Every finding on record at Avon Oaks Nursing Home

Based on medical record review, review of video footage, staff interview, resident representative interview, and policy review the facility failed to ensure residents were free from abuse by staff. This affected one (#1) of three residents reviewed for abuse. The facility census was 94.Findings include:Review of the medical record for Resident #1 revealed an admission date of 01/23/25 with diagnoses that included Parkinson's disease, dementia, and cognitive communication deficit. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and required hands on assistance of two staff persons for completing her activities of daily living (ADLs) including dressing, bathing, and toileting. Review of the Resident #1's current care plan revealed Resident #1 was resistive to care related to anxiety and dementia. Interventions included to provide the resident with opportunities for choice during care provision. If possible, negotiate a time for ADLs so the resident participates in the decision-making process and return at agreed upon time.Review of video footage dated 07/12/26 from the stationary camera located in Resident #1's room, provided by Resident #1's Power of Attorney (POA), revealed Certified Nurse Aide (CNA) #100 and CNA #101 were in Resident #1's room attempting to toilet the resident. In the early portions of the video, Resident #1's expressed her desire to go to the bathroom and sit on the toilet. Both CNA #100 and CNA #101 denied her request, place her on the bed, and begin to provide incontinence care to Resident #1. While care is being performed, Resident #1's becomes extremely combative, shouting at both CNAs to stop care, stating she does not like the care being provided, and she wished harm to both CNAs. CNAs #100 and CNA #101 continued to ignore Resident #1's pleas to stop and continued with care. Toward the end of the video, while putting Resident #1's incontinence brief on, Resident #1 began to kick her legs in anger and CNA #101 openly laughed at Resident #1. Interview with the Resident #1's POA on 08/28/26 at 9:47 A.M. stated she watched the video footage with facility administration the week following the incident and felt as though the incident rose to an abusive act on the part of CNA #100 and CNA #101.Interview with the Administrator and the Director of Nursing (DON) on 08/28/26 at 11:11 A.M. verified they were aware of the events of the video footage and verified the authenticity of the video provided to the surveyor by Resident #1's POA. Further interview with the Administrator and the DON confirmed the acts by CNA #100 and CNA #101 toward Resident #1 on the video footage.Review of the policy titled, Abuse, Mistreatment, Neglect, Injuries of Unknown Source, Exploitation and Misappropriation of Resident Property, dated 01/01/24, revealed the facility will not tolerate mistreatment, abuse, neglect or exploitation of its residents.This deficiency represents non-compliance investigated under Complaint Number 3177231.

Based on medical record review, review of self-reported incidents, review of video footage, resident representative interview, staff interview, and policy review, the facility failed to report an allegation of abuse to the State Survey Agency as required. This affected one (#1) of three residents revealed for abuse. The facility census was 94.Findings include:Review of the medical record for Resident #1 revealed an admission date of 01/23/25 with diagnoses that included Parkinson's disease, dementia, and cognitive communication deficit. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and required hands on assistance of two staff persons for completing her activities of daily living (ADLs) including dressing, bathing, and toileting. Review of the Resident #1's current care plan revealed Resident #1 was resistive to care related to anxiety and dementia. Interventions included to provide the resident with opportunities for choice during care provision. If possible, negotiate a time for ADLs so the resident participates in the decision-making process and return at agreed upon time.Review of video footage dated 07/12/26 from the stationary camera located in Resident #1's room, provided by Resident #1's Power of Attorney (POA), revealed Certified Nurse Aide (CNA) #100 and CNA #101 were in Resident #1's room attempting to toilet the resident. In the early portions of the video, Resident #1's expressed her desire to go to the bathroom and sit on the toilet. Both CNA #100 and CNA #101 denied her request, place her on the bed, and begin to provide incontinence care to Resident #1. While care is being performed, Resident #1's becomes extremely combative, shouting at both CNAs to stop care, stating she does not like the care being provided, and she wished harm to both CNAs. CNAs #100 and CNA #101 continued to ignore Resident #1's pleas to stop and continued with care. Toward the end of the video, while putting Resident #1's incontinence brief on, Resident #1 began to kick her legs in anger and CNA #101 openly laughed at Resident #1. Interview with the Resident #1's POA on 08/28/26 at 9:47 A.M. stated she watched the video footage with facility administration the week following the incident and felt as though the incident rose to an abusive act on the part of CNA #100 and CNA #101.Review of the facility's self-reported incidents revealed no evidence the allegation of abuse between Resident #1 and CNA #100 and CNA #101 was reported to the State Survey Agency. Interview with the Administrator and the Director of Nursing (DON) on 08/28/26 at 11:11 A.M. verified they were aware of the events of the video footage and verified the authenticity of the video provided to the surveyor by Resident #1's POA. Further interview with the Administrator and the DON confirmed the acts by CNA #100 and CNA #101 toward Resident #1 on the video footage, and verified the allegation was not reported to the State Survey Agency.Review of the policy titled, Abuse, Mistreatment, Neglect, Injuries of Unknown Source, Exploitation and Misappropriation of Resident Property, dated 01/01/24, any allegations of abuse, neglect, mistreatment, exploitation, injuries of unknown source, and misappropriation of resident property must be reported immediately to both the Administrator and to the Ohio Department of Health (State Survey Agency). The Administrator or Designee must report to the Ohio Department of Health (ODH) via the ODH Gateway within two (2) hours for allegations of abuse or serious injury. For all other allegations or suspicions, the ODH requires notification as soon as possible, but not to exceed twenty-four (24) hours after the incident or discovery of the injury.This deficiency represents non-compliance investigated under Complaint Number 3177231.

Based on observations, resident record review, resident interviews, staff interviews, and facility policy review, the facility failed to ensure call lights were within reach. This affected four residents (#6, #13, #73, and #95) of four residents reviewed for call lights. The facility census was 92.Findings include:1. Review of the medical record for Resident #6 revealed he was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture of the right hand, and contracture, left and right knee.Review of the physician orders dated 10/04/22 revealed an order for fall prevention per protocol.Review of the physician orders dated 08/16/24 revealed an order for Hoyer (mechanical lift) for transfers.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. Review of the MDS assessment revealed Resident #6 was impaired on both sides of his upper and lower extremities and was dependent on staff for activities of daily living (ADL).Review of the care plan dated 02/02/26 revealed Resident #6 had a self-care performance deficit related to stroke and hemiparesis of the right upper and lower extremities and was at risk for falls with interventions that included assistance with ADL and keep the call light within reach.Review of the progress notes dated 02/23/26 at 2:59 P.M. revealed Resident #6 had a care plan meeting that indicated he was at a moderate risk for falls.Observation and interview on 03/18/26 at 10:44 A.M. revealed Resident #6 lying in bed leaning and facing the left side wall. Resident #6's bed was against the wall. Resident #6's call light was observed to be located approximately three feet away and tucked inside the drawer of bedside nightstand. Resident #6 revealed he could not locate his call light, and he did not know where it was located.Interview and observation on 03/18/26 at 10:46 A.M. with Certified Nursing Assistant (CNA) #919 revealed Resident #6 was dependent on staff for ADL and his call light should be within reach. CNA #919 revealed she removed Resident #6's call light during his breakfast meal. CNA #919 was then observed removing Resident #6's call light from the nightstand drawer and placing it on the bed. CNA #919 confirmed and verified the above findings at the time of the interview.2. Review of the medical record for Resident #13 revealed he was admitted to the facility on [DATE] with diagnoses that included stiff-man syndrome, spinal stenosis and muscle weakness.Review of the physician orders dated 06/09/25 revealed an order for fall prevention protocol.Review of the MDS assessment dated [DATE] revealed Resident #13 had a BIMS score of 14 that indicated he was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #13 had impairment on both sides of his upper and lower extremities and was dependent on staff for ADL.Review of the care plan dated 03/05/26 revealed Resident #13 had a limited functional range of motion related to stiff-man syndrome and was at risk for falls with interventions that included keep call light within reach.Review of the progress note dated 03/05/26 at 3:22 P.M. revealed Resident #13 had a care pan meeting that indicated he was at moderate risk for falls.Observation and interview on 03/18/26 at 10:29 A.M. revealed Resident #13 lying in bed. Resident #13's call light was not visible and not within reach. Resident #13 revealed he did not know where his call light was located and was observed moving his right arm in a back-and-forth motion attempting to locate the call light. Resident #13 stated wherever it is, I can't reach it.Interview and observation on 03/18/26 at 10:40 A.M. with Rehabilitation Therapist (RT) #970 revealed he was familiar with Resident #13, and his call light should be within reach. RT #970 was observed unwrapping the call light from around the head of the bed frame, directly behind Resident #13 head, and placing it in the bed next to him. RT #970 confirmed and verified the above findings at the time of the interview.3. Review of the medical record for Resident #73 revealed she was admitted to the facility on [DATE] with diagnoses that included systematic lupus erythematosus, rheumatoid arthritis, fracture of nasal bones, injury of head, and history of falling.Review of the physician orders dated 03/17/23 revealed an order for fall prevention per protocol.Review of the physician orders dated 08/23/24 revealed an order for stand-up lift for transfers.Review of the progress note dated 11/26/25 at 1:29 P.M. revealed Resident #73 had a care plan meeting that indicated she was at high risk for falls.Review of the progress note dated 12/22/25 at 1:17 P.M. revealed Resident #73 was found lying on the floor in her room near doorway with a large hematoma on forehead and bilateral nostrils epistaxis. Resident #73 reported she was trying to move for the people behind her. Resident #73 was noted to only be in the room with her bedbound roommate. Resident #73 was sent to the emergency room (ER). Review of the progress note dated 12/22/25 at 9:24 P.M. revealed Resident #73 returned from the ER with a diagnosis of nasal fracture.Review of the MDS assessment dated [DATE] revealed Resident #73 had a BIMS score of eight, indicating moderate cognitive impairment. Review of the MDS assessment revealed Resident #73 was dependent on staff for ADL.Review of the care plan dated 01/01/26 revealed Resident #73 was at risk for falls with interventions that included keep call light within reach.Review of the physician orders dated 02/25/26 revealed an order for occupational therapy (OT) evaluation and treatment for wheelchair positioning.Interview and observation on 03/18/26 at 10:21 A.M. revealed Resident #73 sitting in her wheelchair with her back to the entrance of the room. Resident #73's call light was not visible and was not within reach. Resident #73 revealed she had a history of falling and recalled a fall that resulted in her hitting her head. Resident #73 revealed she did not know where her call light was located and would have to yell for help.Interview and observation on 03/18/26 at 10:25 A.M. with Licensed Practical Nurse (LPN) #805 revealed Resident #73 was at a high risk for falls and was dependent on staff for total care. LPN #805 revealed Resident #73 had a history of falls in which one resulted in a broken nose. LPN #805 revealed Resident #73's fall was a result of confusion and sitting in her wheelchair. LPN #805 revealed Resident #73 was required to have all fall interventions in place including call light within reach. Observation revealed LPN #805 attempting to locate Resident #73 call light by following the cord from the wall to the nightstand directly behind Resident #73. Resident #73 call light was approximately five feet away and out of reach. LPN #805 confirmed and verified the above findings at the time of interview.4. Review of the medical record for Resident #95 revealed he was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, acquired absence of the right leg above the knee, type II diabetes, and need for assistance with personal care.Review of the physician orders dated 08/05/25 revealed an order for fall prevention per protocol.Review of the physician orders dated 09/14/25 revealed an order for bed pad alarm every day and night shift.Review of the physician orders dated 12/05/25 revealed an order to remind Resident #95 to use call light for assistance for fall intervention.Review of the physician orders dated 01/31/26 revealed an order for floor mat to floor while in bed for fall intervention.Review of the care plan dated 02/08/26 revealed Resident #95 was at risk for falls and had decreased ability to perform ADL with interventions that included keeping the call light within reach.Review of the MDS assessment dated [DATE] revealed Resident #95 had a BIMS score of six, indicating severe cognitive impairment. Review of the MDS assessment revealed Resident #95 had impairment on one side of lower extremity and was dependent on staff for ADL.Review of the progress note dated 02/19/26 at 4:37 P.M. revealed Resident #95 had a care plan meeting that indicated he was at high risk for falls.Review of the physician orders dated 02/25/26 revealed an order for body pillow to edge of bed for safety for fall intervention.Review of the progress note dated 02/25/26 at 1:44 A.M. revealed Resident #95 was found on the floor, lying face down adjacent to the bed stating he was trying to get out of there.Review of the progress note dated 03/05/26 at 9:58 P.M. revealed Resident #95 was found on the floor stating that he was trying to crawl out of bed. Resident #95 was placed back in bed with call light in reach.Observation and interview on 03/18/26 at 10:33 A.M. revealed Resident #95 lying in bed screaming for help. Resident #95 revealed he needed help to be repositioned in bed and needed help with eating his breakfast meal and a drink of water. Resident #95 was observed to be slouched down beneath his over the bed table with his breakfast tray untouched. Resident #95's call light was not visible or within reach.Interview and observation on 03/18/26 at 10:40 A.M. with RT #970 revealed he was familiar with Resident #95, and his call light should be within reach. RT #970 was observed grabbing Resident #95's call light from his recliner which was approximately five feet away from the bed and placed it next to Resident #95. RT #970 confirmed and verified the above findings at the time of the interview.Review of the facility document titled Falls/Safety Program, reviewed May 2025, revealed the facility had a policy in place to prevent or minimize injuries caused by accidental falls. Review of the policy revealed residents would be assessed for fall risk, call lights would be left within reach, and interventions would be put in place to prevent future falls. Review of the facility document titled Call Light/Bell Policy, revised May 2025, revealed the facility had a policy in place to provide transmission of call alerts from resident rooms to alert staff a resident may require assistance. Review of the policy revealed each resident would have a means of calling for assistance.

Based on observations, resident record review, resident interviews, staff interviews, and facility document review, the facility failed to honor Resident #51's preferences. This affected one resident (#51) of one reviewed for preferences. The facility census was 92.Findings include:Review of the medical record for Resident #51 revealed he was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, cerebral infarction, muscle weakness and difficulty in walking.Review of the physician orders dated 10/24/24 revealed an order for fall prevention per protocol.Review of the physician orders dated 01/22/25 revealed an order for perimeter mattress and floor mat for fall prevention.Review of the progress note dated 01/21/26 at 4:16 P.M. revealed Resident #51 had a care plan meeting that indicated he was at risk of wandering and was at high risk for falls.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of seven that indicated he had cognition impairment. Review of the MDS assessment revealed Resident #51 was dependent on staff for activities of daily living (ADL).Review of the fall risk assessment dated [DATE] revealed Resident #51 was at high risk for falls.Review of the progress note dated 03/09/26 at 5:23 P.M. revealed the Administrator would be replacing Resident #51's body pillow and made Resident #51's spouse aware.Review of the concern log dated 03/10/26 revealed Resident #51's spouse had a documented concern regarding Resident #51's body pillow missing. Review of the concern log revealed a resolution of the body pillow being replaced.Review of the care plan dated 03/12/26 revealed Resident #51 had a decreased ability to perform ADL and was at risk for falls with interventions that included assistance from staff for ADL including bed positioning and/or mobility, transfers and the need for a bolstered mattress to define perimeter with mat on the floor.Observation on 03/18/26 at 11:16 A.M. revealed Resident #51 lying in bed. Observation of Resident #51's recliner located adjacent to his bed revealed a sign that read No pillows, blankets, sheets on this chair. Observation revealed there were three regular pillows and one body pillow piled on top of the recliner.Interview and observation on 03/18/26 at 11:18 A.M. with Licensed Practical Nurse (LPN) #835 revealed Resident #51 was confused at times, required some assistance from staff with ADL and always tried to climb out of bed. LPN #835 revealed Resident #51's bed should be in the lowest position, and his body pillow should be placed in the bed and tucked under the sheet around the perimeter to stop him from falling out of the bed. LPN #835 revealed the body pillow was a preference of Resident #51's spouse, and it helped him not fall out of bed because he liked to roll back and forth while in bed. LPN #835 revealed the signs posted in Resident #51's room were reminders for staff to implement Resident #51's spouse preferences. LPN #835 was observed stating she doesn't want these pillows here, but we put them there to keep out of the way. LPN #835 confirmed and verified Resident #51's spouse preferences were not honored to decrease the risk of falls.Interview on 03/19/26 at 8:38 A.M with Resident #51's spouse revealed the facility rarely honored her preferences when it came to Resident #51's care. Resident #51's spouse revealed Resident #51 had a history of falls and the body pillow helped eliminate the risk.Interview on 03/19/26 at 3:22 P.M. with the Administrator and Director of Nursing (DON) confirmed and verified they were aware of Resident #51's spouse preference for the body pillow to decrease the risk of falls and have replaced it in the past.

Based on observations, resident record review, resident and staff interviews, the facility failed to ensure Resident #95, who was dependent on staff for care, was assisted with activities of daily living (ADL). This affected one resident (#95) of one reviewed for ADL. The facility census was 92.Findings include:Review of the medical record for Resident #95 revealed he was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, acquired absence of the right leg above the knee, type 2 diabetes, dysphagia oral phase and oropharyngeal phase and need for assistance with personal care.Review of the physician orders dated 08/05/25 revealed an order for fall prevention per protocol.Review of the physician orders dated 09/22/25 revealed an order for a no added sugar and no concentrated sweets diet, mechanical soft texture and regular and/or thin consistency.Review of the nutritional risk assessment dated [DATE] revealed Resident #95 remained malnourished.Review of the care plan dated 02/08/26 revealed Resident #95 was at risk for falls and had decreased ability to perform ADL, had a history of dehydration, and was at nutrition and/or hydration risk due to diagnosis of severe protein calorie malnutrition with interventions that included keeping the call light within reach, nutritional support as appropriate, and providing feeding assistance as needed.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #95 had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. Review of the MDS assessment revealed Resident #95 had impairment on one side of lower extremity and was dependent on staff for ADL.Observation and interview on 03/18/26 at 10:33 A.M. revealed Resident #95 lying in bed screaming for help. Resident #95 revealed he needed help to be repositioned in bed and needed help with eating his breakfast meal and a drink of water. Resident #95 was observed to be slouched down beneath his over the bed table with his breakfast tray untouched. Resident #95's breakfast tray consisted of bacon, eggs, a bowl of unknown white substance, a cup of coffee and a glass of water. Resident #95's call light was not visible or within reach.Interview and observation on 03/18/26 at 10:40 A.M. with Rehabilitation Therapist (RT) #970 revealed he was familiar with Resident #95, and he required some assistance from staff. RT #970 was observed repositioning Resident #95 in bed and proceeded to grab Resident #95's glass of water and provided a drink. RT #970 verified Resident #95's need for assistance and above findings at the time of the interview.Interview and observation on 03/18/26 at 10:42 A.M. with Certified Nurse Assistant (CNA) #868 outside of Resident #95's room, revealed he was aware of Resident #95's care needs and him yelling out for help. CNA #868 was observed walking away from Resident #95's room without entering and stated He doesn't need any help. He just having a bad day. CNA #868 verified, despite Resident #95's yelling out for help, he did not need any assistance, and he was not going into the room. CNA #868 was then observed walking away.Interview on 03/19/26 at 9:59 A.M. with Registered Dietician (RD) #858 revealed Resident #95 was at high risk for malnutrition, had wounds, required some assistance and had a poor appetite. RD #858 revealed Resident #95 required set-up assistance with prompting and reminders during his meals. RD #858 revealed Resident #95 also required the need for high calorie supplements due to his intake amounts and was monitored for changes in his condition. RD #858 verified the above finding at the time of the interview.

Based on resident record review, resident and staff interviews, and facility policy review, the facility failed to ensure weight loss prevention interventions were completed as ordered. This affected two residents (#11 and #65) of two residents reviewed for nutrition. The facility census was 92.Findings include:1. Review of the medical record for Resident #11 revealed she was admitted to the facility on [DATE] with diagnoses that included moderate protein-calorie malnutrition, paraplegia, and dysphagia oropharyngeal phase.Review of the physician orders dated 09/26/25 revealed an order for a regular diet, regular texture and regular consistency with a Greek yogurt daily at breakfast.Review of the physician orders dated 01/25/26 revealed an order to weigh Resident #11 every Sunday.Review of the care plan dated 02/14/26 revealed Resident #11 had potential fluid deficit related to sepsis and had a nutrition and/or hydration risk due to moderate protein calorie malnutrition with interventions that included monitoring vital signs as ordered per protocol and recording and monitoring weights.Review of the physician orders dated 02/14/26 revealed an order for Ensure Plus (nutritional supplement) two times a day and Pro-Stat (protein supplement)30 milliliters (ml) two times a day.Review of the nutritional risk assessment dated [DATE] revealed Resident #11 was at high risk and had a weight loss of 7% in less than 30 days. Review of the assessment revealed interventions were in place for Resident #11 to not have further weight loss.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Review of the MDS assessment revealed Resident #11 required some assistance from staff for activities of daily living (ADL), had complaints of difficulty or pain when swallowing, and had a loss of 5% or more in the last month or loss of 10% or more in last six months.Review of the progress note dated 03/14/26 at 11:20 A.M. revealed Resident #11 had a weight change note warning that indicated she had a significant weight loss. Resident #11 revealed she didn't have much interest in food. Review of the progress note revealed Resident #11 will be continuously monitored.Interview on 03/18/26 at 8:40 A.M. with Resident #11 revealed she had a weight loss that was not on purpose, and she had been trying to eat her meals. Resident #11 revealed Registered Dietician (RD) #858 ordered her special drinks, but she had issues finishing her meals.Review of the weight summary revealed Resident #11 weighed 153.4 pounds (lbs.) on 02/01/26, 142.4 lbs. on 03/05/26, and 140 lbs. on 03/15/26 that indicated Resident #11 had a continuous steady weight loss.Further review of the weight summary revealed Resident #11 was not weighed on 02/08/26, 02/15/26, 02/22/26, 03/01/26 and 03/08/26 as required by the physician orders dated 01/25/26 to ensure no significant weight loss.Interview on 03/19/26 at 9:59 A.M. with RD #858 revealed Resident #11 was high-risk for nutrition due to significant weight loss, wounds, very little interest in food, depression and requiring a lot of encouraging. RD #858 revealed Resident #11 was being monitored for changes and was to be weighed according to the physician's orders. RD #858 verified the above findings at the time of the interview.2. Review of the medical record for Resident #65 revealed she was admitted to the facility on [DATE] with diagnoses of type II diabetes, dysphagia oropharyngeal phase and dementia.Review of the MDS assessment dated [DATE] revealed Resident #65 had a BIMS score of six, indicating severe cognitive impairment. Review of the MDS assessment revealed Resident #65 required supervision and/or touch assistance for eating.Review of the care plan dated 01/16/26 revealed Resident #65 was at nutrition and/or hydration risk due to suboptimal intakes with interventions that included steroids to increase appetite and monitoring dietary intake and weight.Review of the physician orders dated 01/16/26 revealed an order for no added salt, no added concentrated sweets, mechanical soft diet, soft texture and thin consistency and to weigh every Sunday. Further review of the weight summary revealed Resident #65 was not weighed on 01/25/26, 02/08/26, 02/22/26, 03/08/26, and 03/15/26 according to the physician's orders dated 01/16/26 to ensure no significant weight loss.Interview on 03/19/26 at 9:59 A.M. with RD #858 revealed residents who were high-risk for nutrition were to be monitored for changes and were to be weighed according to physician's orders. RD #858 verified the above findings at the time of the interview.Review of the facility document titled Weight Management, reviewed May 2025, revealed the facility had a policy in place that resident's weights would be monitored in an attempt to prevent unplanned significant weight changes. Review of the policy revealed residents would be weighed weekly for four weeks upon admission and monthly thereafter, if weights were stable and/or scheduled weights were required due to a decrease, increase in appetite or weight variance.

Based on observations, resident record review, resident and staff interviews, and facility policy review, the facility failed to ensure respiratory care was implemented as ordered for Resident #65. This affected one resident (#65) of one reviewed for respiratory care. The facility census was 92.Findings include:Review of the medical record for Resident #65 revealed she was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypercapnia, shortness of breath, dependence on supplemental oxygen, and chronic respiratory failure with hypercapnia.Review of the physician orders dated 01/15/26 revealed an order for 2 liters per minute (LPM) of oxygen as needed for shortness of breath and to maintain pulse oximetry over 92 percent (%) as needed and oxygen continuously via nasal cannula.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. Review of the MDS assessment revealed Resident #65 required oxygen therapy, the use of a non-invasive mechanical ventilator and/or Bilevel Positive Airway Pressure (BiPAP) machine and was dependent on staff for activities of daily living (ADL).Review of the care plan dated 01/16/26 revealed Resident #65 had decreased ability to perform ADL due to oxygen dependence and respiratory failure and had altered respiratory status and/or difficulty breathing with interventions that included supplemental oxygen use and monitoring for respiratory distress such as decreased pulse oximetry. Review of the physician orders dated 01/19/26 revealed an order to change oxygen tubing and label and date the tubing every Monday night. Observation and interview on 03/18/26 at 10:51 A.M. revealed Resident #65's spouse sitting on a rollator next to Resident #65 while she sat in a wheelchair outside of her room. Resident #65 was observed wearing a nasal cannula that was wrapped around her shoulders and attached to a portable oxygen tank positioned on the back of her wheelchair. Resident #65's nasal cannula and tubing were not dated. Resident #65's spouse appeared upset and approached surveyor with tears in his eyes and stated Can you help? Her oxygen tank is almost empty. Resident #65's spouse revealed the facility staff did not ensure her oxygen tank was always full, did not monitor her pulse oximetry to ensure she could breathe and did not keep her nasal cannula, tubing and nebulizer cleaned and sanitized. Observation of Resident #65's portable oxygen tank revealed the regulator gauge needle was near the red zone, indicating close to empty and requiring a refill. Resident #65 was observed repeatedly tilting her head back and opening her mouth and stated, I think I'm okay.Observation on 03/18/26 at 10:53 A.M. of Resident #65's oxygen equipment located in her room revealed her BiPAP machine tubing, oxygen tubing, and a partially filled bottle of clear liquid solution were not dated.Observation and interview on 03/18/26 at 10:57 A.M. with the Director of Nursing (DON) verified Resident #65's portable oxygen tank was near the red zone indicating a need for a refill or new tank, and her oxygen equipment not dated. The DON revealed Resident #65 was closely monitored for her oxygen needs and she was going to get a replacement tank. The DON returned without an oxygen tank and reported the nurse would bring it.Observation and interview on 03/18/26 at 11:03 A.M. revealed Resident #65's spouse reach into his coat pocket and place a portable pulse oximeter on Resident #65's finger to measure her blood oxygen saturation level. Observation of the pulse oximeter revealed Resident #65 had a pulse oximetry reading of 77% indicating severe hypoxemia. Resident #65's spouse stated see! She needs help, and no one cares or does anything.Interview and observation on 03/18/26 at 11:04 A.M. revealed Licensed Practical Nurse (LPN) #825 walking past Resident #65. LPN #825 was stopped, after surveyor intervention, and revealed she monitored Resident #65 pulse oximetry levels and oxygen tank levels frequently. LPN #825 revealed Resident #65 had a new portable oxygen tank in her room that she was going to switch out after tending to another resident. LPN #825 revealed Resident #65's spouse always intervened with Resident #65's care and she was currently okay with no need for intervention. LPN #825, after surveyor intervention, checked Resident #65's pulse oximetry levels and had a returned reading of 74%. LPN #825 was then observed removing Resident #65 from the hallway and escorting her into her room to provide care. LPN #825 revealed Resident #65 had an order in place to keep her pulse oximetry levels over 92%. LPN #825 verified Resident #85's oxygen equipment was not dated; her portable oxygen tank was in the red zone and a low pulse oximetry reading indicating a need for immediate intervention.Review of the facility document titled Oxygen Therapy, revised May 2025, revealed the facility had a policy in place that after a physician order was put in place residents would be assessed and monitored.

Based on observation, staff interview, and review of policy, the facility failed to ensure food items were labeled and dated and further failed to ensure refrigerators did not contain expired items. This had the potential to affect all 87 residents who received food from the kitchen. The facility identified one Resident (#32) as receiving nothing by mouth (NPO). The facility census was 88. Findings include: 1. Observation on [DATE] from approximately 8:10 A.M. to 8:45 A.M. with Dietary Aide #223 revealed the following concerns: In the refrigerator located in the kitchen, there were two undated and unlabeled cups containing a yellow substance, one undated and unlabeled zip-lock bag containing crackers, one undated and unlabeled plate containing an unknown food substance, one undated and unlabeled cup containing an unknown liquid, and two undated and unlabeled cups with straws. Interview at the time of observation, with Dietary Aide #223, confirmed the areas of concern and stated all items in the refrigerator belonged to staff, and stated although staff were not supposed to store items in the refrigerator located in the kitchen. 2. Observation on [DATE] at 11:55 A.M., of the unit refrigerator located on the secured unit with Registered Nurse #219 revealed the following concerns: In the refrigerator, there was an undated and unlabeled lunch tote, one unlabeled and undated cup containing a brown, creamy substance, three undated and unlabeled cups containing diced peaches, eleven undated and unlabeled plastic cups which contained watermelon, one undated and unlabeled brown paper bag which contained two hard rolls and a disposable container with an unknown food item. The freezer compartment contained three undated and unlabeled disposable cups containing an unknown orange substance, and three undated and unlabeled popsicles. Signage posted on the refrigerator stated to Please label ALL food and drink items: name, content, date, and discard date. Interview at the time of observation, Registered Nurse #219 confirmed the areas of concern and reported items should be dated and labeled. Observation on [DATE] at approximately 12:10 P.M., of the refrigerator located near the dining area of the 300-hall and the 400-hall with Dietary Aide #223 revealed the following concerns: In the refrigerator, there was one brown paper bag containing chips and salsa labeled with a staff member's name and dated [DATE]th of an unknown year, one undated and unlabeled paper bag containing food items from a donut shop, two opened pop bottles which were not labeled with a name, one opened bottle of lemon juice which expired on [DATE], and one bottle of flavored water which expired on [DATE]. Signage posted on the refrigerator stated to Please label ALL food and drink items: name, content, date, and discard date. Interview at the time of observation, with Dietary Aide #223 confirmed the areas of concern and reported items should be dated and labeled. Dietary Aide #223 reported the chips and salsa, pop bottles, and flavored water likely belonged to staff. 3. Observation on [DATE] at approximately 1:15 P.M. of the refrigerator located near the dining area of the 100-hall and 200-hall with Dietary Manager #235 revealed the following concern: In the refrigerator, there was one sandwich labeled with a name and dated [DATE]. Signage posted on the refrigerator stated to Please label ALL food and drink items: name, content, date, and discard date. Interview at the time of observation, Dietary Manager #235 confirmed the areas of concern and disposed of the sandwich. Review of the policy titled Outside Food, dated [DATE], revealed food brought in from the outside would be labeled with the resident's name, content, the date it was prepared, and a discard/use-by date. In addition, all refrigeration units would have internal thermometers to monitor for safe food temperatures. Review of the policy titled Food Receiving and Storage, dated [DATE], revealed food items would be stored in a manner that complied with safe food handling practices. Food items stored in refrigerators would be labeled and dated with a use-by date. Food items kept in refrigerators located on nursing units would be labeled with a use-by date and if belonging to a resident would be labeled with the resident's name, the item, and the use-by date. Beverages would be dated when opened and discarded after 24 hours.

Based on observation, staff interview, review of facility Transmission Based Precautions (TBP) postings, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of facility policies and documents, the facility failed to ensure proper infection control practices were implemented related to residents on TBP. This affected seven residents (#10, #46, #58, #63, #98, and #349), and had the potential to affect 55 ( Resident #2, #3, #4, #6, #7, #11, #12, #14, #15, #16, #17, #19, #22, #23, #24, #25, #28, #30, #31, #32, #34, #35, #36, #38, #39, #40, #42, #43, #48, #52, #54, #59, #60, #64, #67, #68, #70, #71, #72, #74, #76, #77, #79, #83, #86, #87, #97, #99, #100, #101, #198, #347, #348, #350, and #351) additional residents residing on the 100-hall, 300-hall, and 400-hall. The facility census was 88. Findings include: 1. Review of the medical record revealed Resident #25 revealed an admitted [DATE]. Diagnoses included encounter for palliative care, asthma, hyperlipidemia, peripheral vascular disease, hypertension, macular degeneration, and lymphedema. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact. The resident was dependent on assistance from staff for a majority of the activities of daily living. Review of the nursing progress notes dated 12/21/24 and timed 12:08 A.M., revealed on 12/20/24 at approximately 8:00 P.M., a nursing assistant notified the nurse that Resident #25 had red rashes to their right-lower abdomen, all the way around their right-lower back. The physician was in the building and diagnosed the resident with Zoster and the resident was placed on Zoster precautions. Review of the nursing progress notes dated 01/12/25 and timed 9:53 A.M., revealed Resident #25 was having nausea, emesis, and diarrhea. The resident was on precautions due to nausea, vomiting, and diarrhea. Review of Resident #25's current physician orders identified an order dated 12/20/24 for Zoster precautions, an order dated 01/12/25 for contact precautions due to loose stools and vomiting, and an order dated 01/12/25 for a stool sample to check for norovirus. Review of the plan of care dated 12/22/24 revealed Resident #25 had an active shingles infection. Interventions included covering the rash, following Zoster precautions, and washing hands often for at least 20 seconds before and after care, toileting and all tasks. Observation on 01/13/25 at 12:53 P.M., of Resident #25's room revealed signage was posted indicating the resident was on contact precautions. The signage indicated those entering must clean their hands before entering and when leaving the room. Providers and staff must also put on gloves and a gown before room entry and discard the gloves and the gown before exiting the room. Additional posted signage stated Zoster Precautions Plus Airborne and Contact Precautions. There was no signage posted specifically indicating what was required for the airborne precautions. Observation on 01/13/25 at 12:54 P.M., revealed Certified Nursing Assistant (CNA) #267 entered Resident #25's room wearing a medical-surgical mask which was currently required throughout resident care areas. CNA #267 did not put on a gown, gloves, or an N-95 respirator. Interview on 01/13/25 at 12:56 P.M., with CNA #267 revealed staff were supposed to wear a gown, gloves and a N-95 respirator when entering Resident #25's room. Interview on 01/13/25 at 1:04 P.M., with Registered Nurse #217 revealed Resident #25 was on precautions shingles and for a gastrointestinal illness that was going around. Registered Nurse #217 was unsure of whether staff were required to wear an N-95 respirator into the room. Observation on 01/13/25 between 1:10 P.M. and 1:55 P.M., revealed CNA #267 entered Resident #25's room to retrieve a meal tray and placed it on a cart located in the hallway. CNA #267 was not wearing a gown, gloves, or N-95 respirator when entering or while in the resident's room. CNA #267 then went into the shared room of Resident #46 and #63 and retrieved Resident #46's meal tray, placing it on the cart located in the hallway. CNA #267 then went down the hallway and retrieved a mechanical lift, retrieved gloves from a cart located in the hallway, and re-entered Resident #25's room. CNA #267 was not wearing a gown, gloves, or respirator when entering Resident #25's room for the third time. CNA #267 also did not wash or sanitize their hands between going into Resident #25's room and retrieving the meal tray, going into the shared room of Resident #46 and #63, retrieving the mechanical lift, or going back into Resident #25's room. Interview on 01/13/25 at 1:57 P.M., with CNA #267 verified the staff member was not wearing a gown, gloves, or an N-95 respirator when entering Resident #25's room. CNA #267 reported they thought they only needed to don personal protective equipment and practice precautions when providing direct care, not when retrieving meal trays. Review of the facility signage provided for residents who were on airborne precautions revealed those entering resident rooms were to put on a fit-tested N-95 or higher level respirator before room entry. Review of the undated facility document titled Contact Precautions, revealed contact precautions were intended to prevent transmission of infectious agents which were spread by direct or indirect contact with the resident or resident environment. The document further stated organisms could be spread by contact with the person or contaminated surfaces. 35033 2. Review of the medical record for Resident #10 revealed an admitted [DATE]. diagnosed included end stage renal disease, type two diabetes mellitus, dementia, atrial fibrillation, and hypertension. Review of a physician order dated 01/11/25 revealed Resident #10 was ordered droplet precautions after testing positive for COVID-19. Review of the medical record for Resident #349 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, hypertension, atrial fibrillation, and chronic kidney disease. Review of a physician order dated 01/09/25 revealed Resident #349 was ordered droplet precautions after testing positive for COVID-19. Review of the medical record for Resident #98 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus and hypertension. Review of a physician order dated 01/15/25 revealed Resident #98 was ordered droplet precautions after testing positive for COVID-19 on 01/14/25. Observation on 01/14/25 beginning at 8:17 A.M., during medication administration revealed Licensed Practical Nurse (LPN) #205 wore personal protective equipment (PPE) including a N 95 respirator into Resident #10's room to check the resident's blood sugar. Resident #10 was on droplet precautions for COVID-19. Before applying the N 95 respirator, LPN #205 lowered her surgical mask below her chin, where it remained. Upon exiting the room LPN #205 walked to the medication cart in the 300 hallway and removed the N 95 respirator and placed the contaminated mask on top of the medication cart then pulled up the contaminated surgical mask from below her chin to cover her face. LPN #205 then prepared Resident #10's medications. LPN #205 once again lowered the surgical mask below her chin then picked up the contaminated N 95 respirator and put it back on. LPN #205 then donned PPE before entering the room and administered the resident's medications. LPN #205 removed the PPE except the contaminated surgical mask and contaminated N 95 respirator and returned to the medication cart. LPN #205 removed the contaminated N 95 and placed in her pocket. Observation on 01/14/25 beginning at 8:36 A.M., revealed LPN #205 applied PPE to check Resident #349's blood sugar. Resident #349 was on droplet precautions for COVID-19. LPN #205 removed the contaminated N 95 from her pocket and placed the contaminated N 95 mask over the contaminated surgical mask that had been previously worn in Resident #10's room. LPN #205 checked the resident's blood sugar, removed the PPE except the surgical mask and N 95 and returned to the medication cart in the hallway. LPN #205 removed the contaminated N 95 and placed in her pocket. LPN #205 prepared Resident #349's medications. LPN #205 then applied PPE, lowered the contaminated surgical mask below her chin, reapplied the contaminated N 95 respirator and administered medications to Resident #349. LPN #205 removed the PPE before exiting the room except for the contaminated N 95 and surgical masks and returned to the medication cart in the 300 hallway. Observation on 01/14/25 beginning at 8:45 A.M., revealed LPN #205 continued to wear the contaminated masks with the surgical mask below her chin and the N 95 respirator covering her face. LPN #205 prepared medications for Resident #98. Further observation on 01/14/25 at 8:50 A.M., revealed LPN #205 administered medications to Resident #98 while wearing both contaminated masks then returned to the medication cart in the 300 hallway. At the time of the medication administration Resident #98 was not positive for COVID-19 and was not on droplet precautions. Interview on 01/14/25 at 9:14 A.M., with LPN #205 verified not discarding the contaminated masks when removing the PPE. LPN #205 verified wearing the contaminated surgical mask and N 95 respirator in the hallway after administering medication to Resident #10 and continuing to wear the contaminated masks into the rooms of Resident #349 and Resident #98. Review of the undated policy titled, How to Safely Remove Personal Protective Equipment, revealed to remove all PPE before exiting the resident room except the respirator. Remove the respirator and discard after leaving the resident room. 3. Review of the medical record for Resident #58 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease, and hypertension. Review of a physician order dated 01/14/25 revealed Resident #58 tested positive for COVID-19 and was placed on droplet precautions. Observation on 01/15/25 beginning at 11:50 A.M., revealed a sign on the resident's door indicated the resident was on enhanced droplet precautions and to apply PPE including a N 95 respirator, protective eyewear, gown, and gloves before entering the room. Further observation revealed Certified Nursing Assistant (CNA) #317 was wearing a surgical mask. CNA #317 applied PPE but had not applied a N 95 respirator mask and entered Resident #58's room. Further observation revealed CNA #317 exited the resident's room on the 100 hallway without removing the contaminated PPE. Interview on 01/15/25 at 11:53 A.M., with CNA #317 verified not wearing a N 95 respirator into the room and not removing her PPE before exiting the room. CNA #317 stated I forgot. Review of the undated policy titled, How to Safely Remove Personal Protective Equipment, revealed to remove all PPE before exiting the resident room except the respirator. Remove the respirator and discard after leaving the resident room. Review of the Centers for Disease Control and Prevention Infection Control Guidance SARS CoV-2 dated 06/24/24 revealed in healthcare setting including nursing homes indicated a NIOSH Approved particulate respirator with N 95 filters or higher during the care of a patient with SARS-CoV2 infection and should be removed and discarded after the patient care encounter.

Based on review of the medical record, resident representative interview, staff interview, and policy review, the facility failed to ensure a resident's representative was provided notification of the resident's change in condition. This affected one (#23) of one resident reviewed for notification of change in condition. The facility census was 88. Finding include: Review of the medical record revealed Resident #23 had an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis, aphasia, obstructive and reflux uropathy, benign prostatic hyperplasia, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired. The resident had an indwelling catheter. Review of a nurses progress note dated 01/04/25 at 12:33 A.M., revealed the resident had new physician orders for the antibiotic gentamicin 160 milligrams intramuscular three times a day for seven days for a urinary tract infection. The resident was also ordered laboratory (labs) testing including a complete blood count and basic metabolic panel on 01/06/25. Interview on 01/13/25 at 10:08 A.M., with Resident #23's guardian revealed the facility was not consistently providing updates regarding changes and concerns with the resident's care. Interview on 01/14/25 at 2:12 P.M., with Registered Nurse (RN) #218 revealed she had not notified the resident's representative of the new orders for antibiotics and labs. RN #218 revealed it was too late to call and passed the information onto the day shift nurse to notify the resident's representative. Interview on 01/14/25 at 2:18 P.M., with RN #215 revealed RN #218 had let her know to notify the resident's representative of the new orders. RN #215 thought she notified the family but looked in the progress notes and verified there was no documentation of the notification. Review of the policy titled, Change of Condition Notification, revised March 2024, revealed the facility would notify the resident's responsible party of significant changes in the resident's status and when there was a need to alter the resident's treatment significantly. Nurses would record the notification in the resident's medical record.

Based on record review and staff interview, the facility failed to ensure Notice of Medicare Non Coverage (NOMNC) notification was provided in writing to the resident or family member prior to services ending. This affected two (#198 and #199) of three reviewed for notices. The facility census was 88. Findings include: Review of the medical record revealed Former Resident #198 received Medicare Part A skilled services with an episode start date of 07/24/24 and a last date of coverage of Part A Service being 09/23/24. Review of the undated and untimed NOMNC revealed a telephonic notification was communicated to the family. There was no evidence of the written NOMNC being sent to the resident or family regarding the discharge date of [DATE]. Review of the medical record revealed Former Resident #199 received Medicare Part A skilled services with an episode start date of 09/13/24 and a last date of coverage of Part A Service being 10/29/24. Review of the NOMNC revealed a telephonic notification was communicated on 10/26/24 to family. There was no evidence of the written NOMNC being sent to the resident or family regarding the discharge date of [DATE]. Interview on 01/15/25 at 11:54 A.M., with the Administrator revealed that the previous social worker was recently terminated and is unable to locate the signed NOMNC. The Administrator then offered to give a signed statement of NOMNC notification.

Based on observation, staff interview, family interview, resident interview, and medical record review, the facility failed to ensure alternative methods of communication were provided to facilitate adequate communication for a resident who spoke limited English. This affected one (#349) of one resident reviewed for alternate methods of communication. The facility census was 88. Findings include: Review of the medical record revealed Resident #349 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, chronic kidney disease, hypertension, muscle weakness, and difficulty in walking. Review of the admission Minimum Data Set assessment dated [DATE] revealed a brief interview for mental status was not completed due to Resident #349 being rarely or never understood. Resident #349's primary language was Serbian and the resident needed/wanted an interpreter to communicate with a doctor or health care staff. Review of the current plan of care dated 10/31/24 revealed Resident #349 had an interpretation need, spoke Serbian, and was able to navigate and communicate through a translation application and/or a family interpreter. Interventions included the resident having translation needs (interpreter), and the resident's preferred language being Serbian. Review of the current plan of care dated 11/04/24 revealed Resident #349 had a psychosocial well-being problem related to family discord, a language barrier, and recent admission. Interventions included allowing the resident time to answer questions and to verbalize feelings through an interpreter or a translation application. Review of the nursing progress notes dated 10/30/24 and timed 9:38 A.M. revealed Resident #349 did well following directions in therapy when using a language translating device. Review of the nursing progress notes dated 11/09/24 and timed 10:02 P.M. revealed Resident #349 was difficult to understand due to a language barrier. Review of the nursing progress notes dated 11/18/24 and timed 3:31 A.M. revealed Resident #349 engaged in conversation, which was limited due to a language barrier. Review of the nursing progress notes dated 12/30/24 and timed 10:37 P.M. revealed Resident #349 was very chatty and speaking excessively to staff in her native language. Review of the nursing progress notes dated 01/10/25 and timed 5:11 A.M. revealed Resident #349 was yelling at staff in her foreign language. Observation on 01/15/25 at 8:45 A.M. revealed Certified Nursing Assistant (CNA) #320 exited Resident #349's room and stated to an unidentified staff member that Resident #349 was trying to say something but did not speak any English, only Spanish. CNA #320 then asked the nurse on duty if they spoke Spanish. The nurse stated they did not and asked if the resident's family was present. CNA #320 reported the family was not present and resumed caring for other residents. As of 9:14 A.M., no staff members entered the room of Resident #349 in effort to determine what they were previously attempting to communicate. CNA #320 then proceeded to give report and stated they would return later in the day. Interview on 01/15/25 at 9:22 A.M. with CNA #320 revealed Resident #349 spoke very little English. CNA #320 reported the resident would use non-verbal communication, knew a few words in English, and sometimes had someone visiting who could translate. CNA #320 reported no knowledge of an interpreter being available outside of that, or any communication devices or applications. Interview on 01/15/25 at 11:03 A.M. with Resident #349's family member revealed the family member visited the facility regularly. The family member reported facility staff tried their best to understand and communicate with Resident #349 were not really able to. The family member was unaware of any communication devices or an accessible interpreter, aside from family. The family member reported an unknown nurse recently reported attempting to use a translation application but that it did not work for the resident. Observation on 01/16/25 at approximately 8:22 A.M. revealed Resident #349 was sitting up in their room. There was no signage regarding how the resident communicated or any communication device/information observed. There were two signs hanging on the wall near the head of the resident's bed which were printed in English. One of the signs stated to please call the nurse if having pain, and the other stated your telephone number is, followed by a telephone number. An interview, at the time of observation, revealed Resident #349 spoke limited English and was unable to fully answer questions.

Based on review of the medical record, observation, staff interviews, and policy review, the facility failed to a pressure ulcer was assessed according to policy, physician ordered dressing was applied, and interventions were implemented to promote wound healing. This affected one (#30) of one resident reviewed for pressure ulcers. The facility identified five residents with pressure ulcers. The facility census was 88. Findings include: Review of the medical record revealed Resident #30 had an admitted [DATE] and a readmitted [DATE]. Diagnoses included cerebral edema, malignant neoplasm of the bronchus, secondary malignant neoplasm of the brain, type two diabetes mellitus, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for bed mobility. The resident was identified with one stage three pressure ulcer. The resident was identified as risk for pressure ulcers. Review of the care plan revised on 04/24/24 reviewed the resident was at risk for skin breakdown due to decreased mobility, weakness and incontinence. Interventions included to frequent repositioning, float heels or utilize heel protector boots while in bed, low air loss mattress and pressure reduction cushion to wheelchair. Review of a skin assessment dated [DATE] revealed the resident had an open area to the right heel measuring 1.2 centimeters (cm) in length, 1.2 cm in width, with a depth of 0.3 cm. The wound was described as circular, with pink edges, pink moist wound bed with scant clear watery drainage. The wound was not classified or staged. A treatment was initiated and administered per physician orders. The resident was discharged from the facility on 10/17/24 and returned on 10/24/24. Review of a readmission skin assessment dated [DATE] at 3:06 P.M., revealed the resident had an open area to the right heel measuring 1.1 cm in length by 1.3 cm in width by 0.2 cm in depth. The type of wound was not documented and there was no assessment of the wound bed. Review of the physician orders dated 10/24/24 revealed the resident had orders for frequent turning and repositioning and a pressure reduction mattress. A wound treatment was ordered and documented as completed per physician orders. Review of skin observation note dated 10/28/24 revealed the resident had a vascular wound to the right heel measuring 1.1 cm in length by 1 cm in width by 0.2 cm in depth. There was no description of the wound bed. Review of a wound nurse practitioner (NP) progress note dated 10/31/24 at 10:00 A.M. revealed the resident had a stage three pressure ulcer to the right heel. The wound was shallow full thickness comprised primarily of 90 percent red, moist tissue with 10 percent yellow slough noted to the dermal layer. The surrounding skin was dry intact with edema and medium serosanguinous drainage. There was no sign of infection. The wound measured 1.7 cm in length by 0.9 cm in width by 0.2 cm in depth. A treatment was ordered and documented as completed per physician orders. Review of the care plan initiated 11/11/24 revealed the resident had a stage three pressure ulcer to the right heel. Interventions included to administer treatments as ordered and monitor for effectiveness, assess, monitor, record wound healing, monitor nutritional status, offload pressure on bilateral heels, encourage frequent position changes, float heels while in bed with pillows or heel suspension boots, pressure reduction devices, and nutritional support as appropriate. Review of a physician order dated 01/03/25 revealed an order for Vashe wound external solution 0.033 percent apply to right heel topically one time a day every Monday, Wednesday, Friday for right heel wound. Cleanse with Vashe and gauze, pat dry. Apply dime thick medihoney and cut to fit calcium alginate. Cover heel and back of right leg/posterior calf with abdominal pad and wrap with Kerlix, change three times week and as needed. Review of wound NP note dated 01/10/25 at 4:26 P.M., revealed the stage three pressure ulcer to the right heel measured 1.3 cm in length by 1 cm in width by 0.2 cm in depth. The wound was 50% red and 50% scattered thin slough with moderate serosanguinous drainage. The NP noted the residents heel boots were not in place and the resident was agreeable to wearing. Review of the medication administration records (MAR) and treatment administration records (TAR) from 12/01/24 through 01/15/25 revealed wound treatments and pressure reducing interventions were documented as completed per physician orders. Observation on 01/13/25 at 11:00 A.M. revealed Resident #30 was in bed. The resident's feet were lying flat on the bed and not elevated. The resident was not wearing heel boots. The boots were in the room. Interview on 01/13/25 at 11:00 A.M., with Certified Nursing Assistant (CNA) #301 verified the resident's feet were not elevated off the bed and the resident was not wearing the heel boots. CNA #301 was unsure when the resident needed to wear the heel boots. Further interview with CNA #301 revealed she found out the resident should be wearing the heel boots when she was in bed. Review of the nurses notes for 01/12/25 and 01/13/25 revealed no documentation the resident had refused to wear the heel boots or elevate her heels. Interview on 01/13/25 at 10:36 A.M., with the Director of Nursing (DON) revealed the nurses were instructed to not stage pressure ulcers as they do not stage correctly. The DON stated she would have to check what the facility policy was regarding staging and assessing wounds. Review of a physician order dated 01/14/25 revealed the resident was admitted to hospice with end stage diagnoses of malignant neoplasm of unspecified lung. No further labs or therapy. Observation on 01/15/25 at 11:27 A.M., of wound care with LPN #222 and RN #218 revealed there was no wound dressing on the right heel. The resident had a circular wound on the bottom of the heel with 80 percent granulation tissue and 20 percent slough. There was no drainage or odor. The surrounding skin was intact and dry. LPN #222 measured the wound. The wound measured 2.2 cm in length by 1.6 cm in width by 0.1 cm in depth. The wound treatment was completed per physician orders. Interview on 01/15/25 at 11:27 A.M., with LPN #222 verified the nursing assistants had not notified her the dressing was off of the resident's right heel. Interview on 01/15/25 at 1:15 P.M., with Certified Nurse Assistant (CNA) #294 revealed removing the resident's heel boots this morning to clean the resident. CNA #294 revealed when she removed the heel boots there was no wound dressing in place to the right heel. CNA #294 revealed she found the wound dressing on the floor. CNA #294 revealed she had not notified the nurse the wound dressing was not in place. Review of the policy titled, Prevention and Treatment of Pressure Ulcers and Other Skin Conditions, revised March 2024, revealed nurses would complete as assessment of wound characteristics including location, type of skin condition, length, width, depth, stage as defined by NPUAP guidelines, drainage, necrotic tissue, evidence of granulation and color of wound tissue and pain in wound or with treatment. Further review of the policy revealed staff would ensure a reduction in tissue load and would float heels off surfaces if indicated. Additionally, the dietician would complete a nutritional assessment on admission, quarterly, and as needed. The dietician would document interventions as appropriate including nutritional supplement in orders and in care plan as needed.

Based on observation, staff interviews, and record review, the facility failed to ensure fall interventions were implemented to prevent resident at risk from falls. This affected two (#28 and #38) of two residents reviewed for falls. The facility census was 88. Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including: acute respiratory failure with hypoxia, asthma, Type II diabetes mellitus, chronic combined systolic and diastolic heart failure, hypoglycemia, cellulitis of part of limb, hypertensive heart and chronic kidney disease with heart failure, hypothyroidism, hyperlipidemia, benign prostatic hyperplasia, sick sinus syndrome, personal history of transient ischemic attack and cerebral infarction, anxiety disorder, glaucoma, atrial fibrillation, chronic kidney disease stage 3, heart failure, atherosclerotic heart disease, presence of cardiac pacemaker. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/14/24, revealed the resident had intact cognition. The resident required moderate staff assistance for bed mobility, supervision/touching assist with upper body dressing, and substantial maximum assist with toileting hygiene, shower and or bathing, and lower body dressing. The assessment indicated the resident was frequently incontinent of bowel and bladder. Review of the fall risk assessment completed 01/08/25 revealed the resident was at high risk for falls. Review of progress note dated 01/08/25 at 8:39 P.M., revealed at 2:45 A.M., Resident #28 stated he was attempting to get up out of bed and transfer to wheelchair in order to use the restroom. Resident #28 attempted to utilize the call light but at the time could not locate it and needed to go. During the attempt to transfer, Resident #28 started to slide and slid down the side of the bed to the floor where he then started to holler for help and the nurse aid came to assist. Nurse assessed for injuries, per nurse no injuries noted. Range of Motion (ROM) intact to all extremities. Review of the revised plan of care, dated 01/09/25, revealed Resident #28 is at risk for falls/behaviors related to impulsivity, impaired cognition and diagnosis of hypotension . Interventions included appropriate fitting clothing, appropriate fitting footwear, call light attached to clothing, call light in reach, call light is to be clipped to resident when resident is in bed, do not leave wheel chair alongside bed when resident is in bed, fall matt alongside bed when resident is in bed, extra lighting, glasses, hearing aides, or other sensory items in place/reach, instruct on use of call light, keep items in reach, night light, noise and stimulation reduction, recliner chair. Observation on 01/13/25 at 9:47 A.M., revealed Resident #28 was sleeping in bed. There was no fall mat observed alongside the bed and the wheelchair was located next to exit of bed. Observation on 01/13/25 at 12:13 P.M., revealed Resident #28 was awake lying in bed. There was no fall mat observed alongside of bed and the wheelchair was located next to exit of bed. Interview on 01/13/25 at 4:41 P.M., with Registered Nurse (RN) #217 verified Resident #28 had orders from 12/07/24, for do not leave wheelchair alongside bed when resident is in bed every day and night shift; and a fall mat alongside bed when resident is in bed every day and night shift. RN#217 and verified the measures were not in place at this time. Observation on 01/14/25 at 3:40 P.M., revealed Resident #28 was lying in bed, wheelchair at foot of bed and fall mat was folded in corner behind the nightstand. Interview on 01/14/25 at 3:51 P.M., with Certified Nurse Aide (CNA) #264 confirmed the fall mat was folder up behind the night stand and the wheel chair was beside the bed. Observation on 01/15/25 at 12:30 P.M., revealed Resident #28 was lying asleep in bed, the wheelchair was next to bed, and the fall mat was folded in corner behind nightstand. Interview on 01/15/25 at 12:33 P.M., with CNA #264 confirmed the fall the fall mat was folder up behind the night stand and the wheel chair was beside the bed. 44454 2. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, muscle weakness, dysphagia, anxiety, depression, and hypertension. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #38 was cognitively intact. The resident was dependent on staff assistance for a majority of the activities of daily living. Review of the plan of care dated 04/04/24 revealed Resident #38 was at high risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, and psychoactive drug use. Interventions included a body pillow while in bed. Review of Resident #38's physician orders identified an active order dated 04/26/24 for body pillow while in bed every day and night shift for fall intervention. Observation on 01/13/25 at 12:02 P.M., revealed Resident #38 was lying in bed on their back. There was no body pillow observed next to the resident or in or near the bed. A body pillow was observed folded and in a chair in the room. Interview on 01/13/25 at 12:06 P.M., with Certified Nursing Assistant #299 verified the body pillow was supposed to be in place and was not.

Based on review of the medical record, observation, staff interview, resident interview, and policy review, the facility failed to ensure recommended nutritional interventions were implemented for significant weight loss. This affected one (#30) of seven residents reviewed for nutrition. The facility census was 88. Findings include Review of the medical record revealed Resident #30 had an admitted [DATE] and a readmitted [DATE]. Diagnoses included cerebral edema, malignant neoplasm of the bronchus, secondary malignant neoplasm of the brain, type two diabetes mellitus, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for bed mobility. The resident was identified with one stage three pressure ulcer and had unplanned significant weight loss. Review of the nutritional care plan revised 12/05/24 revealed the resident was at risk with clinically significant weight loss. Interventions included to provide supplements and protein modules per dietician recommendations. Review of a nutritional assessment dated [DATE] at 9:22 A.M., revealed the resident had a ten percent weight loss in the past 30 days and 13% in the last 90 days. The resident had a regular diet with an average intake of 50 percent to 75 percent. The dietician noted the resident had increased nutritional needs due to skin concerns and was at risk clinically for significant weight loss. The dietician recommended Glucerna (nutritional supplement) daily to help meet needs and liqucel (protein supplement) 30 milliliters (ml) twice daily to promote skin healing. Care plan updated and will monitor. Further review of the medical record revealed no documentation the resident had refused the recommendation for nutritional and protein supplementation. Review of the physician orders for December 2024 and January 2025 revealed no orders for the Glucerna or liqucel. Review of the weight documentation on 07/01/24 the resident weighed 271 pounds. On 01/02/25 the resident weighed 224 pounds. A 17 percent weight loss. Review of the medication administration records (MAR) and treatment administration records (TAR) from 12/01/24 through 01/15/25 revealed no documentation the resident had received the recommended nutritional interventions. Review of a physician order dated 01/14/25 revealed the resident was admitted to hospice with end stage diagnoses of malignant neoplasm of unspecified lung. No further labs or therapy. Interview on 01/16/25 at 9:14 A.M., with Registered Nurse (RN) #225 verified the recommendation for liqucel and Glucerna. RN #225 verified orders for the supplements were never entered into the electronic health record. RN #225 revealed the dietician usually would put the orders in. RN #225 revealed she was unable to see where any nutritional interventions were implemented for the resident's significant weight loss. RN #225 revealed the dietician and physician were notified when the resident had significant weight loss. Interview on 01/16/25 at 10:06 A.M., with Resident #30 revealed she weighed too much and was okay with some weight loss. Resident #30 revealed had not been receiving any nutritional supplements and would take them to help with her wound. Interview on 01/16/25 at 10:43 A.M., with Registered Dietician (RD) #600 revealed she had recommended nutritional and protein supplements for Resident #30. RD #600 revealed the resident had significant weight loss and wounds. RD #600 revealed interventions were put in place for residents with significant weight loss. RD #600 revealed she was responsible to enter orders for nutritional supplements. RD #600 was not sure why the orders were not entered. RD #600 revealed if the resident would have refused the recommendation, then she would have documented the refusal. Observation on 01/16/25 at approximately 10:50 A.M. with RN #225 revealed two nursing assistants obtained the resident's weight in the mechanical lift. The resident weighed 206 pounds, a 23 percent weight loss from 07/01/24. Interview on 01/16/25 at 1:11 P.M., the Director of Nursing (DON) revealed the dietician was responsible for entering physician orders for nutritional recommendations. Review of the policy titled, Weight Management, revised 03/2024, revealed resident weights would be monitored and interventions initiated in an attempt to prevent unplanned significant weight changes. The facility would encourage residents to follow outlined procedures as they have the right to refuse.

Based on medical record review, policy review, and staff interview, the facility failed to ensure residents on dialysis were assessed and monitored routinely and according to policy. This affected one (#10) of one resident reviewed for dialysis. The facility census was 88. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE] and diagnoses including end stage renal disease, dependence on renal dialysis, breakdown of surgically created arteriovenous shunt, diabetes mellitus, dementia, and renal osteodystrophy. Review of physician's order dated 11/01/24 revealed Resident #10 had dialysis on Tuesdays, Thursdays, and Saturdays. Review of physician's order dated 01/13/25 revealed to monitor fistula site for bruit and thrill, signs and symptoms of infection, and placement daily. Resident #10 was to be monitored upon return from dialysis with blood pressure, signs and symptoms of bleeding, and adverse reaction to treatment. Review of Care Plan updated 01/13/25 revealed Resident #10 was on dialysis with interventions including to monitor fistula site daily, nursing to perform assessment upon return from dialysis including blood pressure, bleeding, adverse reactions and response to treatments, monitor vital signs, and monitor for signs of infection to access site. Review of the electronic medical record and physical paper chart revealed there was no evidence of ongoing assessment or monitoring of Resident #10's dialysis site or condition following treatments from 11/01/24 to 01/13/25. Interview on 01/15/25 at 10:25 A.M. with Director of Nursing (DON) confirmed there was no documented evidence of ongoing assessment or monitoring of Resident #10's dialysis site completed by the facility. DON confirmed the orders for fistula monitoring and return assessments were added on 01/13/25. Review of the policy titled Residents receiving Dialysis Outside of the Facility - Communication and Transportation dated February 2024 revealed the facility would monitor fistula sites daily for signs and symptoms of infection and significant changes in functioning. Qualified staff would perform an assessment upon the resident's return from dialysis treatments including dialysis center weights, any adverse reactions to treatment, blood pressure, and signs and symptoms of bleeding.

Based on observation, staff interview, record review, and review of policy, the facility failed to ensure a resident on was provided the appropriate meal consistency per physician orders. This affected one (#3) of 10 residents reviewed for food and nutrition. The facility census was 88. Findings include: Review of the medical record revealed Resident #3 was initially admitted to the facility on [DATE]. The resident went out to the hospital on 01/10/25 and returned to the facility on [DATE]. Review of the Medicare five-day Minimum Data Set assessment dated [DATE] revealed Resident #3 was cognitively impaired and required assistance from staff for a majority of the activities of daily living. Review of the nursing progress notes dated 01/14/25 and timed 6:17 P.M., revealed Resident #3 returned from the hospital. The dietitian at the hospital indicated a pureed diet was appropriate, however the resident would be pleasure feeds. Review of Resident #3's current physician orders identified an order dated 01/14/25 for a pureed diet with pureed texture. The order was revised on 01/15/25 to state that the resident may have pleasure foods outside of orders per their request. Observation on 01/15/25 at approximately 12:50 P.M., revealed Activities Staff Member #342 delivered a meal tray containing chicken [NAME], pasta fagioli soup, rice pilaf, green beans, and mandarin oranges, all of which were regular texture, to Resident #3's room. Resident #3's daughter was present and in the room and informed Activities Staff Member #342 the resident was now on a pureed diet. Activities Staff Member #342 took the tray back to the cart containing meal trays and asked another staff member how to let the kitchen know Resident #3's diet had changed, as they were now on a pureed diet. Review of the meal ticket on the meal tray revealed Resident #3 was listed as being on a regular diet. Interview immediately following the observation with Activities Staff Member #342 verified Resident #3 had received a meal tray containing food items of a regular texture and that the resident was now supposed to receive a pureed diet. Interview on 01/15/25 at approximately 1:15 P.M., with Dietary Manager #235 was informed Resident #3 had a diet order for pureed texture and had received a meal tray containing food items of regular texture for the lunch meal. Dietary Manager #235 reported the resident had recently returned from the hospital and had previously been receiving a diet of regular texture. Review of the undated policy titled Resident Centered Dining, revealed diet spreads and allergy reports would be utilized during meal service to ensure accuracy and resident safety.

Based on medical record review, family and staff interview, review of the facility ' s policy and record review and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to have interventions in place to prevent the development of pressure ulcers for Resident #5 who was assessed to be at risk for developing pressure ulcers. This resulted in Actual Harm when Resident #5 developed facility acquired deep tissue injuries (pressure-related subcutaneous tissues under intact skin with the appearance of a deep purple bruise) to both his right and left heels. This affected one (#5) of three residents reviewed for pressure ulcers. The facility identified four residents with in-house acquired pressure ulcers. The facility census was 95. Finding include: Review of the closed medical record for Resident #5 revealed he was re-admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Review of the Braden scale assessment (an assessment that predicts the risk of developing pressure ulcers or injuries), dated 10/29/19, revealed he was at risk for pressure ulcers due to his sensory perception was slightly limited, he was occasionally moist, he was chairfast, his mobility was very limited, and he had a potential problem for friction and shearing. Review of the admission form titled, Skin Observation- V2, dated 10/29/19, revealed the resident did not have any pressure ulcers or deep tissue injuries noted to his right or left heels on re-admission Review of the care plan, dated 10/30/19, revealed the resident had activities of daily living self-care deficit due to limited mobility. Interventions included he required extensive to dependent assistance of one to two people for bed mobility and transfers. The resident also had a care plan for the potential risk and actual skin integrity impairment of the neck related to surgical wounds. Interventions included to avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, encourage good nutrition and hydration in order to promote healthier skin, monitor and document location, size and treatment of [REDACTED]. There were no interventions including pressure reducing mattress, turning or repositioning, keep heels off loaded, heel boots or any interventions regarding the prevention of pressure ulcers to his heels. Review of the physician orders, dated 10/29/19 through 11/04/19, revealed there were an order for [REDACTED]. Review of the five-day Medicare Minimum Data Set (MDS) assessment, dated 11/05/19, revealed the resident had impaired cognition. The resident had verbal aggression one to three days during the assessment period. He required extensive assist of two persons with bed mobility and transfers. He was at risk for pressure ulcers and had two deep tissue pressure ulcers during the assessment period that were not present on admission. Review of the form titled, Skin Observation- V2, dated 11/05/19, completed by Registered Nurse Unit Manager #601, revealed the resident had a pressure area to his left heel that measured in length of five centimeters (cm.) and width of six cm. The area was unstageable and suspected to be a deep tissue injury. He also had a right heel pressure area that measured in length of five cm. and a width of six cm. His right heel was unstageable and was suspected to be a deep tissue injury. Review of the nursing note, dated 11/05/19 at 1:05 P.M. per Registered Nurse Unit Manager #601, revealed Resident #5 had blisters forming to both heels that were dark purple in color. Both areas on his heels measured five cm. in length by six cm. in width. The nurse practitioner was notified and ordered skin prep to bilateral heels, pad and protect heels every day, heel boots to bilateral feet, and a wound consult. Subsequent review of the physician orders, dated 11/05/19, revealed he was ordered a wound consult for bilateral heels and heel boots to bilateral feet. On 11/14/19, an order to start Liquacel (oral supplement to promote wound healing). On 11/15/19, an order to elevate his heels on a pillow when in bed and remove boots when in bed. Review of the form titled, Wound Tracker, completed per Registered Nurse Unit Manager #601 dated 11/08/19, revealed he had a left heel pressure area that originated on 11/05/19 and measured the length of 6.5 cm., by the width of eight cm. The area was a flat blister that was dark purple and red. The area was non-blanchable and unstageable as it was suspected to be a deep tissue injury. Resident #5 had also a right heel pressure area that measured a length of 6.5 cm. and a width of nine cm. The right heel was described as a serous blister (a blister containing pale yellow body fluid), dark purple in color and non-blanchable. The right heel was unstageable as it was suspected to be a deep tissue injury. Review of the progress note per Wound Nurse Practitioner #607, dated 11/08/19, revealed Resident #5 was admitted after cervical three through cervical six laminectomy surgery. She revealed he had altered mobility. She revealed he had facility acquired deep tissue injury pressure ulcer to the left heel that measured 6.5 cm. in length and eight cm. in width. The area was a flat blister with underlying non-blanchable deep purple and red tissue. She also revealed Resident #5 had a facility acquired deep tissue pressure ulcer to his right heel that measured 6.5 cm. in length and nine cm. in width. The right heel had a serous blister with underlying non-blanchable deep purple discoloration. Interview on 01/10/20 at 9:41 [NAME]M. with Resident #5's wife revealed Resident #5 had back surgery and returned to the facility after his surgery on 10/29/19. She revealed he was not able to move his arms and legs for the first week and he did not get out of bed for several days. She revealed he developed pressure sores to his heels because the staff did not have interventions in place to prevent the sores. Interview on 01/10/20 at 12:06 P.M. with State tested Nursing Assistant (STNA) #603 revealed she looked on the computer at the care plan to see what interventions were to be used for each resident regarding interventions to prevent pressure ulcers. Interview on 01/10/20 at 2:06 P.M. with STNA #606, and #606 revealed they review the resident ' s care plan to see what interventions were to be implemented for each resident regarding their preventive measures to prevent pressure ulcers including how often they were to be turned, if they had heel boots or if their heels were to be off loaded. Interview with Registered Nurse Unit Manager #601 and the Director of Nursing (DON) on 01/10/20 at 2:55 P.M. verified Resident #5 was admitted on [DATE] following surgery to his cervical spine. They verified Resident #5 required extensive assist of two people for bed mobility and transfers. They verified on admit he did not have any pressure ulcers to his right or left heel. They verified Resident #5 was at risk for developing pressure ulcers and he only had a physician order [REDACTED]. They verified the left heel pressure ulcer was found measuring a length of five cm. and width of six cm. and his right heel pressure ulcer was found measuring a length of five cm. and width of six cm. The DON revealed the care plan on admission should have included interventions to prevent pressure ulcers to his left and right heels. Review of the facility ' s policy titled, Prevention and treatment of [REDACTED]. The facility would outline interventions to prevent and treat skin integrity problems. The facility would complete a pressure ulcer risk assessment upon admission. The pressure ulcer assessment and nursing observation would be considered in the decision to proceed with specific and individualized interventions. Preventative strategies suggested per the policy was skin and early treatment guidelines by inspecting the skin routinely, distribution of pressure, friction, and shear on the tissue that may include repositioning, pressure reducing air mattress, and pillow or foam wedge to keep boney prominences from direct contact such as heels. Review of information from the NPUAP revealed a deep tissue pressure injury is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use deep tissue pressure injury to describe vascular, traumatic, neuropathic, or dermatologic conditions. Further review of the NPUAP revealed staff should assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows and beneath medical devices, implement interventions to ensure that the heels are free from the bed and use heel offloading devices or [MEDICATION NAME] foam dressings on individuals at high-risk for heel ulcers. This deficiency substantiates Complaint Number OH 166.

Based on staff interview and record review, the facility failed to accurately care plan the resident's preventative measures for pressure ulcer development and failed to revise the resident's care plan after the resident developed pressure ulcers. This affected one (#5) of three residents reviewed for pressure ulcers. The facility identified five residents with pressure ulcers. The facility census was 95. Finding include: Review of the closed medical record for Resident #5 revealed he was re-admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Review of the physician orders, dated 10/29/19, revealed there were an order for [REDACTED].>Review of the nursing note, dated 11/05/19 at 1:05 P.M. per Registered Nurse Unit Manager #601, revealed Resident #5 had blisters forming to both heels that were dark purple in color. Both areas on his heels measured five cm. in length by six cm. in width. The nurse practitioner was notified and ordered skin prep to bilateral heels, pad and protect heels every day, heel boots to bilateral feet, and a wound consult. Review of the physician orders, dated 11/05/19, revealed he was ordered a wound consult for bilateral heels and heel boots to bilateral feet. On 11/14/19, an order to start Liquacel (oral supplement to promote wound healing). On 11/15/19, an order to elevate his heels on a pillow when in bed and remove boots when in bed. Review of the care plan, dated 10/30/19, revealed there was a potential risk and actual skin integrity impairment of the neck related to surgical wounds. The pressure reducing mattress, Liquacel, elevate the resident's heels on a pillow while in bed and remove boots when bed were not listed as interventions on the care plan. Interview on 01/10/20 at 12:06 P.M. with State tested Nursing Assistant (STNA) #603 revealed she looked on the computer at the care plan to see what interventions were to be used for each resident regarding interventions to prevent pressure ulcers. Interview on 01/10/20 at 2:06 P.M. with STNA #606, and #606 revealed they review the resident's care plan to see what interventions were to be implemented for each resident regarding their preventive measures to prevent pressure ulcers including how often they were to be turned, if they had heel boots or if their heels were to be off loaded. Interview with Registered Nurse Unit Manager #601 and the Director of Nursing on 01/10/20 at 2:55 P.M. verified Resident #5 did not have any pressure ulcers to his right or left heel on admission on 10/29/19. They verified Resident #5 was at risk for developing pressure ulcers and he only had a physician order [REDACTED]. This deficiency substantiates Complaint Number OH 166.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to notify the Certified Nurse Practitioner (CNP) or Physician of a residents elevated blood pressure in accordance with a physician order. This affected one (#63) out of five residents reviewed for unnecessary medications. The facility census was 97. Findings include: Medical record review revealed Resident #63 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #63's physician orders [REDACTED]. Review of the residents vital signs record revealed Resident #63's systolic blood pressure was greater than 160 mmHg on the following instances: on 06/17/19 at 7:35 A.M. blood pressure reading 160/62; on 06/18/19 at 4:18 P.M. blood pressure reading 167/71; on 06/23/19 at 8:00 A.M. blood pressure reading 178/60; on 06/23/19 at 4:33 PM. blood pressure reading 178/73; on 06/26/19 at 8:12 A.M. blood pressure reading 183/62; on 06/27/19 at 8:04 A.M. blood pressure reading 181/75; on 07/01/19 at 6:13 P.M. blood pressure reading 166/62; on 07/02/19 at 7:36 A.M. blood pressure reading 162/63; on 07/03/19 at 7:51 A.M. blood pressure reading 176/74; on 07/11/19 at 9:46 A.M. blood pressure reading 186/69; on 07/12/19 at 7:46 A.M. blood pressure reading 164/69 and on 07/15/19 at 4:27 P.M. blood pressure reading 162/73 Review of Resident #63's progress notes revealed no evidence the facility notified the CNP or Physician of the residents systolic blood pressure readings greater than 160 mmHg on the dates listed. Interview on 07/17/19 at 3:26 P.M. the Director of Nursing (DON) confirmed the resident's systolic blood pressure was greater than 160 mmHg on 06/17/19, 06/18/19, 06/23/19, 06/26/19, 06/27/19, 07/01/19, 07/02/19, 07/03/19, 07/11/19, 07/12/19 and 07/15/19. The DON further confirmed the facility was unable to provide evidence the facility notified the CNP or Physician of the blood pressure readings. Review of a facility policy titled, Monitoring of Vital Signs for Residents, most recent revision date 12/18/19, revealed if a resident's vital signs were out of normal range, or specific perimeter as ordered by physician, the nurse was to call and inform the physician or hold medications as ordered.