878 earlier that same morning. Resident #105's daughter revealed after the nurse was notified, she told staff that Resident #105's symptoms were a sign of his recent urinary tract infection (UTI). Resident #105's daughter revealed his symptoms were different than those experienced during a UTI and demanded an ambulance be called. Resident #105's daughter revealed nursing staff questioned the idea of sending him to the hospital. Interview on 06/24/26 at 11:45 A.M. with CNA #878 revealed Resident #105 was alert and oriented with some confusion but could always talk and communicate his needs. CNA #878 revealed on the day of the change in condition, Resident #105 appeared more tired than he normally would be and out of it. CNA #878 revealed he required more time and help than he normally did for his ADLs. CNA #878 revealed Resident #105 had never seemed that tired before, confused, and he was less talkative than normal. CNA #878 revealed she offered to give Resident #105 a bed bath due to his weakness and being tired, but his daughter insisted he receive a shower. CNA #878 revealed Resident #105 had pressed his call light at least 15 times during that timeframe, which was out of the ordinary for him, but did not need anything. CNA #878 revealed after noticing his left-sided facial droop, 911 was called and he was sent to the ER. CNA #878 confirmed and verified the above findings at the time of the interview. Interview on 06/24/26 at 2:19 P.M. with CNP #900 revealed Resident #105 was alert and oriented to person, place, and time and able to communicate his needs. CNP #900 revealed Resident #105 typically sat in the dining hall with his family and required some assistance with his ADLs. CNP #900 revealed Resident #105 was not disoriented, confused or delirious at baseline. CNP #900 revealed she often observed Resident #105 playing cards. CNP #900 revealed she did not find out about Resident #105's change in condition until 06/03/26 during a census check, approximately three days later, as no one from the facility had reached out to her. CNP #900 confirmed and verified the above findings at the time of the interview. Interview on 06/24/26 at 3:22 P.M. with the Director of Nursing (DON) revealed she was not in the facility at the time of Resident #105's change in condition; however, he was not confused at baseline. The DON confirmed and verified the above findings at the time of the interview. Interview on 06/25/26 at 8:53 A.M. with RN #827 revealed Resident #105 was alert and oriented and able to make his needs known. RN #827 revealed CNA #878 came and got her due to Resident #105 not seeming like his normal self. RN #827 revealed Resident #105 seemed really tired and after being assessed didn't seem out of the ordinary. RN #827 revealed Resident #105 kept pressing his call light every 20 minutes but couldn't state what he needed or didn't remember why he pressed his call light. RN #827 revealed she assessed him multiple times, at least every 15 to 20 minutes, but verified no documentation of repeated assessments. RN #827 revealed she asked Resident #105 to hold a cup, but he was shaky and had to be directed to bring it to his mouth. RN #827 revealed after CNAs #878 and #907 showered and dressed him after being insisted by Resident #105's daughter, she observed him to be weak on his right side with a left-side facial droop. RN #827 revealed Resident #105 was not confused at baseline but more forgetful. RN #827 revealed it was hard to determine if Resident #105 was having a change in condition due to a possible stroke or if he was still having residual effects to recent diagnosis and treatment for a urinary tract infection (UTI). RN #827 revealed Resident #105 was treated in the hospital and at the facility for a UTI and it had been at least 3 days since his return from the hospital and treatment had been started. RN #827 revealed Resident #105 had no signs or symptoms that he was still having residual effects of a UTI. RN #827 verified that Resident #105 being unable to grasp a cup, pressing his call light every 20 minutes without stating need, being confused, having choking and/or coughing episodes while eating and being tired and weak was not his baseline. RN #827 also confirmed and she had only documented one set of vitals from the time she was notified of a change in condition to the time he was transferred to the hospital, approximately a 4-hour timeframe. RN #827 confirmed the above findings at the time of the interview. Interview on 06/26/26 at 10:23 A.M. with Medical Director (MD) #901 revealed Resident #105 had a history of stroke and dementia. MD #901 revealed Resident #105 presented with weakness, was very confused and had a change in his behavior. MD #901 revealed the CNP was called and neuro checks and monitoring were put in place. MD #901 revealed residents with dementia can have confusion and it's not likely to send them to the hospital for simple things. MD #901 revealed most of the time, monitoring to watch for worsening symptoms was the first step. MD #901 revealed Resident #105, at the time, was currently being treated for a UTI and sometimes you can can't determine if you're treating the right issue. MD #901 confirmed and verified Resident #105 had a change in condition; however, the effects were not significant enough for Resident #105 to be sent to the ER. Review of the facility document titled Resident Change in Condition dated 07/28/22, revealed the facility had a policy in place to ensure timely and appropriate care and services when a resident experiences a change in condition or is likely to cause serious life-threatening harm or injuries and/or adverse negative health outcomes. Review of the policy revealed the facility would take immediate action to ensure timely and appropriate care and services were met when a resident change in condition is identified. Further review of the policy revealed a change in condition included, but not limited to, physical changes, non-physical changes and an alteration in mental status. 2. Review of the medical record for Resident #4 revealed an admission date of 06/20/25 with diagnoses including pneumonia, chronic obstructive pulmonary fibrosis, type II diabetes, anxiety, fracture of clavicle and dysuria. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was dependent on the staff for toileting. The resident was incontinent of bowel and bladder. Review of the physician orders dated June 2026 revealed two treatment orders to apply barrier cream to buttocks after each incontinent episode as needed and apply zinc oxide 20 % to buttocks three times a day and as needed for excoriation. There was no order to apply miconazole powder to groin area. Review of the wound nurse practitioner (NP) note dated 06/12/23 stated the resident had contact dermatitis to the groin, and buttocks that was improving. Treatment included zinc oxide cream and briefs off in bed. Observation on 06/25/26 at 12:00 P.M. with Registered Nurse (RN) #866 of Resident #4 stated she did not complete the zinc treatment to the buttocks for resident. RN #866 revealed staff just changed her and put miconazole powder on the resident. Resident #4 was not interviewable. Interview on 06/25/26 at 12:04 P.M. with RN #902, the Assistant Director of Nursing (ADON) confirmed staff applied for miconazole powder to the resident's buttocks without an order due to the resident requesting the miconazole power. This deficiency represents non-compliance investigated under Complaint Number 3005283, 2993232, 2711143, 2732611.

Based on observation, resident interviews, staff interviews, review of Resident Council meeting minutes, and review of the facility handbook, the facility failed to ensure staff did not utilize their personal phones in resident care areas of the facility. This had the potential to affect all residents residing in the facility. The facility census was 89.Findings include:Interview on 06/22/26 at 10:01 A.M. with Resident #51 revealed staff were often utilizing their personal cell phones while working in the facility. Resident #51 reported that on one occasion, a staff member told the resident they were being rude by interrupting the staff member who was on the phone with their boyfriend at the time.Interview on 06/22/26 at 12:42 P.M. with Resident #66 revealed staff were often seen walking by the resident's room while on their cell phones.Interview on 06/22/26 at 12:57 P.M. with Resident #82 revealed staff members working in the facility were often seen using personal cell phones. Resident #82 reported staff often walked by their room while on their phone.Interview on 06/22/26 at 4:12 P.M. with Resident #14 revealed staff could often be seen on their personal cell phones while working in the facility.Observation on 06/24/26 at 5:25 A.M. revealed Certified Nursing Assistant (CNA) #838 was sitting in a darkened corner of a resident common area with a personal cell phone in hand and face illuminated by the light from the phone. Once the state surveyor approached CNA #838, the cell phone was dimmed and placed in the pocket of CNA #838's scrub pants.An interview at the time of observation with CNA #838 was unsure of what the facility's policy was for personal cell phones, although she was sure they were prohibited from using them during work hours. CNA #838 confirmed she did not have a work cell phone, only her personal one.Review of the Resident Council meeting minutes dated 05/07/26 revealed that regarding the nursing department, residents stated some aides were on their phones too much. Staff education regarding cell phone usage was provided.Review of the Resident Council meeting minutes dated 06/05/26 revealed that regarding the nursing department, residents stated some aides were on their phones too much. Review of the Resident Council departmental response forms for the nursing department 06/05/26 revealed numerous concerns were listed but did not address staff being on their cell phones.Review of the employee handbook, page 30, revealed the use of cell phones in resident areas may violate regulations and was prohibited in the work area.This deficiency represents non-compliance investigated under Complaint Number 3005283.

Based on medical record review, resident and staff interview, review of facility call light tracking records, review of complaint intakes, and review of Resident Council meeting minutes, the facility failed to have adequate staffing to meet the care needs of all residents. This directly affected seven (#41, #14, #51, #93, #77, #101, #31) of seven residents reviewed for staffing and had the potential to affect all residents residing in the facility. The facility census was 89. Findings include:1. Review of Resident #41's medical record revealed the resident was admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, muscle weakness and unsteadiness on feet. Review of Resident #41's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition, was frequently incontinent of bladder and always incontinent of bowel. Review of Resident #41's care plans revealed an intervention revised on 09/04/25 for the resident would like to get up out of bed between 9:00 A.M. and 10:00 A.M. The care plans revealed an intervention revised on 01/27/26 which stated the resident was an extensive/total assist of one to two staff for toileting; and an intervention dated 01/23/25 to check and change on care rounds and as needed. Review of Resident #41's care plans revealed an intervention dated 05/26/26 that the resident had a right to make lifestyle choices and requested to stay in bed throughout the day at times. The resident would like to be check and changed every four hours (after the survey started). Interview on 06/24/26 at 10:38 A.M. with Resident #41 revealed she could not remember when the last time she was provided incontinence care. Observation on 06/24/26 at 10:43 A.M. with Certified Nursing Assistant (CNA) #870 and CNA #872 of Resident #41's incontinence care revealed the resident's brief appeared saturated. The bed was not wet. Interview on 06/24/26 at 10:42 A.M. with CNA #870 confirmed this was the first time she had been in Resident #41's room since she started for the day. She confirmed her shift was from 6:00 A.M. to 6:00 P.M. and the last time the resident was provided incontinence care was on nightshift. Review of the Incontinence Care policy dated 12/2022 revealed the purpose was to ensure a resident who was incontinent of bowel and/or bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible. 2. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, diabetes mellitus, anxiety, asthma, chronic kidney disease, tachycardia, depression, obstructive sleep apnea, muscle weakness, and need for assistance with personal care. Review of the Medicare five-day Minimum Data Set assessment dated [DATE] revealed Resident #14 was cognitively intact. The resident was dependent on assistance from staff for the activities of daily living, including transfers. Review of the plan of care, revised 04/10/26, revealed Resident #14 had an ADL self-care performance deficit. Interventions included encouraging the resident to use their call bell for assistance. Interview on 06/22/26 at 4:12 P.M. with Resident #14 revealed there were not enough staff to meet her needs in a timely manner. Resident #14 reported when she activated her call light, it sometimes took staff a prolonged period of time to respond. Review of the call light tracking logs for 06/01/26 through 06/24/26 for Resident #14 revealed there were 86 occurrences where call light response time was greater than 20 minutes, 22 of which were greater than 45 minutes and up to two hours and 29 minutes. Interview on 06/25/26 at 10:50 A.M. with the Administrator revealed the expectation for answering call lights was 15 to 20 minutes or less. 3. Review of the medical record revealed Resident #51 was initially admitted to the facility on [DATE]. Diagnoses included heart failure, type II diabetes mellitus, anemia, depression, hypertension, muscle weakness, need for assistance with personal care, history of falling, pain, repeated falls, and altered mental status. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed the resident was cognitively intact. The resident was dependent on assistance from staff for the activities of daily living (ADLs). Review of the plan of care, revised 02/03/26, revealed Resident #51 had an ADL self-care performance deficit. Interventions included encouraging the resident to use their call bell for assistance. Interview on 06/22/26 at 10:07 A.M. with Resident #51 revealed the facility did not have enough staff to meet her needs. The resident reported when she activated her call light, it sometimes took staff between one and one and a half hours to respond. Review of the call light tracking logs for 06/01/26 through 06/24/26 for Resident #51 revealed there were 24 occurrences where call light response time was greater than 20 minutes, eight of which were greater than 45 minutes and up to one hour and 13 minutes. Interview on 06/25/26 at 10:50 A.M. with the Administrator revealed the expectation for answering call lights was 15 to 20 minutes or less. 4. Review of the medical record revealed Resident #93 was initially admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, bipolar disorder, insomnia, anxiety, depression, other hallucinations, lack of coordination, panic disorder, tremors, and muscle weakness. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed the resident was cognitively intact. The resident was dependent on assistance from staff for the activities of daily living (ADLs). Review of the plan of care dated 10/02/24 revealed Resident #93 had an ADL self-care performance deficit. Interventions included encouraging the resident to use their call bell for assistance. Interview on 06/23/26 at 3:00 P.M. with Resident #93's family member revealed there were not enough staff to meet resident needs in a timely manner. Resident #93's family member reported that a CNA would often have an assignment where they would work on the secured memory care unit and would then cover the hallway that Resident #93 resided on, which was not on the secured unit. Resident #93's family member reported Resident #93 would wait for a prolonged period of time for staff assistance. Interview on 06/23/26 at 3:12 P.M. with Resident #93 revealed that when the resident activated their call light, staff often did not respond for a prolonged period of time. Review of call light tracking records for Resident #93 for 06/01/26 through 06/25/26 noted several days staff did not answer call lights in a timely manner. Response times noted 55 minutes on 06/01/26, 49 and 53 minutes on 06/03/26, 2.38 hours on 06/04/26, 39, 46, 51 and 59 minutes on 06/06/26, 1 hour and 30 minutes on 06/07/26, 40 and 48 minutes on 06/08/26, 1 hour and 48 minutes and 1 hour and 49 minutes on 06/09/26, 57 minutes on 06/11/26, 1 hour and eight minutes and 2 hours and 33 minutes on 06/16/26, 1 hour and five minutes on 06/18/26, 1 hour and 14 minutes and 1 hour and 35 minutes on 06/20/26, and 51 minutes on 06/21/26. Interview on 06/25/26 at 10:50 A.M. with the Administrator revealed the expectation for answering call lights was 15 to 20 minutes or less. 5. Interview on 06/22/26 at 10:11 A.M. revealed Resident #43 waited a prolonged period of time for their call light to be answered. Interview on 06/22/26 at 10:34 A.M. with Resident #40 revealed staffing was an issue at the facility. Interview on 06/22/26 at 11:37 A.M. with Resident #2 revealed the resident waited a long period of time for their call light to be answered. Interview on 06/22/26 at 12:11 P.M. with Resident #8 revealed the resident sometimes waited up to an hour for their call light to be answered when activated. Interview on 06/22/26 at 12:24 P.M. with Resident #32 revealed there were never enough staff working in the facility. Interview on 06/22/26 at 12:20 P.M. with Resident #46 revealed call lights were not answered in a timely manner. Interview on 06/22/26 at 4:35 P.M. with Resident #24 revealed the resident sometimes waited up to 45 minutes for their call light to be answered when activated. Interview on 06/24/26 at 5:25 A.M. with CNA #838 revealed there were not enough staff on night shift to be able to meet resident needs in a timely manner. Interview on 06/24/26 at 5:37 A.M. with LPN #834 revealed there were often not enough CNAs to meet resident needs in a timely manner. LPN #834 reported that an aide working on the secured memory care unit would often have to come off of the unit to care for residents on another hall and had difficulty answering call lights. LPN #834 reported night shift often did not receive help with covering vacancies when they were short staffed and that management never came in to cover shifts. Interview on 06/24/26 at 6:03 A.M. with CNA #912 revealed the staff member was often assigned to work on the secured memory care unit and was also assigned residents who were not on the unit during the night shift. CNA #912 reported that residents often reported their call lights were not answered in a timely manner. CNA #912 reported she was going back and forth between the units, often did not know and could not see when call lights were activated, and was not able to get to residents in a timely manner to provide care. CNA #912 further reported they were unable to complete necessary work, including timely checks, answering call lights, and providing incontinence care. Review of complaint intakes for the facility revealed there were seven complaints that alleged concerns including not enough staff to timely meet resident needs, prolonged call light response time, and untimely assistance with ADLs. Review of the Resident Council meeting minutes dated 06/05/26 revealed that regarding the nursing department, one resident stated their call light response wasn't as prompt as usual. Residents were reminded about call light response monitoring and to see management immediately if any issues arose. This deficiency represents non-compliance investigated under Complaint Numbers 3005283, 2998572, 2732611, 2711583, 2707866, and 2701315.

Based on record review and interview, the facility failed to ensure Resident #41's PureWick incontinence device was implemented per the physician's order. This finding affected one (Resident #41) of three residents reviewed for incontinence care. Findings include: Review of Resident #41's medical record revealed the resident was admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease and unspecified dementia.Review of the email to the hospital dated 01/19/26 at 4:02 P.M. revealed the Power-of-Attorney (POA) had concerns about returning and would like to address them at a care conference shortly after readmission. The concerns included the PureWick system which she was aware that the facility was unable to accommodate at any of the buildings and possibly not getting the proper medications at the proper times.Review of an email from the facility to Ombudsman #737 on 02/26/26 at 9:34 P.M. revealed the team shared that it was communicated to the facility that there was confusion regarding why the facility continued not to follow an order for which it had been cited. The clarification that the citation was not due to failure to follow the order itself, but rather due to a failure to communicate that they facility were unable to follow the order. Effectively, the facility failed to clearly communicate the inability to follow the order prior to admission or were ineffective by not reconciling the orders on the new admission timely. Although Resident #41's POA indicated she contacted several progressive quality care facilities and were told that four of them provided this type of care, a clarification was obtained that no facility within their company had PureWick system in place, nor was authorized to use this system. As a company, the facility does not use the PureWick system. Additionally, following the resident's most recent hospital stay, it was communicated to both the hospital and representative prior to re-admission that the facility does not use the PureWick system and therefore would not be able to accommodate the order. The facility specifically asked the hospital to educate the representative on this limitation, and they stated they had done so. Upon review of the resident's orders at re-admission, there was no order for the PureWick system.Review of Resident #41's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #41's Urology Visit note dated 04/14/26 revealed the resident with urinary incontinence presented for evaluation and worsening leakage. She is accompanied by a companion who provided additional history. The resident had urinary incontinence that was bothersome, with episodes most notable in the morning after she was dressed and seated, when she experienced sudden large-volume gushing leakage that can soak under her legs and sometimes up to her waist. The form indicated a letter of medical necessity was provided documenting clinical need and expected benefit for PureWick use. Caregiver to submit for facility and state review and appeals.Review of Resident #41's progress note dated 05/02/25 at 3:48 P.M. revealed the Director of Nursing (DON) spoke with the urology office regarding the use of the Pure wick system. The office expressed that her and her office had recommended this device to be used at home before the resident was in a facility. The office stated that all risks and benefits were reviewed with the family and the office agreed that prompted toileting should help with deficits, but also the resident was difficult to transfer to a commode. Resident #41 was currently on a toileting program.Review of Resident #41's progress note dated 05/08/25 at 3:06 P.M. documented as a late entry revealed a care conference was held with the POA, unit manager, DON, Administrator, and Ombudsman #737. The PureWick system was discussed, and the facility was unable to meet the request of the use of the system. Per the conversation with urology, a toileting program was implemented a few weeks back. The resident, at times, refused to allow staff to provide care or to check and change her. The resident did well during a transfer with therapy but did not trust nurse CNAs to complete transfer. Therapy to work with resident, but was recently cut due to no progress being made. Ombudsman and POA were aware of current interventions and in agreement at this time.Telephone interview on 06/22/26 at 11:41 A.M. with Ombudsman #737 revealed Resident #41 used the PureWick system at home and the POA had reported that she wanted the system in the facility. Ombudsman #737 stated the POA had told her the resident had a current order for the PureWick system.Telephone interview on 06/22/26 at 12:23 P.M. with Resident #41's POA revealed she provided a letter of medical necessity for the resident's PureWick system that the facility would not honor.Interview on 06/22/26 at 1:47 P.M. with Resident #41 revealed she did not have a PureWick incontinence system in the facility and she wanted one. Resident #41 confirmed that the facility had educated her that the incontinence system was contraindicated and not permissible in the facility.Interview on 06/22/26 at 2:01 P.M. with the DON revealed Resident #41's PureWick system was contraindicated and Resident #41 was educated for contraindications for pure wick.Interview on 06/23/26 at 6:30 A.M. with the DON revealed Resident #41's PureWick incontinence system was contraindicated due to mobility issues, and the facility was unable to meet the Pure Wick needs of the resident. Interview on 06/23/26 at 7:44 A.M. with the Administrator revealed Resident #41's POA wanted the resident to have a PureWick system and was educated that the facility did not accommodate the incontinence system and the resident was not a candidate for the system.Interview on 06/23/26 at 7:47 A.M. with Admissions #867 revealed Resident #41 had known she was not to use the PureWick incontinence system in the facility prior to returning to the facility from the hospital. Admissions #867 confirmed the facility advised the resident and POA that they do not use the system in the facility and still wanted to come here. Stated had a verbal conversation with the hospital and the resident prior to her coming back from the hospital and she still wanted to come back to the facility. Interview on 06/24/26 at 8:25 a.m. with NP #734 confirmed she would order the PureWick system for Resident #41 if the resident wanted one.Telephone interview on 06/26/26 at 10:40 A.M. with Resident #41's urology office revealed the urology office placed an order for the PureWick system on 08/12/25 and then provided a letter of medical necessity on 04/14/26 for the use of the PureWick system.Telephone interview on 06/26/26 at 10:40 A.M. with Resident #41's urology office revealed the urology physician assistant provided a letter of medical necessity for the resident to use the PureWick incontinence system. The letter of necessity was provided to the POA to give to the facility for implementation of the PureWick incontinence system.Telephone interview on 06/26/26 at 2:50 P.M. with Resident #41's POA confirmed she gave the PureWick order and letter of necessity to the facility and discussed the order on 04/14/26 when the resident returned to the facility.Review of Incontinence Care policy dated 12/2022 revealed the purpose of the policy was to ensure a resident who was incontinent of bowel and/or bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.This deficiency represents non-compliance investigated under Complaint Numbers 2785497, 2732611, 2711583, 2711143.

Based on observation, record review, and interview, the facility failed to ensure medications were administered as ordered. This affected three (#77, #93 and #101) of four residents reviewed for medication administration. The facility census was 89.Findings include: 1. Review of the medical record for Resident #101 revealed an admission date of 12/23/25 with diagnoses including cerebral infarction, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), congestive heart failure, anxiety, atrial fibrillation, chronic kidney disease, Review of the admission MDS assessment dated [DATE] revealed the resident was cognitively intact and was dependent on staff for bathing, transfers, dressing and toileting. Review of the physician order revealed evening medication included Atorvastatin 80 milligrams (mg), Famotidine 20mg, Fluoxetine 20 mg, Topirate 100mg. Morning medications including Metoprol 25 mg and Omeprazole 40 mg. Review of the Medication Administration Record for December 2025 revealed evening medications on 12/23/25 included Atorvastatin 80 milligrams (mg), Famotidine 20mg, Fluoxetine 20 mg, Topirate 100mg were not administered. Morning medication including Metoprol 25 mg and Omeprazole 40 mg. were not administered. Review of the automatic medication dispensing system log revealed the system stocked the following medications: Atorvastatin 80 milligrams (mg), Famotidine 20mg, Fluoxetine 20 mg, Topirate 100mg, Metoprol 25 mg, and Omeprazole 40 mg. Interview on 06/23/24 at with the Director of Nursing (DON) verified the nurse did not administer the medications in the evening and morning. The DON stated the medication were stocked in the automatic medication dispensing system and she would expect the nurses to pull the medications from the automatic medication dispensing system. 2. Review of the medical record for Resident #77 revealed an admission date of 06/20/25 with diagnoses including quadriplegia, autonomic dysreflexia, neuromuscular dysfunction of bladder, neurogenic bowel, anxiety, contracture of the right and left knee. Review of the quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact and was dependent on the staff for eating, dressing, bathing, transfers indwelling catheter and colostomy care. Review of the physician order for June 2026 revealed an order for Testosterone 200 milligram (mg) per milliliter (ml) to inject 0.5 ml intramuscular every Wednesday. Review of the Medication Administration Record (MAR) for June 2026 revealed testosterone was administered on 06/03/26, 06/10/26, 06/20/26 and 06/24/26. Interview on 06/24/26 at 5:33 P.M. with the DON verified the medication was not administered as ordered. The testosterone was backordered from the pharmacy and was not available for administration on 06/17/26. The testosterone was rescheduled for 6/20/25 and administered. The testosterone was administered again four days later on 06/24/26 by mistake. 3. Review of the medical record revealed Resident #93 was initially admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, bipolar disorder, insomnia, anxiety, depression, other hallucinations, lack of coordination, panic disorder, tremors, and muscle weakness. Review of the quarterly MDS assessment dated [DATE], revealed the resident was cognitively intact. The resident was dependent on assistance from staff for the activities of daily living. Review of the plan of care, revised 03/13/26, revealed Resident #93 had Parkinson's disease, affecting mobility, eating, and coordination. Interventions included giving medications as ordered by the physician. Review of Resident #93's physician orders for June 2026, identified an order for Carbidopa-Levodopa oral tablet 25-100 milligrams, give two tablets by mouth four times per day for Parkinson's disease. The medication was scheduled for 8:00 A.M., 11:00 A.M., 2:00 P.M., and 5:00 P.M. The resident also had an order for Carbidopa-Levodopa tablet 25-100 milligrams, give one tablet by mouth one time per day for Parkinson's disease, scheduled for 12:00 A.M. Review of the medication audits dated 06/01/26 through 06/21/26 revealed the medication was given at 12:07 P.M. instead of 11:00 A.M. on 06/05/26, at 12:17 P.M. instead of 11:00 A.M. on 06/08/26, 4:01 P.M. instead of 2:00 P.M. on 06/08/26, given again at 5:11 P.M. on 06/08/26 (one hour and 10 minutes after the last dose), 3:08 P.M. instead of 2:00 P.M. on 06/11/26, 3:09 P.M. instead of 2:00 P.M. on 06/14/26, 2:58 A.M. instead of 12:00 A.M. on 06/16/26, 9:09 A.M. instead of 8:00 A.M. on 06/17/26, 3:03 P.M. instead of 2:00 P.M. on 06/19/26, 4:08 A.M. instead of 12:00 A.M. on 06/21/26, and 11:45 P.M. instead of 8:00 P.M. on 06/21/26. Interview on 06/23/26 at 3:00 P.M. with Resident #93's family member revealed that Resident #93's medication for Parkinson's disease was not always administered timely. Resident #93's family member reported there was a camera in the resident's room and the family member would check to see if the resident received their midnight medications. When the resident had not received them in a timely manner, the family member would attempt to call the facility via telephone but often had trouble reaching anyone at the facility. Resident #93's family member reported that when the resident did not receive this medication on time, the resident would visibly slow down and was significantly physically affected. Interview on 06/25/26 at 7:29 A.M. with the DON verified the findings. This deficiency represents non-compliance investigated under Complaint Numbers 299572, 2732611 and 2707866.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents were provided with assistive devices per physician orders and the plan of care. This affected one (Resident #14) of one resident reviewed for adaptive equipment. The facility census was 89.Findings include:Review of the medical record revealed Resident #14 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, diabetes mellitus, anxiety, asthma, chronic kidney disease, tachycardia, depression, obstructive sleep apnea, muscle weakness, and need for assistance with personal care.Review of the Medicare five-day Minimum Data Set assessment dated [DATE] revealed Resident #14 was cognitively intact. The resident was dependent on assistance from staff for the activities of daily living, including transfers.Review of the plan of care dated 04/10/23 revealed Resident #14 had the potential for altered nutrition/hydration related to diagnoses, therapeutic diet, diuretic medication use, non-compliance with therapeutic diet, and multiple snacks in the room. A revision was made on 06/18/26 for weighted built-up utensils. Interventions included providing adaptive equipment as ordered to improve grasp/coordination and promote self-feeding.Review of the physician orders for June 2026 identified an order dated 06/19/26 for built-up handle weighted utensils for all meals/snacks that require utensils.Observation on 06/22/26 at 4:38 P.M. revealed the resident was sitting up in bed in her room. An unidentified staff member brought a meal tray into the room and sat it on Resident #14's tray table that was located across the room and out of reach of the resident. The staff member then left the room without saying anything. The meal tray contained regular silverware, including a metal spoon, fork, and butter knife. The meal ticket located on the meal tray read Adaptive Equipment: Weighted Utensils, Staff to assist Resident to cut into bite size pie.Interview on 06/22/26 at 4:40 P.M. with Resident #14 revealed she was supposed to receive adaptive equipment with all meals, as weighted utensils allowed her to hold them better.Observation and interview on 06/22/26 at 4:48 P.M. with Licensed Practical Nurse #740 verified Resident #14 received regular silverware and did not receive the necessary adaptive equipment needed for her meal.Review of the facility policy titled Assistive Devices, not dated, revealed assistive devices shall be provided to residents who need them for all meals to maintain or improve their ability to eat independently.

Based on observation and interview the facility failed to ensure staff wore gloves while administering insulin to maintain infection control. This affected one Resident (Resident #4) of two receiving receiving insulin on the 200 hallway. Findings include:Review of the medical record for Resident #4 revealed an admission date of 06/20/25 with diagnoses including pneumonia, Chronic obstructive pulmonary fibrosis, type II diabetes, anxiety, fracture of clavicle and dysuria.Review of the comprehensive Minimum Data Set assessment dated [DATE] revealed the resident had impaired cognition and was dependent on the staff for toileting. The resident was receiving insulin.Review of the physician orders for June 2026 revealed two insulin orders scheduled for the morning administration including Novolog, a short acting insulin, to inject according to sliding scale per glucose level and Lantus, a long-acting insulin to inject 12 units one time a day I the morning.Observation on 06/23/26 at 8:15 A.M. of Resident #4's room revealed Licensed Practical Nurse (LPN) #807 was observed standing next to Resident #4's bed administering injections. LPN #807 primed an injection pen, dialed the dose and injected it into Resident #4's abdomen. RN #890 primed another pen dialed the dose and injected into the abdomen. LPN #807 was observed not wearing gloves while administering the injections.Interview on 06/23/26 at 8:17 A.M. with Licensed Practical Nurse (LPN) #807 verified she was not wearing gloves while injecting the insulin by pen. LPN #890 stated she usually wears gloves but forgot to apply them prior to administering the insulin injections.Review of the facility policy titles Subcutaneous injections undated stated to prepare medication, perform hand hygiene, don gloves, clean site for injection and administer injection.

Based on medical record review, observation, staff interview, family interview, and employee handbook review, the facility failed to ensure resident family members and other individuals were able to contact facility staff members via telephone. This directly affected one resident (Resident #93) of one resident reviewed for resident access. The facility census was 89.Findings include:Review of the medical record revealed Resident #93 was initially admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, bipolar disorder, insomnia, anxiety, depression, other hallucinations, lack of coordination, panic disorder, tremors, and muscle weakness.Review of the quarterly Minimum Data Set assessment dated [DATE], revealed the resident was cognitively intact. The resident was dependent on assistance from staff for the activities of daily living.During an interview on 06/23/26 at 3:00 P.M., Resident #93's family member reported that when attempting to contact the facility in the evening or at night via telephone, it rings forever. The family member reported it was very difficult to reach someone by telephone and that this issue had been brought to the facility's attention multiple times. The family member also reported that Resident #93 received a medication that was time-sensitive and had a camera in their room. The family member saw that the resident had not received their medication in a timely manner on multiple occasions and attempted to call the facility via telephone to ask that the resident receive their medication. The family member reported they were often unable to reach a staff member when calling into the facility.Interview on 06/24/26 at 4:53 A.M. with Licensed Practical Nurse (LPN) #915 revealed nurses and aides were responsible for answering telephones on the night shift. LPN #915 reported the telephones were located in the nursing stations and that there were no cordless telephones available. LPN #915 reported that when administering medications, the nurses were unable to answer the phones and individuals attempting to contact the facility via telephone would get upset that they could not get ahold of anyone.Interview on 06/24/26 at 5:01 A.M. with Certified Nursing Assistant (CNA) #919 revealed the CNAs did not answer telephones at the facility and the nurses answered the telephones on the night shift if they were at the nursing station. CNA #919 reported if the nurse was administering medications or was not at the nursing station, no one answered the telephone.Interview on 06/24/26 at 5:25 A.M. with CNA #838 revealed the nurses were responsible for answering incoming calls to the facility on the night shift. CNA #838 reported they had never been trained or instructed to answer telephones at the facility. CNA #838 reported staff could barely hear the telephones ringing past the nursing station.Interview on 06/24/26 at 5:37 A.M. with LPN #834 revealed during the night shift, incoming calls went to a telephone located at every nursing station. LPN #834 reported there was not always someone at the nursing station and if nurses were passing medications, the odds of the telephone being answered were very slim. LPN #834 reported that during medication administration, nurses could not hear the phones ringing from the nursing station.Interviews on 06/25/26 at 8:47 A.M. with Receptionist #738 and Receptionist #857 revealed there was a receptionist present and working in the facility from 8:30 A.M. to 8:00 P.M. seven days per week. During these times, the receptionist was responsible for answering incoming calls to the facility. Outside of these times, the phone system was placed on night life, and all calls were instead routed to the nursing stations. The nurses were then responsible for answering telephones between 8:00 P.M. and 8:30 A.M.Review of the employee handbook, page 30, revealed when answering the facility's phone, staff were to do so promptly.This deficiency represents non-compliance investigated under Complaint Number 2701315.

Based on observation, record review, interview and review of manufacturer's instructions for use, the facility failed to ensure mechanical lift (Hoyer) devices were properly maintained to promote safe transfers. This had the potential to affect 31 residents (#3, #4, #6, #8, #10, #12, #13, #26, #27, #30, #33, #35, #36, #37, #38, #43, #44, #46, #47, #61, #65, #68, #70, #73, #80, #82, #84, #85, #87, #91, and #96) who were identified to require a mechanical lift for transferring. The facility census was 100.Review of the medical record for Resident #84 revealed an admission date of 08/10/21 with diagnoses to include quadriplegia, anxiety disorder and hypothyroidism. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #84 was cognitively intact and was dependent for activities of daily living. Observation and interview of three Hoyer lifts on 12/16/25 at 6:01 A.M. with Certified Nursing Assistant (CNA) #359 verified that the right wheel did not move to allow the legs of Hoyer #1, with the weight scale, to open. There were several strings in the wheel, which made it stick. Interview on 12/15/25 at 10:49 A.M. with Resident #84 stated that the Hoyer lift does not work properly.Interview on 12/16/25 at 5:22 A.M. with CNA #359 revealed that Hoyer lifts were not working properly. The Hoyer lift with the scale is not working, the spotter must kick the wheels to get the legs to come apart and be able to move. Interview on 12/16/25 at 5:13 A.M. with CNA #256 revealed that Hoyer lifts were not working properly. Interview on 12/16/25 at 6:04 A.M. with Maintenance Director (MD) #230 revealed that he did not service the Hoyer lift with the scale but will fix it right away. Interview on 12/16/25 at 8:15 A.M. with Administrator revealed that the Former Maintenance Director #600 ordered wheels for the Hoyer lifts and did not put them on. Interview of 12/17/25 at 2:28 P.M. with Director of Nursing identified 31 residents (#3, #4, #6, #8, #10, #12, #13, #26, #27, #30, #33, #35, #36, #37, #38, #43, #44, #46, #47, #61, #65, #68, #70, #73, #80, #82, #84, #85, #87, #91, and #96) who required the use of a mechanical (Hoyer) lift for transferring.Review of the undated manufacturer's instruction for Hoyer lifts revealed that casters and axle bolts require inspections. The legs of the lift must be in maximum open position for optimum stability and safety. This deficiency represents non-compliance investigated under Complaint Number 2659063 and Complaint Number 2589091.

Based on observation, review of the medical record, staff interview, resident interview, and policy review, the facility failed to ensure medications were administered per physician orders resulting in a medication error exceeding five percent. 41 opportunities were observed with six medication errors, resulting in a medication error rate of 14 percent. This affected four (#37, #80, #84, #89) of four residents observed for medication administration. The facility census was 100. 1. Review of the medical record for Resident #89 revealed an admission date of 03/25/25. Diagnoses included chronic obstructive pulmonary disease, hypertension, dementia, and adjustment disorder.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the 12/2025 physician orders revealed the resident had morning medication orders with a scheduled time of 7:00 A.M. for Spiriva Respimat Inhalation Solution 1.25 microgram (mcg)/actuation (act) one inhalation in morning, a multivitamin in the morning, Sertraline 50 milligrams (mg) 1.5 tablet in morning, potassium gluconate 595 mg one tablet in morning, Cholecalciferol 25 mcg in the morning, Anastrozole one milligram in the morning, levetiracetam 750 milligrams one tablet two times a day for seizures, cyanocobalamin 500 mcg in the morning, Memantine 5 mg one tablet two times a day for dementia, and ferrous sulfate 325 mg in the morning.Observation on 12/15/25 at 11:23 A.M. of medication administration for Resident #89 revealed Licensed Practical Nurse (LPN) #290 administered the resident the Spiriva Respimat Inhalation Solution 1.25 microgram (mcg)/actuation (act) one inhalation in morning, a multivitamin in the morning, Sertraline 50 milligrams (mg) 1.5 tablet in morning, potassium gluconate 595 mg one tablet in morning, Cholecalciferol 25 mcg in the morning, Anastrozole one milligram in the morning, levetiracetam 750 milligrams one tablet two times a day for seizures, cyanocobalamin 500 mcg in the morning, Memantine 5 mg one tablet two times a day for dementia, and ferrous sulfate 325 mg in the morning. This resulted in two medication errors for the late administration of the levetiracetam and Memantine, both scheduled twice daily. Review of the medication administration record (MAR) dated 12/15/25 revealed LPN #290 documented the morning medications were administered at 11:25 A.M. Interview on 12/15/25 at 11:23 A.M., LPN #290 verified the medications were administered late. LPN #290 revealed morning medication should be administered between 7:00 A.M. and 11:00 A.M.Interview on 12/15/25 at 11:29 A.M., Resident #89 revealed the morning medications were late today. Resident #89 revealed the medications were usually administered around 9:00 A.M.2. Review of the medical record for Resident #84 revealed an admission date of 10/29/24. Diagnoses included neurogenic bowel, anxiety disorder, and iron deficiency anemia. Review of the annual MDS assessment dated [DATE] revealed the resident had intact cognition.Review of the 12/2025 physician orders revealed the resident had morning medications orders with a scheduled time of 7:00 A.M. for Cholecalciferol 25 mcg three capsules in the morning, Colace 100 mg two times a day, Levothyroxine 100 mcg in the morning, over the counter (OTC) hemp CBC gummy twice daily for appetite, multivitamin one tablet in the morning, pseudoephedrine 30 mg tablet daily in the morning, Gabapentin 300 mg one tablet three times a day for nerve pain, Senna 8.6 mg two tablets in the morning, and polyethylene powder 17 grams two times a day for constipation.Interview on 12/15/25 at 10:49 A.M., Resident #84 revealed he had not got his morning medications as of yet and they were supposed to be given between 7:00 A.M. and 9:00 A.M. Observation on 12/15/25 at 12:01 P.M. revealed LPN #290 administered Resident #84 the morning medication including Cholecalciferol 25 mcg three capsules in the morning, Colace 100 mg two times a day, Levothyroxine 100 mcg in the morning, multivitamin one tablet in the morning, OTC Hemp CBC gummy 20 mg, pseudoephedrine 30 mg tablet daily in the morning, Gabapentin 300 mg one tablet three times a day for nerve pain, Senna 8.6 mg two tablets in the morning, and polyethylene powder 17 grams two times a day for constipation. This resulted in one medication error for the late administration of the Gabapentin which was scheduled three times per day. Review of the MAR dated 12/15/25 revealed LPN #290 administered the morning medications at 12:02 P.M.Interview on 12/15/25 at 12:02 P.M., LPN #290 verified the morning medications had been administered late. 3. Review of the medical record for Resident #80 revealed an admission date of 07/01/24. Diagnoses included type two diabetes mellitus, congestive heart failure, hypertension, atrial fibrillation, and depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition.Review of the 12/2025 physician orders revealed the resident had orders for morning medications with a scheduled time of 7:00 A.M. for aspirin enteric coated 81 mg in the morning, ascorbic acid 500 mg two times per day, omega-3 fish oil capsule 2000 mg two times a day, potassium 20 milliequivalents in the morning, multivitamin one tablet in the morning, Allopurinol 100 mg tablet in morning, Spironolactone 25 mg in the morning, vitamin D oral tablet 3000 units in the morning, and Depakote delayed release 125 mg two times a day for major depressive disorder. Observation on 12/15/25 at 12:15 P.M. revealed LPN #290 administered Resident #80 morning medications including aspirin enteric coated 81 mg in the morning, ascorbic acid 500 mg two times per day, omega-3 fish oil capsule 2000 mg two times a day, potassium 20 milliequivalents in the morning, multivitamin one tablet in the morning, Allopurinol 100 mg tablet in morning, Spironolactone 25 mg in the morning, vitamin D oral tablet 3000 units in the morning, and Depakote delayed release 125 mg two times a day for major depressive disorder. This resulted in one medication error for late administration of the Depakote requiring administration twice daily.Review of the MAR dated 12/15/25 revealed the resident's morning medications were documented as administered by LPN #290 at 12:18 P.M.Interview on 12/15/25 at 12:15 P.M., LPN #290 verified Resident #80's morning medications were administered late.4. Review of the medical record for Resident #37 revealed an admission date of 08/27/24.Diagnoses included chronic obstructive pulmonary disease, asthma, atrial fibrillation, hyperlipidemia, and depression. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition.Review of the 12/2025 physician orders revealed the resident had orders for morning medications with a scheduled time of 7:00 A.M. for Flonase allergy relief nasal suspension 50 mcg/act one spray in each nostril in the morning, Apixaban 5 mg one tablet two times a day for atrial fibrillation, cyanocobalamin 1000 mcg one tablet in the morning, Dulera inhalation aerosol 200-5 mcg/act two puffs inhale two times a day for chronic obstructive pulmonary disease, fish oil 1000 mg capsule in the morning, Ocuvite eye plus multi one tablet in morning, Colace 100 mg one capsule two times a day for constipation, Midodrine 10 mg in the morning for hypotension hold if systolic blood pressure is greater than 130, Miralax 17 grams in morning, Mucinex 600 mg, one tablet two times a day, vitamin C 500 mg two tablets in morning give 1000 mg, and Furosemide 20 mg give one tablet in morning.Observation on 12/15/25 at 12:42 P.M. of medication administration revealed LPN #290 administered Resident #37 Flonase allergy relief nasal suspension 50 mcg/act one spray in each nostril in the morning, Apixaban 5 mg one tablet two times a day for atrial fibrillation, cyanocobalamin 1000 mcg one tablet in the morning, Dulera inhalation aerosol 200-5 mcg/act two puffs inhale two times a day for chronic obstructive pulmonary disease, fish oil 1000 mg capsule in the morning, Ocuvite eye plus multi one tablet in morning, Colace 100 mg one capsule two times a day for constipation, Midodrine 10 mg in the morning for hypotension hold if systolic blood pressure is greater than 130, Miralax 17 grams in morning, Mucinex 600 mg, one tablet two times a day, vitamin C 500 mg two tablets in morning give 1000 mg. This resulted in two medication errors for the late administration of the Apixaban, and Dulera medications scheduled twice daily. LPN #290 had not administered the Furosemide 20 mg and revealed the medication would be pulled later. Review of the MAR dated 12/15/25 revealed LPN #290 documented administering the morning medications at 12:43 P.M. Resident #37's Furosemide 20 mg was documented as administered at 2:51 P.M.Interview on 12/15/25 at 12:43 P.M., LPN #290 verified the morning medications were administered late. Observation on 12/15/25 at 12:45 P.M. revealed Resident #73 and Resident #9 had not received their morning medications.Interview on 12/15/25 at 12:45 P.M., LPN #290 verified Resident #73 and Resident #9 had not yet received their morning medications. LPN #290 then asked the unit manager for assistance. LPN #290 revealed she had not asked for assistance prior to 11:00 A.M. when she was aware several of the residents' medications would be administered late. LPN #290 revealed the late medications had been an ongoing problem she had complained about in the past. LPN #290 revealed being told, no one else had problems getting done. LPN #290 revealed she was not going to take shortcuts. Interview on 12/15/25 at 3:39 P.M., the Director of Nursing (DON) verified LPN #290 had administered the morning medications late. The DON revealed she had been working with the nurse to increase her efficiency in administering medications. The DON revealed LPN #290 was the only nurse with difficulty completing the medication pass timely. The DON revealed during the morning of 12/15/25, she had asked LPN #290 if she had needed assistance and the nurse denied needing assistance. Further interview with the DON revealed the residents with the late medications had no adverse effects and the nurse practitioner had been notified with no new orders. Review of the facility policy Medication Administration General Guidelines, revised 08/2014, revealed medication are administered within six minutes of the schedule time unless otherwise specified by the prescriber. Routine medications would be administered according to the established medication administration schedule for the facility. Review of the facility policy Electronic Health Record (EHR) Standard Medication Administration Times, revealed the facility would strive to provide a consistent medication schedule and ensure safe and timely medication administration to all residents. Standard schedules would be used for all order entries unless a physician order specified otherwise. Stat, as needed (PRN), antibiotics, anticoagulants, and critical medication do not apply and would be scheduled at specific times. Further review of the policy revealed morning medication started at 7:00 A.M. and ends at 11:00 A.M.This deficiency represents noncompliance investigation under Complaint Number 1401651 and Complaint Number 1401647.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure resident representatives were notified of medication changes. This affected two (#95, #43) of three residents reviewed for changes in condition. The facility census was 100. 1.Review of the medical record for Resident #95 revealed an admission date of 05/06/21. Diagnoses included type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of a physician order dated 05/05/25 revealed the resident had an order for metformin 500 milligrams (mg), give one tablet daily for type two diabetes mellitus. Review of the nurses' notes dated 05/05/25 through 05/28/25 revealed no documentation the resident's representative was notified of the new orders for the metformin.Interview on 12/15/25 at 3:30 P.M., the Director of Nursing (DON) verified the nurses should have notified the resident's representative when the new medication was ordered. 2. Review of the medical record for Resident #43 revealed a readmission date of 06/26/25. Diagnoses included chronic obstructive pulmonary disease, hypertension, dementia, osteoarthritis, and gastroesophageal reflux disease (GERD). Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of a physician order dated 06/25/25 revealed the resident was ordered lansoprazole 30 milligrams by mouth in the morning for GERD. Review of a physician order dated 08/11/25 revealed the resident was ordered omeprazole 10 mg by mouth in the morning for GERD.Review of the nurses' notes dated 08/11/25 through 08/30/25 revealed no documentation the resident's representative was notified of the new medication order. Interview on 12/17/25 at 8:13 A.M., the DON revealed a therapeutic interchange for the resident's GERD medication had been completed. The DON revealed the resident's representative should have been notified of the change in GERD medications. Review of the facility policy Resident Change in Condition, dated 07/28/22, revealed the facility would notify the resident's responsible party of changes in the resident's condition or status. This deficiency represents non-compliance investigated under Complaint Number 2602463 and Complaint Number 1401649.

Based on interview and record review, the facility failed to ensure that care plans were revised to reflect Resident #95's allergies and Resident #103's morning arise time. This affected two residents #95 and # 103. The facility's census was 100. 1. Review of the medical record for Resident #103 revealed an admission date of 04/01/22 and readmission date of 01/08/24 with a discharge date of 07/10/25. Diagnoses included type Alzheimer's disease, atrial fibrillation, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition and required moderate assistance for activities of daily living. Review of the concern dated 05/22/25 revealed that Resident #103's daughter requested that she stay in bed longer before getting resident up for the day. Review of Resident #103's care plan dated 04/30/25 revealed Resident #103 was an early morning get up for increased safety. The care plan was not revised regarding Resident #103's daughter's request. Interview on 12/17/25 at 10:13 P.M. with Administrator verified that Resident #103's care plan was not revised as per conversation with Administrator on 05/22/25. Review of the facility policy dated 11/16 with a revision date of 12/22 titled, Care Plan -Advance Care Plan Process, revealed the interdisciplinary team with the resident and/or their responsible party, an appropriate plan of care for the resident's needs or wishes specific to person centered care based on the assessment and reassessment process within the required timeframes. 2. Review of the medical record for Resident #95 revealed an admission date of 05/06/21. Diagnoses included type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of Resident #95's allergy alert profile dated 05/26/21 revealed the resident had allergies to metformin, Depakote, Geodon, Lexapro, Pravachol, Seroquel, and Zetia. On 08/27/24 an allergy to Ativan was added. The allergy to metformin was noted as unknown severity. Review of Resident #95's care plan revealed the resident had allergies to Abilify, Depakote, Geodon, Lexapro, Pravachol, Seroquel, and Zetia. Intervention included to review allergies quarterly, flag chart, notify all disciplines of allergy and known reactions, and notify pharmacy of known allergies. The allergies to metformin and Ativan were not noted on the care plan. Interview on 12/17/25 at 11:10 A.M., MDS Coordinator #229 revealed everything for the resident including allergies should be reviewed quarterly. MDS Coordinator #229 verified Resident #95's allergies to metformin and Ativan had not been updated on the care plan. Review of the facility policy Care Plan Advanced Care Plan Process, revised 12/2022, revealed the interdisciplinary team in collaboration with the resident, would meet and review the care plan upon admission, quarterly, and annually. The plan of care identifies the date, problem, measurable and realistic goals, and time frames. This deficiency represents non-compliance investigated under Complaint Number 1401651, Complaint Number 1401649 and Complaint Number 1401647.

Based on review of the medical record, staff interview, resident interview, and policy review, the facility failed to ensure an external catheter system for incontinence care was provided per physician orders. This affected one (#43) of three residents reviewed for incontinence care. The facility census was 100. Review of the medical record revealed Resident #43 had an admission date of 01/23/25. Diagnoses included chronic obstructive pulmonary disease, hypertension, gastroesophageal reflux disease, and dementia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was frequently incontinent of bladder and always incontinent of bowel. The resident was dependent for transfers and required substantial/maximal assistance for toileting.Review of Resident #43's admission referral and admission physician orders revealed the resident was admitted directly from another nursing facility. Further review of the referral admission orders current as of 01/22/25 revealed the resident had orders for an external urinary catheter to be applied every night shift, one time a day.Review of the resident's incontinence care plan last revised 06/19/25 revealed the resident was incontinent of bowel and bladder due to weakness, decreased mobility, limited range of motion, and diuretic use. Interventions included incontinence briefs or pantiliners when out of bed, call light within easy reach, toileting per request and as needed, and check and change on care rounds and as needed. There were no interventions for the use of the external catheter system. Review of a urology consult progress note dated 02/24/25 revealed the facility refused to use the external urinary catheter per the resident's representative and was told it was against facility policy. Review of a urology consult progress note dated 05/01/25 revealed the resident required the external urinary catheter due to urinary incontinence. The resident would benefit in reducing skin breakdown and infection using the external urinary catheter daily. Review of a nurse's note dated 05/02/25 at 3:48 P.M. revealed the Director of Nursing (DON) spoke with the urology provider regarding the use of the external urinary catheter. The provider expressed the device had been recommended for the resident at home prior to being in a facility. The provider revealed all the risks and benefits were reviewed with the family. The provider agreed that prompted toileting would help with deficits but also the resident was difficult to transfer to the commode. The DON noted the resident was currently on a toileting program. Review of a nursing progress note dated 05/08/25 at 3:06 P.M. revealed a care conference was held with the resident, resident representative, Unit Manager, Director of Nursing, Ombudsman, and Administrator. The external urinary catheter system was discussed and the facility was unable to meet the request of the use of this system. Review of a nurse's note dated 05/19/25 at 11:20 A.M. revealed the resident was requesting to be checked and changed in bed and does not want put on the toilet, as getting on the toilet was too much. The resident requested to be changed every four hours. The staff would continue to encourage two-hour toileting. Review of a nurse's note dated 11/10/25 revealed the nurse spoke with the resident regarding the external urinary catheter. The resident stated she had used one at home. The resident stated she knew the facility would not allow the external urinary catheter, so she was okay with getting checked and changed.Review of the Treatment Administration Record dated 01/23/25 through 12/15/25 revealed no documentation the external urinary catheter system was implemented per physician orders. Interview on 12/16/25 at 8:32 A.M., the DON revealed the facility had no policy for the use of the external urinary catheter system. The DON revealed the facility also had no policy stating the system could not be utilized in the facility. The DON verified the resident had not been provided the external urinary catheter. The DON revealed the facility could not use the external urinary catheter system. The DON revealed the urinary catheter system was contraindicated for residents with bowel incontinence. Interview on 12/16/25 at 9:05 A.M., Resident #43 revealed the facility told her the external urinary catheter system was not allowed in the facility. Resident #43 revealed she would like to use the external urinary catheter. Resident #43 revealed the facility had asked her if she was okay with the check and change. Resident #43 revealed she agreed only because the external urinary catheter was not allowed. Interview on 12/17/25 at 10:55 A.M., the Administrator verified there was no information documented in the admission agreement or admission packet stating the external urinary catheter was not allowed in the facility. Review of a facility admission agreement and information packet provided to residents upon admission to the facility revealed no notice the external urinary incontinence care system was not allowed. This deficiency represents non-compliance investigated under Complaint Number 2602463 and Complaint Number 1401651.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident allergy was identified for a physician ordered medication during the monthly medication regimen review. This affected one (#95) of three residents reviewed for medication allergies. The facility census was 100.Review of the medical record for Resident #95 revealed an admission date of 05/06/21. Diagnoses included type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of Resident #95's allergy alert profile dated 05/26/21 revealed the resident had allergies to metformin, Depakote, Geodon, Lexapro, Pravachol, Seroquel, and Zetia. On 08/27/24 an allergy to Ativan was added. The allergy to metformin was noted as unknown severity.Review of Resident #95's care plan revealed the resident had allergies to Abilify, Depakote, Geodon, Lexapro, Pravachol, Seroquel, and Zetia. Intervention included reviewing allergies quarterly, flag chart, notify all disciplines of allergy and known reactions, and notify pharmacy of known allergies. The allergies to metformin and Ativan were not noted on the care plan.Review of a physician order dated 09/29/24 revealed an order for metformin 500 milligrams (mg) daily for elevated blood sugar.Review of a progress orders note dated 10/01/24 at 3:57 A.M. revealed the system had identified a possible drug allergy for the following order: metformin oral tablet 500 mg, one time a day for type two diabetes mellitus and elevated blood glucose.Review of a progress note dated 10/01/24 at 11:32 A.M. noted the pharmacy was called as resident had an allergy to metformin. The Nurse Practitioner was notified for clarification.Review of a progress note dated 10/01/24 at 11:58 A.M., the nurse practitioner gave new order to hold metformin until the order could be reviewed and reassessed. Review of a physician order dated 10/08/24 revealed the metformin was discontinued. Review of the medication administration record for 09/29/24 through 10/08/24 revealed the metformin was not administered. Review of a nurse practitioner progress note dated 05/05/25 revealed the provider handwrote the resident's allergies on the top of the form. The provider noted the resident's elevated blood glucose levels and then ordered metformin 500 mg daily. Review of a physician order dated 05/05/25 revealed an order for metformin oral tablet 500 mg, give one tablet daily for type two diabetes mellitus. Further review of the electronic physician order revealed an alert on the side of the order noted the resident's allergy to metformin. Review of the pharmacy documentation dated 05/05/25 noted the resident had an allergy to metformin and noted a previous script was discontinued. Review of the nurse's notes dated 05/06/25 through 05/28/25 revealed no documentation the resident's representative was notified of the new orders for the medication metformin. Further review of the nurses' notes revealed no documentation the physician had been notified of the order for metformin and the resident's allergy to the medication. Also, there was no documentation the order had been reviewed or clarified.Further review of the electronic progress notes in the clinical record revealed no orders alert noting the resident's allergy to the metformin. Review of a pharmacy review progress note dated 05/17/25 at 2:56 P.M. revealed the pharmacist reviewed the resident's medication regimen and had noted any irregularities and/or observations on a separate report to the Director of Nursing and prescriber. Review of a monthly pharmacy review recommendation dated 05/17/25 revealed no documentation the consultant had noted the resident's order for metformin and allergy to the metformin. Review of the medication administration record (MAR) dated 05/01/25 through 05/29/25 revealed the resident was administered the medication daily for 24 days from 05/06/25 through 05/29/25 by four different nurses. Review of a nurses note dated 05/29/25 revealed the nurse had spoken with hospice regarding the resident's representative's request to discontinue the resident's metformin. The resident was noted as tolerating the medication well with no signs or symptoms of diarrhea at this time. The resident's representative was adamant the metformin be discontinued so hospice discontinued the medication.Review of the bowel task documentation from 05/01/25 through 05/30/25 revealed the resident had no diarrhea documented. Review of a nurse practitioner progress note dated 06/02/25 revealed the provider noted the resident had been started on metformin. After initiation of the medication, the resident's representative demanded the medication be discontinued due to an allergy. The resident's representative was educated the resident's side effect of diarrhea was no longer existent and it was not a true medication allergy. Interview on 12/15/25 at 3:30 P.M., the Director of Nursing (DON) revealed the allergy was addressed and the nurse practitioner was contacted regarding the allergy and the medication was discontinued. The DON was not aware why the medication order was not flagged with a pharmacy alert in the electronic medical record progress notes. The DON also revealed the nurses should be checking for allergies before administering medications. The DON also verified the resident's representative should have been notified when the medication was ordered. The DON also revealed there was no documentation the pharmacy had called the facility with notification of the metformin allergy and order for the medication. Interview on 12/17/25 at 9:32 A.M., [NAME] President of Operations (VPO) #448 for the pharmacy revealed the resident had been ordered metformin and had an allergy to the medication and the medication had flagged in the past. VPO #448 noted the medication had been ordered and discontinued by the same nurse practitioner in the past. VPO #448 revealed the pharmacist had noted the allergy on 05/05/25. VPO #448 revealed not having the ability to review phone call records from that time period to check if the pharmacy had called the facility about the allergy. Interview on 12/17/25 at 12:00 P.M. with the facility's monthly Consulting Pharmacist (CP) #450 revealed during the monthly medication review, the resident's medication orders and dosages were reviewed along with allergies and potential medication interactions. CP #450 revealed she saw the resident had an allergy to metformin but had thought the resident had been on the medication previously. CP #450 revealed she had assumed a previous consultant had addressed the allergy and the medication had not been removed from the resident's allergy list. CP #450 revealed in hindsight she should have looked further into it. Review of the undated facility policy Medication Regiment Review Policy, revealed the pharmacist would review each resident's medication according to Federal, State, and Local regulations as well as current standards of practice. The pharmacist must report any irregularities to the attending physician and director of nursing. Review of the facility policy Preventing and Detecting Adverse Consequences and Medication Errors, dated 12/2017, revealed when a resident received a new medication, the medication order would be evaluated for medication allergies. This deficiency represents non-compliance investigated under Complaint Number 1401649.

Based on review of the medical record, staff interview, pharmacist interviews, and policy review, the facility failed to ensure a resident was not administered a medication with a noted allergy without clarification from the physician. This affected one (#95) of three residents reviewed for medication allergies. The facility identified 67 residents with medication allergies. The facility census was 100.Review of the medical record for Resident #95 revealed an admission date of 05/06/21. Diagnoses included type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of Resident #95's allergy alert profile dated 05/26/21 revealed the resident had allergies to metformin, Depakote, Geodon, Lexapro, Pravachol, Seroquel, and Zetia. On 08/27/24 an allergy to Ativan was added. The allergy to metformin was noted as unknown severity.Review of Resident #95's care plan revealed the resident had allergies to Abilify, Depakote, Geodon, Lexapro, Pravachol, Seroquel, and Zetia. Intervention included reviewing allergies quarterly, flag chart, notify all disciplines of allergy and known reactions, and notify pharmacy of known allergies. The allergies to metformin and Ativan were not noted on the care plan.Review of a physician order dated 09/29/24 revealed an order for metformin 500 milligrams (mg) daily for elevated blood sugar.Review of a progress orders note dated 10/01/24 at 3:57 A.M. revealed the system had identified a possible drug allergy for the following order: metformin oral tablet 500 mg, one time a day for type two diabetes mellitus and elevated blood glucose.Review of a progress note dated 10/01/24 at 11:32 A.M. noted the pharmacy was called as resident had an allergy to metformin. The nurse practitioner was notified for clarification.Review of a progress note dated 10/01/24 at 11:58 A.M., the nurse practitioner gave new order to hold metformin until the order could be reviewed and reassessed. Review of a physician order dated 10/08/24 revealed the metformin was discontinued. Review of the medication administration record for 09/29/24 through 10/08/24 revealed the metformin was not administered. Review of a nurse practitioner progress note dated 05/05/25 revealed the provider handwrote the resident's allergies on the top of the form. The provider noted the resident's elevated blood glucose levels and then ordered metformin 500 mg daily. Review of a physician order dated 05/05/25 revealed an order for metformin oral tablet 500 mg, give one tablet daily for type two diabetes mellitus. Further review of the electronic physician order revealed an alert on the side of the order had noted the resident's allergy to metformin. Review of the pharmacy documentation dated 05/05/25 noted the resident had an allergy to metformin and noted a previous script was discontinued. Review of the nurse's notes dated 05/06/25 through 05/28/25 revealed no documentation the resident's representative was notified of the new orders for the medication metformin. Further review of the nurses' notes revealed no documentation the physician had been notified of the order for metformin and the resident's allergy to the medication. Also, there was no documentation the order had been reviewed or clarified.Further review of the electronic progress notes in the clinical record revealed no orders alert noting the resident's allergy to the metformin. Review of a pharmacy review progress note dated 05/17/25 at 2:56 P.M. revealed the pharmacist reviewed the resident's medication regimen and had noted any irregularities and/or observations on a separate report to the Director of Nursing and prescriber. Review of a monthly pharmacy review recommendation dated 05/17/25 revealed no documentation the consultant had noted the resident's order for metformin and allergy to metformin. Review of the medication administration record (MAR) dated 05/01/25 through 05/29/25 revealed the resident was administered the medication daily for 24 days from 05/06/25 through 05/29/25 by four different nurses. Review of a nurses note dated 05/29/25 revealed the nurse had spoken with hospice regarding the resident's representative's request to discontinue the resident's metformin. The resident was noted as tolerating the medication well with no signs or symptoms of diarrhea at this time. The resident's representative was adamant the metformin be discontinued so hospice discontinued the medication.Review of the bowel task documentation from 05/01/25 through 05/30/25 revealed the resident had no diarrhea documented. Review of a nurse practitioner progress note dated 06/02/25 revealed the provider noted the resident had been started on metformin. After initiation of the medication, the resident's representative demanded the medication be discontinued due to an allergy. The resident's representative was educated the resident's side effect of diarrhea was no longer existent and it was not a true medication allergy. Interview on 12/15/25 at 3:30 P.M., the Director of Nursing (DON) revealed the allergy was addressed and the nurse practitioner was contacted regarding the allergy and the medication was discontinued. The DON was not aware why the medication order was not flagged with a pharmacy alert in the electronic medical record progress notes. The DON also revealed the nurses should be checking for allergies before administering medications. The DON also verified the resident's representative should have been notified when the medication was ordered. The DON also revealed there was no documentation the pharmacy had called the facility with notification of the metformin allergy and order for the medication. Interview on 12/17/25 at 9:32 A.M., [NAME] President of Operations (VPO) #448 for the pharmacy revealed the resident had been ordered metformin and had an allergy to the medication and the medication had flagged in the past. VPO #448 noted the medication had been ordered and discontinued by the same nurse practitioner in the past. VPO #448 revealed the pharmacist had noted the allergy on 05/05/25. VPO #448 revealed not having the ability to review phone call records from that time period to check if the pharmacy had called the facility about the allergy.Interview on 12/17/25 at 12:00 P.M. with the facility's monthly Consulting Pharmacist (CP) #450 revealed during the monthly medication reviewed, the resident's medication orders and dosages were reviewed along with allergies and potential medication interactions. CP #450 revealed she saw the resident had an allergy to metformin but had thought the resident had been on the medication previously. CP #450 revealed she had assumed a previous consultant had addressed the allergy and the medication had not been removed from the resident's allergy list. CP #450 revealed in hindsight she should have looked further into it. Review of the undated facility policy Medication Regiment Review Policy, revealed the pharmacist would review each resident's medication according to Federal, State, and Local regulations as well as current standards of practice. The pharmacist must report any irregularities to the attending physician and director of nursing. Review of the facility policy Preventing and Detecting Adverse Consequences and Medication Errors, dated 12/2017, revealed when a resident received a new medication, the medication order would be evaluated for medication allergies. This deficiency represents noncompliance investigation under Complaint Number 1401649.

Based on observation and staff interview, the facility failed to ensure daily staffing information was posted on 08/29/24. This had the potential to affect all 92 residents in the facility. Findings include: On 08/29/24 at 11:38 A.M., observation of the daily staffing information posted at the front desk revealed it was dated 08/27/24. Further observation revealed the staffing information for 08/28/24 was tucked behind the sheet for 08/27/24 and there was no staffing information available for 08/29/24. Interview at the time of observation with the Administrator verified the posted staffing information was dated 08/27/24 and the staffing information for 08/29/24 was not available.

Based on observation, medical record review, hospital documentation review, and staff interview, the facility failed to ensure surgical wound and wound drainage care was provided as ordered by a physician following re-admission to the facility. This affected one (#52) of three residents reviewed for wounds. The facility census was 93. Findings include: Review of Resident #52's medical record identified admission to the facility occurred on 11/16/23 with medical diagnoses including bipolar disorder, urine retention, multiple sclerosis, Alzheimer's disease, and neoplasm of the genital organs. Further review of the medical record revealed Resident #52 required hospitalization from [DATE] through 05/07/24 for a scrotal abscess that required incision and drainage surgery. Review of Resident #52's hospital discharge documentation dated 05/07/24 revealed physician orders, under the section for drain and tube care, for the resident to have a nurse change the Kerlix dressing (antimicrobial rolled dressing) twice a day with wet to dry and maintain a Penrose drain (a soft, flexible rubber tube that drains fluid away from a wound) to allow for continued discharge. Review of Resident #52's re-admission nursing assessment dated [DATE] at 5:48 P.M., revealed, under the skin condition section, revealed instructions for staff to indicate all body marks such as old and recent scars (surgical or other). Further review of the assessment revealed no assessment or indication the resident had a scrotal surgical wound or Penrose drain. Observation of Resident #52 occurred on 05/09/24 at 10:14 A.M. with assistance from State tested Nurse Aide (STNA) #200. Resident #52 was observed in bed at the time of the observation and Resident #52's scrotal area was observed with a Penrose drain in place with no covering or dressing noted to the site. Review of Resident #52's treatment administration record (TAR) for May 2024 and current physician orders dated 05/07/24 following hospital discharge revealed no evidence of any dressing changes to the Penrose drainage tube. Interview with Licensed Practical Nurse (LPN) #400 on 05/09/24 at 10:32 A.M. stated she was told in report that morning Resident #52 had a sacral abscess and there was no mention of a drainage tube. LPN #400 confirmed there are no physician orders for a Penrose drain or dressing. LPN #400 also confirmed the Penrose drain was in the resident's scrotal area not sacral area. Observation of Resident #52 was completed with the Director of Nursing (DON) and the Administrator on 05/09/24 at 11:01 A.M. The DON confirmed Resident #52 had a scrotal incision site with a Penrose drain with no dressing in place. This deficiency is an example of continued noncompliance from the survey dated 04/09/24.

Based on observation, medical record review, hospital documentation review, and staff interview, the facility failed to ensure resident re-admission and skin assessments were accurate. This affected one (#52) of three residents reviewed for wounds. The facility census was 93. Findings include: Review of Resident #52's medical record identified admission to the facility occurred on 11/16/23 with medical diagnoses including bipolar disorder, urine retention, multiple sclerosis, Alzheimer's disease, and neoplasm of the genital organs. Further review of the medical record revealed Resident #52 required hospitalization from [DATE] through 05/07/24 for a scrotal abscess that required incision and drainage surgery. Review of Resident #52's hospital discharge documentation dated 05/07/24 revealed physician orders, under the section for drain and tube care, for the resident to have a nurse change the Kerlix dressing (antimicrobial rolled dressing) twice a day with wet to dry and maintain a Penrose drain (a soft, flexible rubber tube that drains fluid away from a wound) to allow for continued discharge. Review of Resident #52's re-admission nursing assessment dated [DATE] at 5:48 P.M., revealed, under the skin condition section, revealed instructions for staff to indicate all body marks such as old and recent scars (surgical or other). Further review of the assessment revealed no assessment or indication the resident had a scrotal surgical wound or Penrose drain, not documentation of a suprapubic catheter, or skin impairment to the left side of the neck. Review of a facility skin assessment dated [DATE] for Resident #52 identified the resident had no skin issues. Observation of Resident #52 occurred on 05/09/24 at 10:14 A.M. with assistance from State tested Nurse Aide (STNA) #200. Resident #52 was observed in bed at the time of the observation and Resident #52's scrotal area was observed with a Penrose drain in place with no covering or dressing noted to the site. Resident #52 was also observed with a large dressing dated 05/04/24 covering the left side of his neck down to the shoulder and a dressing in place around a suprapubic catheter tubing with dried red drainage noted. Interview with Licensed Practical Nurse (LPN) #400 on 05/09/24 at 10:32 A.M. confirmed the admission assessment dated [DATE] and the skin assessment dated [DATE] for Resident #52 both did not address the resident's surgical wound or Penrose drain, did not identify the resident's suprapubic catheter, and did not address the dressing over the left side of the resident's neck.

Based on family and staff interviews, record review, review of hospital records, review of facility policy, and review of facility fall investigations, the facility failed to ensure Resident #100 received adequate and timely care and treatment following an unwitnessed fall with major injury. Actual Harm occurred on 03/03/24 following an unwitnessed fall at 7:00 P.M. when the facility failed to adequately identify the resident's injury, treat the resident's pain, and timely obtain an x-ray for Resident #100, who, over the next few days, exhibited signs of pain (including verbal complaints of pain, facial grimacing and winching in pain during care and with movement). The Nurse Practitioner (NP) was notified of Resident #100's pain on 03/05/24 at 5:40 P.M. and ordered bilateral arm x-rays due to pain. The ordered x-rays were not obtained until the afternoon of 03/07/24, and results indicated a left arm fracture. The resident was subsequently transferred to the hospital on 03/07/24 at 4:40 P.M. for treatment where the resident was diagnosed with a markedly displaced fracture and the hospital questioned the facility as to why the resident wasn't sent to the hospital after the fall on 03/03/24. This affected one (Resident #100) of three residents reviewed for falls. The facility census was 96. Findings include: Review of the medical record for Resident #100 revealed an admitted [DATE]. Medical diagnoses included cerebrovascular accident (stroke) with residual right sided weakness, type II diabetes mellitus, and frequent falls. Resident #100 resided in the secured memory care unit. Resident #100 was transferred to a local hospital on 03/07/24 and did not return to the facility. Review of the Minimum Data Set (MDS) 3.0 Medicare 5-day and discharge return not anticipated assessment, dated 03/07/24, revealed Resident #100 had a Brief Interview for Mental Status (BIMS) score of a 00, indicating severely impaired cognition. Resident #100 was recorded as sometimes being understood and sometimes understanding. The assessment referenced Resident #100 required substantial/maximum assistance with activities of daily living and transfers. The resident was recorded as having one fall with major injury since admission to the facility. Review of Resident #100's physician's orders dated 03/03/24 revealed orders for aspirin 81 milligrams (mg) daily (a salicylate and platelet aggregation inhibitor that can cause easy bleeding and bruising) and clopidogrel 75 mg once daily (an antiplatelet medication that can cause easy bleeding and bruising). Review of Resident #100's plan of care revealed no baseline care plan had been implemented upon admission to the facility. A falls plan of care was initiated for Resident #100 on 03/04/24 after she had sustained the fall at the facility. Review of an incident report dated 03/03/24 at 7:00 P.M. revealed Resident #100 was seated with the nurse at the nurse's station when the nurse went to provide care to another resident in the dining room. The nurse heard Resident #100 fall and responded. The nurse assessed the resident and noted a quarter sized knot to the left side of her forehead. The nurse and an unnamed State tested Nurse Aide (STNA) assisted Resident #100 back to her chair. The assessment noted neurological checks were initiated, and vital signs were within normal limits. The resident denied pain and had no signs or symptoms of distress. Notifications were completed to the physician and Resident #100's family. An intervention of a wheelchair change was completed, as the prior wheelchair's height was too high for Resident #100. An entry reflecting the fall was also recorded in Resident #100's interdisciplinary progress notes. Review of subsequent interdisciplinary progress notes dated 03/04/24 at 10:40 P.M. revealed Resident #100 continued neurological checks, with her forehead observed to have a dark purple color spot. Resident #100's range of motion was noted to be within normal limits without pain or discomfort. A subsequent progress note on 03/05/24 at 5:40 P.M. documented Resident #100 complained of bilateral arm pain and the facility nurse practitioner was notified, who ordered x-ray examinations to bilateral (both) arms. The progress note reflected family was notified of new orders. Review of a progress note dated 03/06/24 by Certified Nurse Practitioner (CNP) #250 revealed she assessed Resident #100 to be thin, frail, and in no visible distress. Her only skin condition was a bruise to the forehead. CNP #250 assessed Resident #100 to be confused and have right sided weakness. The assessment referenced CNP #250 was aware of Resident #100's recent fall and reports of bilateral arm pain and noted that x-rays were pending. Review of Resident #100's physician's orders revealed an order dated 03/05/24, transcribed by Registered Nurse (RN) #409, for bilateral arm x-rays. A second order dated 03/07/24, transcribed by RN #306, revealed an order for left upper extremity x-ray due to resident complaints of left arm pain. Review of Resident #100's radiology reports revealed only one report, dated 03/07/24, was present in the medical record. Resident #100 received an x-ray examination of her left upper extremity per mobile service at the facility on 03/07/24 and the report indicated an acute displaced supracondylar fracture of the left humerus. Review of Resident #100's medical record reflected only three skilled charting assessments since admission. These assessments were dated 03/05/24 at 1:54 P.M. (noted as incomplete), 03/06/24 at 4:36 P.M. and 03/06/24 at 9:41 P.M. and revealed on all three notes indicated Resident #100's skin condition as normal. There was no indication of the resident being post-fall or having any bruising or edema. Resident #100's musculoskeletal status was only noted to reflect the resident had a history of strokes with right sided weakness. Review of Resident #100's Medication Administration Record for March 2024 revealed pain was marked as Not Applicable or No pain on each shift from 03/04/24 to 03/07/24. There was no indication of what pain scale was used or how Resident #100's pain was assessed. Review of an interdisciplinary progress note dated 03/07/24 at 4:38 P.M. identified Resident #100 had an x-ray examination of her left arm which showed a possible fracture. The physician was called and ordered Resident #100 be sent to the local emergency room to be evaluated and treated. The note documented Resident #100's family was notified. Review of the local hospital records dated 03/07/24, revealed Resident #100 arrived at the local emergency department with a visible left arm injury. Initial reports recorded in the emergency department record indicated the hospital was told Resident #100 had a fall on 03/02/24, prior to arriving to the facility. A physical examination of Resident #100 revealed significant bruising above her left eye, forehead, and temporal region. Resident #100 was observed to have swelling and bruising over her left wrist, distal humerus, and pain upon range of motion of the left elbow. An x-ray examination completed at the hospital on 03/07/24 revealed a markedly displaced supracondylar fracture with suspected extension to the articular surface. The hospital records reflected multiple calls to unnamed staff at the facility who reported different versions of the events. The hospital first phoned the facility at 5:19 P.M. and was told Resident #100 fell out of bed on 03/03/24 but did not have any further details. The hospital then recorded a second call at 5:36 P.M. to Resident #100's family who verified Resident #100 did fall at the facility. An additional phone call made by the hospital to the facility to discuss the circumstances and details of the fall was made, with the hospital records questioning why Resident #100 was not immediately sent into the hospital as she had a fall on 03/03/24 on blood thinners and had a notable head injury. The facility staff communicated to the hospital Resident #100 fell at home on 03/02/24 prior to arriving to the facility, which was a noted contraindication to what the family had reported to the hospital. The hospital records noted a report was filed with local adult protective services. An interview conducted on 03/27/24 at 3:46 P.M. with a family member of Resident #100 revealed a concern related to Resident #100's care while at the facility. The family member stated Resident #100 fell on [DATE] shortly after admission and hit her head. They had requested for Resident #100 to be sent to the hospital for evaluation but was unsure why she was not sent. Resident #100's family member stated they visited her at the facility on 03/05/24 and assisted her in removing a sweater she was wearing, and Resident #100 winced in pain. The family member identified the arm looked obviously broken and was bruised. The family reported to the nurse on duty a concern related to her arm and were told the nurse would contact the physician and order an x-ray examination. The family denied that the nurse physically examined Resident #100 and they never heard any x-ray results until they phoned the facility on 03/07/24. There was a different nurse on duty who told them the x-ray never came and there was no results to report and she would check on it. Later that day, the family was notified that an x-ray was completed at the facility indicating a left upper arm fracture and Resident #100 would be going to the hospital. Resident #100's family member denied any communication or involvement in a plan of care for Resident #100 and denied that a summary of Resident #100's care needs had been provided to them. An interview on 03/28/24 at 11:09 A.M. with the Director of Nursing (DON) indicated Resident #100 did not return to the facility post-hospitalization . She was unsure of the reason Resident #100 chose not to return to the facility. An interview on 03/28/24 at 3:50 P.M. with State tested Nurse Aide (STNA) #432 revealed she cared for Resident #100 while at the facility and recalled her having bruising to her arms. She additionally recalled Resident #100 being very frail and weak. An interview on 04/01/24 at 11:02 A.M. with Unit Manager (UM) #373 revealed she did not know Resident #100 as she was responsible for covering a different unit. UM #373 stated the facility is down a unit manager, and right now there is no unit manager for the memory care unit. UM #373 stated everyone tries to help out but there is not one designated manager overseeing or coordinating care on the memory care unit. An interview on 04/01/24 at 1:57 P.M. with STNA #350 revealed she cared for Resident #100 on multiple dates. She recalled her being in pain when her arms were moved while getting dressed. She specifically recalled the left arm appeared to hurt more than the right, she remembered Resident #100's left arm being stiff, difficult to move, and painful during activities of daily living. STNA #350 stated she had been told by an unnamed nurse on duty that stiff and painful was Resident #100's baseline. An interview on 04/01/24 at 2:05 P.M. with STNA #361 revealed she recalled caring for Resident #100 on multiple days. She recalled on the day Resident #100 went to the hospital, she was told to be careful while dressing her, and she dressed her slow and easy. When she went to move her left arm, she called out in pain. The nurse on duty, Registered Nurse (RN) #306, was already aware. Later that day, she went to the hospital because the left arm was broken. An interview on 04/02/24 at 9:42 A.M. with RN #306 revealed she admitted Resident #100 to the facility, and cared for her on the day she went to the hospital. She stated she received a call on that day from a family member of Resident #100 who stated they thought her arm was broken. RN #306 stated she looked at Resident #100's arm and it did not look purple or bruised, but when she went to move it the resident winced in pain. RN #306 stated the arm did not really look deformed, but she was guarding and cradling her left arm to protect it. RN #306 stated Resident #100 was still new, the staff didn't know her baseline or mannerisms yet and Resident #100 was aphasic (difficulty formulating language or speech) status post stroke. RN #306 stated she communicated with the hospital the best she could, but she was not in the facility when Resident #100 fell earlier in the week and did not have many details around the circumstances of Resident #100's fall. Attempts to reach RN #409 during the survey were unsuccessful. An interview on 04/02/24 at 11:29 A.M. with the DON revealed RN #409 did transcribe an order for Resident #100 to have arm x-rays on 03/05/24. The DON identified there was a delay in getting the x-ray completed as RN #409 was new and unfamiliar with the facility's process for ordering x-ray examinations. RN #409 attempted to call to order the examination, but the company only accepts online orders for STAT (urgent) examinations. The x-ray provider from the contracted company happened to be in the building on one of the next days providing in-servicing to staff and updated that they could not place orders that way. The DON indicated when RN #306 returned, she placed an order for the x-ray examination for Resident #100's arm and once the report came back the resident was sent to the hospital. The DON stated she was not aware of the delay in x-ray examinations until she happened upon the x-ray provider in the following days. The DON additionally identified that the nurse's should have been completing a 72-hour post-fall assessment each shift for 72 hours post fall and verified there was no post-fall assessments completed. Review of the policy titled, Fall Management, revised in December 2022 revealed the facility will provide an environment that is free from potential hazards. The Interdisciplinary Team will review falls routinely and reports of falls are monitored through the Quality Care Assurance process and routine meetings. The policy did not address what type of monitoring and for what duration residents require post-fall. Review of the policy titled, Resident Change in Condition, dated 07/28/22, revealed the facility will ensure staff provide timely and appropriate care and services when residents are experiencing a change in condition. The licensed nurse will take immediate action to ensure timely and appropriate care and services are met when a resident change in condition is identified. This deficiency represents non-compliance investigated under Complaint Numbers OH00152447, OH00152167, OH00152100, and OH00151975.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interviews with staff and local police officers, review of medical records, review of the facility's investigation, review of data from the Weather Underground website, and review of the facility policy for elopement, the facility failed to ensure one resident (Resident #38) with diagnoses of dementia, mild cognitive impairment, age related cognitive decline, multiple sclerosis (MS) and lack of coordination did not walk away from the facility unsupervised and without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury and/or death when on 07/30/23 at 5:38 P.M., Resident #38 exited through the front door, without staff knowledge, after following another resident's family member out the door which required a code to be entered to exit. Resident #38 was subsequently located in a shopping plaza parking lot after the police received a concerned citizen call at 7:39 P.M. indicating there was an individual who appeared disoriented and was having difficulty ambulating. The police brought Resident #38 back to the facility at 7:50 P.M. at which time she was identified as a facility resident. This affected one (#38) of three residents reviewed for elopement risk of eight sampled residents selected for review during the complaint investigations. The facility identified a total of 24 residents (#2, #9, #14, #24, #34, #51, #55, #59, #65, #70, #73, #84, #87, #88, #89, #92, #95, #96, 97, #98, #99, #100, #101 and #102) as being an elopement risk. The facility census was 102. On 02/06/24 at 3:36 P.M., the Administrator and Regional Registered Nurse (RRN) #301 were notified Immediate Jeopardy began on 07/30/23 at 5:38 P.M. when Resident #38, who had diagnoses of dementia, mild cognitive impairment, age related cognitive decline and lack of coordination walked away from the facility unsupervised and without staff knowledge. Resident #38 was located in a shopping plaza parking lot and returned to the facility by police after a concerned citizen call was received by the local police department on 07/30/23 at 7:39 P.M. indicating there was an individual who appeared disoriented and was having difficulty ambulating in a parking lot. The resident was returned to the facility by the police at 7:50 P.M., approximately two hours after she had eloped from the facility unsupervised and unknown to staff that she was missing. The progress note dated 07/30/23 timed at 7:50 P.M. authored by Licensed Practical Nurse (LPN) #205 revealed LPN #205 received a phone call from another nurse stating Resident #38 was found by the police. LPN #205 made his way outside; however, the police had already dropped Resident #38 off at the facility and left. Resident #38 was without signs of injury and appeared to be overjoyed, dancing and celebrating that she was able to get out. While laughing, Resident #38 stated one of the family members here let me out, he probably thought I was also a family member. Resident #38 was unable to state when she had left the facility; she said she had breakfast at the facility but not lunch. When asked why she left the facility, Resident #38 stated she was tired of looking at the four walls, it felt like a prison, and she did not regret getting out for some fresh air. Resident #38 returned with shopping bags from a local dollar store that included cookies and picture frames. Review of the progress note dated 07/31/23 timed at 7:40 A.M. authored by Nurse Practitioner (NP) #297 revealed she was notified Resident #38 had left the building, went shopping and returned hours later with energy drinks. The note indicated Resident #38 did not recall going shopping. On 07/31/23, the resident was transferred to the secured memory care unit. The Immediate Jeopardy was removed on 08/02/23 when all residents were re-assessed for their elopement risk and care plans updated as warranted for all residents identified as being at risk for elopement. The deficiency remained at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) until it was corrected on 09/21/23 when the facility implemented the following corrective actions: On 07/30/23 at 7:50 P.M., Resident #38 was returned to the facility by the local police and was assessed by nursing staff with no signs of injury. Beginning 07/30/23 at 8:00 P.M., the Administrator began educating all staff on the elopement policy, emergency door codes, not sharing door codes with families, reporting malfunctioning doors to maintenance, staff members to use the rear entrance, use of radios for elopement event, updating door map locations, and calling the Administrator and DON to report an event. Agency staff received education prior to the start of their shifts. Review of an employee roster dated 07/30/23 - 08/01/23 revealed the Administrator placed check marks by each employee name indicating he had provided the staff person the education either via phone or in person and the date the education had been provided. The document indicated all staff had received the training by 08/01/23 at 5:00 P.M. Interviews with staff members across all shifts on 02/14/24 through 02/15/24 confirmed they had received education on elopement policies and procedures by the Administrator. Each staff member was knowledgeable regarding the current policies and procedures. On 07/31/23, the Corporate Director of Clinical Services #415 re-educated the Administrator and the Director of Nursing (DON) on elopement policies and procedures including assessment, identification, monitoring and managing residents at risk for elopement. Review of education acknowledgement documentation dated 07/31/23 confirmed the signatures of the Administrator and DON indicating receipt of the training. Review of a document titled Door Audits for Alarms Checks for Pressure and Release Checks revealed documentation random door audits were completed by the Administrator for a four-week period from 07/31/23 through 09/14/23 with no concerns noted. From 07/31/23 through 12/31/23, monthly elopement drills were completed by Maintenance Director #224. Review of the elopement drill documentation revealed on 07/31/23 an elopement drill was completed at 10:30 A.M., 08/30/23 an elopement drill was completed at 8:00 P.M., and on 09/21/23 an elopement drill was completed at 2:00 A.M. indicating each shift had completed an elopement drill with no concerns noted. From 08/01/23 through 08/02/23, all residents were re-assessed for their elopement risk by the Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Nurse #221 and Unit Manager #222. Medical record review on 02/12/24 confirmed elopement risk assessments were completed, and care plans updated as warranted for all residents identified as being at risk for elopement. On 08/02/23, a Quality Assessment and Assurance (QAA) meeting was held that included the Administrator, DON, ADON, Housekeeping Supervisor #416, Maintenance Director #224, Social Services Designee #425, Central Supply Department Head #428, Admissions Director #426, Marketing Director #427, Therapy Director #417, Minimum Data Set (MDS) Nurse #292, Human Resources #41, Pharmacy Consultant #430, Business Officer Manager #429 and Medical Director #420. At this meeting the corrective action plan for Resident #38's elopement was presented by the Administrator and approved. Review of the sign in sheet for the meeting confirmed attendance. On 08/09/23, the Administrator provided education to families regarding the changing of the door codes and the need to be vigilant that residents were not following visitors out of the building. The administrator posted a sign on the front entrance door for families that were not present at the meeting. Review of an education sign in sheet confirmed families and residents were in attendance. Findings include: Review of the medical records for Resident #38 revealed an admitted [DATE]. Diagnoses included dementia, mild cognitive impairment, age related cognitive decline, lack of coordination, multiple sclerosis (MS), anxiety, bipolar, depression, falls, weakness and unsteadiness on feet. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had impaired cognition, required supervision with ambulation and assistance of one staff for toileting and personal hygiene. The assessment indicated Resident #38 had no behaviors. Review of the elopement assessment dated [DATE] timed at 9:40 P.M. revealed Resident #38 was at risk for elopement. Review of the progress note dated 07/30/23 timed at 7:50 P.M. authored by Licensed Practical Nurse (LPN) #205 revealed LPN #205 received a phone call from another nurse stating Resident #38 was found by the police. LPN #205 made his way outside; however, the police had already dropped Resident #38 off at the facility and left. Resident #38 was without signs of injury and appeared to be overjoyed, dancing and celebrating that she was able to get out. While laughing, Resident #38 stated one of the family members here let me out, he probably thought I was also a family member. Resident #38 was unable to state when she had left the facility; she said she had breakfast at the facility but not lunch. When asked why she left the facility, Resident #38 stated she was tired of looking at the four walls, it felt like a prison, and she did not regret getting out for some fresh air. Resident #38 returned with shopping bags from a local dollar store that included cookies and picture frames. Resident #38's guardian, alternate contact, unit manager and DON were notified. Review of the progress note dated 07/31/23 timed at 7:40 A.M. authored by Nurse Practitioner (NP) #297 revealed she was notified Resident #38 had left the building, went shopping and returned hours later with energy drinks. The note indicated Resident #38 did not recall going shopping. Review of the progress note dated 07/31/23 timed at 3:17 P.M. revealed Resident #38 was transferred to the secured memory care unit. Review of the elopement assessment dated [DATE], which was completed to determine if it was appropriate to transfer Resident #38 back to the unit she previously resided on because she was not adjusting well to the secured memory care environment, revealed Resident #38 was not at risk for elopement. Review of the care plan dated 10/04/23 revealed Resident #38 had impaired self-care abilities related to MS and dementia diagnoses. Interventions included provide cues to use walker during ambulation, supervise transfers and toileting, and assistance of one staff for dressing. Resident #38 had periods of bowel and bladder incontinence. Interventions included check for incontinence every two hours and as needed. Resident #38 had communication deficits related to dementia. Interventions included do not rush and allow time to process information, speak directly to the resident in a clear voice and ask simple yes/no questions and allow adequate time to respond. Resident #38 was at risk for falls related to MS diagnosis and poor safety awareness. Interventions included remind to utilize walker for ambulation. Resident #38 had dementia. Interventions included reorienting resident to unit as needed. Resident #38 was at risk for elopement related to dementia and impaired thought process with history of exit seeking behaviors (this was not in line with the elopement assessment dated [DATE] which indicated Resident #38 was not at risk for elopement). Interventions included escorting resident outside for a walk as needed, provide 1:1 as needed, and document attempts to leave the facility unattended. Review of the progress note dated 10/05/23 timed at 4:02 P.M. revealed Resident #38 was moved from the secured memory care unit to the 200 Hall. Review of the progress note dated 10/31/23 timed at 9:19 P.M. revealed Resident #38 activated a door alarm on the 200 Hall. Resident #38 was observed repeatedly pushing and slamming her shoulder into the door. The progress note did not indicate staff response or if Resident #38 was easily redirected. Interview on 02/05/24 at 11:10 A.M. with Resident #38 revealed Resident #38 was confused and unable to recall leaving the facility. Resident #38 did not know the current month or the day of the week. Interview on 02/05/24 at 11:15 A.M. with LPN #202 revealed she was the assigned nurse for Resident #38 on 07/30/23 from 6:00 A.M. to 6:00 P.M. LPN #202 stated Resident #38 was not alert and oriented and was confused at times with fixated behaviors. Resident #38 ambulated with a walker. LPN #202 recalled administering medications to Resident #38 sometime between 2:00 P.M. and 4:00 P.M. and when she left the facility at approximately 6:00 P.M. she was not aware Resident #38 was not present. LPN #202 said upon her return to work a few days later she was informed Resident #38 had left the facility. LPN #202 was not aware of the details as to what occurred. Interview on 02/05/24 at 12:00 P.M. with STNA #240 revealed she was present on 07/30/23 but she was working on another unit. STNA #240 was aware Resident #38 had left the facility and thought she had been gone for possibly two hours. STNA #240 spoke with Resident #38 after the incident and Resident #38 told her she followed a family member out of the building and went to a restaurant and the dollar store. STNA #240 stated the restaurant and dollar store were approximately a five-minute walk for the average person; however, due to Resident #38's MS it could have taken her longer to get to the location. STNA #240 stated Resident #38 did not adjust well to the surroundings of the secured memory care unit and after a few months she was moved back to the 200 Hall. Telephone interview on 02/05/24 at 1:50 P.M. with a staff member who wished to remain anonymous due to fear of retaliation revealed the staff member was present on the evening of 07/30/23. The staff member received a phone call from the local police department asking if the facility was missing a resident. The description that was provided sounded like Resident #38. The police arrived at the facility and the anonymous staff member, and another staff member identified Resident #38. Resident #38 did not appear to have any injuries and was confused when she arrived. Interview on 02/05/24 at 3:55 P.M. with the Administrator and DON revealed an investigation related to the elopement of Resident #38 was not completed; however, the Administrator had asked staff members some questions. The Administrator stated he was informed Resident #38 had a bout of confusion at the dollar store while reaching for her wallet to pay for her items; however, the Administrator was unable to state who had reported Resident #38 appearing to be confused at the dollar store. The Administrator stated he was unable to determine what time Resident #38 had left the facility. He did state it may have been late afternoon, possibly around dinner time. The Administrator stated local police informed the facility Resident #38 had been located outside of the facility and had she not been found by the police the nurse would have realized she was missing when medications were administered. The DON stated she was not employed at the facility during the event and was not aware of the details related to Resident #38's elopement. Telephone interview on 02/06/24 at 7:33 A.M. with LPN #205 revealed he was the assigned nurse for Resident #38 on 07/30/23 from 6:00 P.M. until 6:00 A.M. When LPN #205 arrived on duty he was not aware Resident #38 was not present in the building and during his evening medication pass (could not recall time), he went to Resident #38's room and she was not present. LPN #205 looked for Resident #38 in the library because she often sat in there, but she was not in the library. Sometime later (unable to recall time) he was notified by STNA #230 the police dropped Resident #38 off at the facility. LPN #205 spoke with Resident #38 upon her return and Resident #38 told him she had seen another resident's family exiting the facility and she had taken the chance and left. LPN #205 stated Resident #38 appeared happy and was dancing when she returned saying she was happy she got out. LPN #205 stated Resident #38 was confused at times and ambulated with a walker. Telephone interview on 02/06/24 at 7:43 A.M. with STNA #237 revealed she was present on 07/30/23 from 6:00 P.M. to 6:00 A.M., but she was not assigned to Resident #38. Approximately an hour or two into her shift STNA #230 received a phone call from the police regarding a missing resident. Based on the description the police had given, STNA #230 identified it was Resident #38. STNA #237 and STNA #230 met the police at the door and assisted Resident #38 back into the building. Resident #38 told STNA #237 she went to a restaurant to get a few drinks. Resident #38 also told STNA #237 she left sometime after lunch. STNA #237 described Resident #38 as being pleasantly confused and ambulatory with a walker. Telephone interview on 02/06/24 at 10:46 A.M. with Police Officer (PO) #400 revealed he and another officer received a call about an individual who was disoriented and stumbling in a parking lot. PO #400 did not respond to the call; the other officer was the responding officer. PO #400 had been advised the individual was unable to state her name but was able to state the name of the facility she resided at but did not know how to get back to the facility. PO #400 stated the other officer took Resident #38 to the facility and staff identified her as being a resident at the facility. Interview on 02/06/24 at 12:17 P.M. with the ADON revealed Resident #38 was placed on the secured memory care unit following the elopement but had not adjusted well. The ADON spoke with Resident #38 and her guardian. Resident #38 promised she would not leave the facility again. Resident #38 and the guardian were in agreement that Resident #38 could be moved back to her previous unit on the 200 Hall. A follow up interview on 02/06/24 at 1:19 P.M. with the Administrator and DON revealed the Administrator was unable to locate the incident number that had been given by the police officer. The Administrator again stated he had not completed an official investigation; however, he had spoken with staff about the incident. A telephone interview on 02/06/24 at 1:47 P.M. with STNA #300 revealed he was not present on 07/30/23 because he had called off work due to illness. STNA #300 stated the next morning he was told by the evening shift STNA that Resident #38 had left the facility. Observation and interview of Resident #38 on 02/07/24 at 8:50 A.M. revealed she had not had breakfast and she would like to go to the dining room. Resident #38 put her shoes on, obtained her rollator walker and exited her room. Resident #38 was unable to state where the dining room was located. As Resident #38 attempted to locate the dining room she walked with a shuffling gait. Review of the facility investigation which was provided on 02/07/24 at 1:18 P.M. revealed the following: A statement dated 07/30/23 authored by the Administrator indicating he was notified by the nursing staff Resident #38 was returned to the facility at approximately 7:30 P.M. by the local police department. Resident #38 was placed on 1:1 supervision at time of return. A statement dated 07/30/23 given by Resident #38 revealed she wanted to go outside and take a walk because it was nice and sunny out. Resident #38 had money and wanted to go to the dollar store to purchase some snacks and other things. Resident #38 stated she went from Point A to Point B and no sooner had she arrived than the police came to bring her back. When asked what time she went to the store she said after dinner, before 6:00 P.M. A statement dated 07/31/23 by Dietary Aide (DA) #298 revealed he delivered a dinner meal to Resident #38 on 07/30/23 between approximately 5:00 P.M. and 5:15 P.M. A statement dated 07/31/23 authored by Maintenance #224 and the Administrator revealed camera footage was reviewed and Resident #38 was observed exiting the facility at approximately 5:38 P.M. Resident #38 followed visiting family members out of the building. A statement dated 08/01/23 authored by Receptionist #299 revealed the receptionist did not observe Resident #38 exiting the facility during her shift on 07/30/23 which ended at 4:15 P.M. A timeline of events that indicated at 4:15 P.M. Receptionist #299 verified Resident #38 was present in the building, and at 5:15 P.M. DA #298 served Resident #38 dinner. Resident #38 left the facility at 5:38 P.M. using her rollator [walker]. At approximately 5:50 P.M. State tested Nursing Assistant (STNA) #248 observed Resident #38 walking around in the facility parking lot. The timeline indicated Resident #38 was out of the facility for a maximum of one hour and 48 minutes. A telephone interview on 02/07/24 at 5:31 P.M. with another staff member who wished to remain anonymous due to fear of retaliation, revealed administrative staff had not asked the staff about the incident prior to 02/07/24. The anonymous staff member received a call on 02/07/24 from a corporate office staff asking if she had observed Resident #38 outside of the building on 07/30/23. The anonymous staff told the corporate office staff when she arrived at the facility at approximately 5:50 P.M. on the evening of 07/30/23, she observed an individual outside on the sidewalk in front of the facility with a walker; however, the anonymous staff member could not identify that individual. The anonymous staff member did not provide a written statement. A follow up telephone interview on 02/08/24 at 10:33 A.M. with STNA #300 (the STNA who previously indicated he called off the day of the incident) revealed he had been present on 07/30/23 but he was unable to recall specific information regarding Resident #38. Interview on 02/08/24 at 10:46 A.M. with Maintenance Director (MD) #224 revealed on the morning of 07/31/23 he and the Administrator reviewed camera footage and observed Resident #38 exiting the facility. MD #224 was unable to recall the time Resident #38 exited the facility but did recall the footage showed she had exited behind another resident's family. Interview on 02/08/24 at 11:02 A.M. with DA #298 revealed he observed Resident #38 in the dining room on the evening of 07/30/23 and served Resident #38 dinner between 5:00 P.M. and 5:15 P.M. DA #298 stated he was told Resident #38 left the facility shortly after DA #298 served her meal and that she exited behind a family member. Telephone interview on 02/08/24 at 11:25 A.M. with PO #401 revealed he responded to a call for concerns regarding a disoriented individual in a parking lot of a shopping plaza on 07/30/23 at 7:39 P.M. PO #401 stated upon arrival the individual appeared to be confused. The individual was able to state where she lived but did not know how to get there. PO #401 took the individual to the facility where staff identified her as a resident, and he departed the facility at 7:50 P.M. Review of the Weather Underground website (httpps://www.wunderground.com) data revealed on 07/30/23 the temperature was between 78-82 degrees Fahrenheit (F), with fair conditions. Review of facility policy titled Elopement revised August 2022 revealed a detailed investigation would be completed by the Administrator and DON. An incident report would be completed, staff interviews would be gathered and interventions to prevent further incidents were to be implemented. This deficiency represents non-compliance investigated under Complaint Number OH00149915.