Every finding on record at Ayden Healthcare of Fairfield

Based on record reviews, interviews, and facility policy review the facility failed to convey funds for a discharged resident in a timely manner. This affected one resident (#124) of six residents reviewed for management of personal funds. The facility census was 69.Findings Include:Review of the medical record revealed Resident #124 was admitted to the facility on [DATE]. Resident #124 was discharged from the facility on 03/16/26. Diagnoses included dementia, hypothyroidism, and hyperlipidemia.Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident's cognitive status was unable to be fully assessed, the former resident did not reject care, and did not wander. Resident #124 required moderate to maximal assistance with activities of Daily Living (ADL's).Review of a facility provided document titled Resident Statement Landscape from Resident Fund Management Service revealed Resident #124's financial management account had not been closed or frozen and had a balance of funds in the account. During an interview on 07/29/26 at 2:09 P.M. the Regional Business Office Manager (RBOM) #900 confirmed Resident #124's financial management account with the facility was currently open though the former resident discharged on 03/16/26. During an interview on 07/30/26 at 8:08 A.M. the RBOM #900 reported that resident financial accounts should be closed within 30 days of discharge from the facility.Review of a facility provided policy titled, Management of Personal Funds and dated 08/01/23 revealed Facility will reconcile and close all account within 30 days of discharge. Funds will be sent to an appropriate agency.This deficiency represents non-compliance investigated under Complaint Number 3093404.

Based on record review, staff interview, and facility policy review, the facility failed to provide the supervision, care and services to reasonably prevent resident falls. This affected one resident, (#39) out of three residents reviewed for falls. The facility census was 69.Findings Include:Resident #39 was admitted on [DATE] with the following medical diagnoses: chronic obstructive pulmonary disease, convulsions, alcohol dependence, paranoid schizophrenia, generalized anxiety disorder, major depressive disorder and nicotine dependence. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. Functional abilities per the MDS revealed Resident #39 required set up assistance for eating and oral hygiene, supervision for toileting hygiene, dressing, personal hygiene, bed mobility and transfers and moderate assist with bathing. Review of fall packet documentation for Resident #39 revealed the resident had a witnessed fall 05/17/26 . Resident #39 fell when entering the building from the patio. Resident #39 stated he lost his balance and had complaints of pain to his back and elbow. Vital signs (VS) were obtained and the Resident's mother was called and informed of incident. Resident #39 wastreated with methocarbamol ( muscle relaxant) and an ice pack. Interdisciplanary Team (IDT) met 05/18/26 and the plan was for the Reisdent's mom to bring him new shoes, as the current pair were noted to not be in good condition. Resident #39 was documented to have a second fall on 06/08/26. This fall was unwitnessed. Resident #39 was observed outside in the smoking area lying face down. Another unnamed resident stated he lost his balance, fell and hit his head. Resident #39 was assessed by nurse. The Director of Nursing (DON) Nurse Practitioner (NP) and Resident's mother notified. New order received to send resident to the hospital. IDT met and reviewed incident, and Resident #39 was educated on taking a break between each cigarette. Review of Resident #39's care plan dated 04/04/26 revealed Resident #39 was at increased risk for falls related to impaired physical mobility with intervention of fall assessment per facility policy. Care plan dated 07/10/26 continues to address falls with only one additional intervention of to obtain orthostatic blood pressure (BPs) for three days. There were no additional interventions added to the care plan after the falls dated 05/17/26 and 06/08/26. Interview with Resident #39 on 07/29/26 at 9:50 A.M. revealed the resident knew he fell and stated he woke up in the hopstial and did not remember anything. Interview with Director of Nursing (DON) on 07/29/26 at 12:05 PM confirmed the procedure for investigating falls was as follows: the IDT team meets next day, gathers statements, looks at medical record, reviews care plan, puts a new intervention into place, and talks to resident if still in the facility. They also make sure notifications were made. The DON confirmed Resident #39 only had two interventions, fall risk assessment and orthostatic blood pressures, on his care plan dated 07/10/26 and she would expect to see the addition of new shoes and resident education on taking a break between cigarettes on the most recent care plan. The DON stated interventions are usually added to the care plan at the IDT meeting. Policy titled Falls and Fall Risk, Managing dated 08/2022 confirmed the staff will identify interventions related to the resident's risks and causes to try to prevent the resident from falling. Resident - centered approaches to managing Falls and Fall Risk:1.The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.2.If a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions.3.If falling recurs despite initial interventions, staff may implement additional or different interventions, or indicate why the current approach remains relevant. This deficiency represents non-compliance investigated under Complaint Number 3073896.

Based on observation, staff interview and facility policy review, the facility failed to ensure medications were stored safely. This affected two residents, (# 64 and #66) out of five residents reviewed for medication administration. Facility census was 69. Findings include: Resident #64 was admitted on [DATE] with the following medical diagnoses: Type II Diabetes with complications, cognitive communication deficit, dysphagia, diastolic heart failure, obesity, and osteoarthritis. Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. Review of functional abilities revealed Resident #64 required set up assist for eating and oral hygiene, supervision for toileting hygiene, bathing, dressing, bed mobility, transfers, and personal hygiene. Resident #66 was admitted on [DATE] with the following medical diagnoses. Type II diabetes, cognitive communication deficit, unspecified arthritis, major depressive disorder, hyperlipidemia, and Gastroesophageal Reflux Disease (GERD). Review of MDS assessment dated [DATE] revealed Resident #66 had moderate cognitive impairment as evidenced by a BIMS score of 12. Review of Functional Abilities revealed Resident #66 required set up assistance for eating, supervision for oral hygiene, moderate assistance for personal hygiene, maximal assistance for toileting hygiene, bathing, dressing, bed mobility and transfers. When entering the room to interview Resident # 64 on 07/29/26 at 9:35 A.M. there was observed Toujeo Max Ilong acting insulin) Solostar injection pen on the over bed table for Resident #64. Observation of the pen revealed it was labeled as the the injector pen for Resident #66. Interview on 07/29/26 at 9:42 A.M. with Registered Nurse (RN) #731 confirmed the medication was sitting on the over bed table unsupervised and should not have been left on the over bed table. RN #731 stated the night shift left it, I haven't been in this room yet. Review of policy titled Storage of Medications dated 09/2018 confirmed Except for those requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart or other designated area. Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. This deficiency represents non-compliance investigated under Complaint Number 3122227.

Based on record review, staff interview, and policy review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to perform any QAPI activities for the entirety of 2025. This had the potential to affect all residents residing in the facility. The facility census was 68. Findings include:Review of the facility documents on 05/05/26 at 3:55 P.M. with Administrator, revealed there was no documentation of QAPI meeting minutes for the entirety of 2025.During an interview on 05/05/2026 at 3:59 P.M., The Administrator verified there was no documentation of QAPI meetings for 2025. Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program dated 04/28/25, revealed the facility will develop, implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals.

Based on medical record review and staff interview, the facility failed to ensure staff notified residents of the risks and benefits of treatment with psychotropic medications. This affected four (Residents #2, #3, #54, and #64) of six residents reviewed for notification of treatment. The facility census was 68 residents. Findings include: 1.Review of the medical record for Resident #64 revealed an admission date of 12/26/26 with diagnoses including bipolar disorder. Review of the Minimum Data Set (MDS) assessment for Resident #64 dated 03/13/26 revealed the resident was cognitively intact. Review of the physician's orders for Resident #64 revealed an order dated 01/30/26 for Zyprexa (an antipsychotic medication) 10 milligrams (mg) at bedtime. Review of the medical record for Resident #64 revealed it did not include documentation of staff informing the resident of the risks and benefits of treatment with Zyprexa. 2. Review of the medical record for Resident #3 revealed an admission date of 02/03/26 with diagnoses including major depressive disorder, dementia, and chronic kidney disease. Review of the physician's orders for Resident #3 revealed an order dated 02/04/26 for Zoloft (an antidepressant medication) 75 mg. Review of the MDS assessment for Resident #3 dated 02/07/26 revealed the resident was moderately cognitively impaired. Review of the medical record for Resident #3 revealed it did not include documentation of staff informing the resident of the risks and benefits of treatment with Zoloft. 3. Review of the medical record for Resident #2 revealed an admission date of 06/17/25 with diagnoses including type two diabetes mellitus, major depressive disorder, and generalized anxiety disorder. Review of the physician's orders for Resident #2 revealed orders dated 02/10/26 for fluoxetine HCl 40 mg and Trintellix 20 mg, both of which are considered psychotropic medications. Continued review of Resident #02's medical record Review of the MDS assessment for Resident #2 dated 02/27/26 revealed the resident was cognitively intact. Review of the physician's orders for Resident #2 revealed orders dated 02/10/26 for Prozac (an antidepressant) 40 mg and Trintellix (an antidepressant) 20 mg. Review of the medical record for Resident #2 revealed it did not include documentation of staff informing the resident of the risks and benefits of treatment with Prozac and with Trintellix. 4. Review of the medical record of Resident #54 revealed an admission date of 02/18/26 with diagnoses including type two diabetes mellitus, major depressive disorder, and anxiety disorder. Review of the physician's orders for Resident #54 revealed an order dated 02/19/26 for Trazodone 100 mg (an antidepressant.) Review of the MDS assessment for Resident #54 dated 02/25/26 revealed the resident was cognitively intact. Review of the physician's orders for Resident #54 revealed an order dated 03/14/26 for Risperdal 1mg (an antipsychotic) Review of the physician's orders for Resident #54 revealed an order dated 04/01/26 for Lexapro 10 mg (an antidepressant.) Review of the medical record for Resident #54 revealed it did not include documentation of staff informing the resident of the risks and benefits of treatment with Trazodone, Risperdal and Lexapro Interview on 04/30/26 at 10:35 A.M. with the Director of Nursing (DON) confirmed medical records for Residents #64, #3, #2, and #54 contained no documentation indicating the resident or the resident's representative were informed in advance of the risks and benefits of psychotropic medications and/or other treatment alternatives.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide clean safe homelike environment for residents. This affected (Residents #5, #12, #52, #66, #6, and #28) of 22 residents sampled. The facility total census was 68 residents . Findings include: 1.Review of the medical record for Resident #5 revealed an admission date of 07/9/13 with diagnoses including esophageal obstruction, anxiety disorder, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment for Resident #5 dated 04/10/26 revealed the resident had intact cognition and required partial assistance with activities of daily living (ADLs.) Observation on 04/27/26 at 9:15 A.M. of Resident #5's room revealed there was a large hole in the wall near the headboard of the resident's bed which measured approximately six inches by four inches. There was a broken window shade in the down position. The overbed light had no pull chain to turn on the light. The floor was sticky. Interview on 04/27/26 at 9:15 A.M. with Resident #5 confirmed he did not like the hole in the wall and could not see out the window because the shade was broken and could not be raised. Resident #5 stated the overbed light would not work so the staff had to use the ceiling lights, which upset his roommate. Resident #5 also confirmed the floors were sticky. 2.Review of the medical record for Resident #6 revealed an admission date of 01/06/26 with diagnoses including cerebral infarction, diabetes, and dementia. Review of the MDS assessment for Resident #6 dated 01/28/26 revealed the resident had impaired cognition and required supervision with ADLs. Observation on 04/27/26 at 9:25 A.M. of Resident #6's room revealed there was a six-foot section of flooring near the bed which was split and was raised approximately one half inch along the edge. The wardrobe had a splintered section on the bottom approximately three feet wide by six inches long. The dresser was a missing drawer, and another dresser drawer was off track. There were two unpainted plaster patches on the wall. There was no shower curtain in the bathroom, and the floor was sticky. Interview on 04/27/26 at 9:25 A.M. with Resident #6 confirmed she was not happy with the split in the flooring, the splintered and broken furniture and the missing shower curtain and further stated she did not live like this at home. 3.Review of the medical record for Resident #52 revealed an admission date of 02/09/23 with diagnoses including anxiety disorder, post-traumatic stress disorder and polyneuropathy. Review of the MDS assessment for Resident #52 dated 03/06/26 revealed the resident had intact cognition and required supervision with ADLs. Observation on 04/27/26 at 9:30 A.M. of Resident #52's revealed there was a six-foot section of the flooring which was split and raised approximately one half inch along the edge. There floor had scattered debris and was sticky. The cover to the heater at the end of the bed was not attached. There was no footboard on the bed. There was a round one-inch brown stain, surrounded by three smaller brown stains on the floor under the heater. There were scattered brown stains on the resident's bed linen. The overbed light had no pull chain to turn on the light. Interview on 04/27/26 at 9:30 A.M. with Resident #52 confirmed she upset the heater had no cover attached and came off in the night. Resident #52 stated the flooring should not be separated and the floor needed to be cleaned. Resident #52 wanted her overbed light to work and she stated she did not live in a room looking like this. 4.Review of the medical record for Resident #66 revealed an admission date of 08/23/24 with diagnoses including hemiplegia affecting left side, dysphagia, and malnutrition. Review of the MDS assessment for Resident #66 dated 02/02/26 revealed the resident had intact cognition and required partial assistance with ADLs. Observation on 04/27/26 at 9:45 A.M. of Resident #66's room revealed near the room entrance there was a three foot section of the wall cove base which was detached from the wall and was in the path of the entranceway. The detached cove base revealed an uncleanable surface. The floor was also sticky. Interview on 04/27/26 at 9:45 A.M. with Resident #66 stated he was concerned about the detached cove base because he thought he might get his scooter wheel caught in it. Resident #66 stated he did not like his floor being sticky. 5.Review of the medical record for Resident #12 revealed an admission date of 10/16/19 with diagnoses including chronic obstructive pulmonary disease, diabetes, and heart failure. Review of the MDS assessment for Resident #12 dated 04/10/26 revealed the resident had intact cognition and required maximum assistance with ADLs. Observation on 04/27/26 at 9:15 A.M. of Resident #12's room revealed the overbed light had no pull chain to turn on the light, and the floor was sticky. Interview on 04/27/26 at 9:15 A.M. with Resident #12 stated the overbed light would not work so the staff had to use the ceiling lights, which upset his roommate. Resident #12 stated the floor should not be sticky. 6.Review of the medical record for Resident #28 revealed an admission date of 12/17/18 with diagnoses including morbid obesity, xeroderma pigmentosa, and lymphedema. Review of the MDS assessment for Resident #28 dated 04/03/26 revealed the resident had impaired cognition and required maximum assistance with ADLs. Observation on 04/29/26 at 11:05 A.M. of Resident #28's room revealed the resident's pillowcase had a six-inch by 12-inch spot of a dried dark brown substance. The floor was sticky and the corners of the floor by the entryway had a heavy buildup of brown debris. Interview on 04/29/26 at 11:05 A.M. with Resident #28 confirmed she did not want to lay her head on a dirty pillowcase. Interview on 04/29/26 at 11:10 A.M. with the Director of Nursing (DON) verified Resident #28's pillowcase had a large dark brown stain, and the staff may have moved the pillow from under the resident's leg and put it under the resident's head. The resident had drainage from her legs. The DON verified the floor was sticky and there was a buildup of debris in the entry corner. Interview on 05/04/26 at 9:36 A.M. with the Administrator and Maintenance Director (MD) #109 verified the rooms of Residents #5, #12, #52, #66, #6, and #28 needed repairs and cleaning. Review of facility policy titled Quality of Life Homelike Environment undated revealed residents should be provided a safe, clean, comfortable and homelike environment.This deficiency represents noncompliance investigated under Master Complaint Number 2992266, and Complaint Numbers 2796154 and 2788683.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), review of police reports, staff interview, and review of the facility policy, the failed to ensure residents' belongings and medications were not misappropriated. This affected four (Residents #71, #12, #40, and #62) of four residents reviewed for misappropriation. The facility census was 68 residents. Findings include: 1.Review of the medical record for Resident #71 revealed an admission date of 03/11/24 with diagnoses including Huntington's disease, major depressive disorder, dysphagia and anxiety disorder. Review of the care plan for Resident #71 dated 07/08/25 revealed the resident was at risk for exploitation and personal item loss due to impaired mobility and cognitive changes. Review of the Minimum Data Set (MDS) assessment for Resident #71 dated 01/23/26 revealed the resident had severely impaired cognition and required staff assistance with activities of daily living (ADLs). Review of a local police report dated 06/12/25 revealed after an investigation CNA #600 was issued a summons for theft, and Resident #71's cell phone was recovered. Review of the progress note for Resident #71 dated 07/22/25 revealed the Interdisciplinary Team (IDT) met to discuss an incident reported on 07/08/25 in which Certified Nursing Assistant (CNA) #600 bought a phone from a resident in what she thought was a voluntary purchase. Review of the Self-Reported Incident (SRI) for Resident #71 dated 07/25/25 revealed on 06/13/25 staff reported Resident #71's cellphone was missing. On 06/16/25 Resident #71's family reported the missing cell phone to the local police and notified the facility. On 07/03/25 local police arrived at the facility with Resident #71's missing phone which they had found CNA #600's home. Interview on 05/04/26 at 9:12 A.M. with Detective #650 confirmed CNA #600 was charged with first degree theft of Resident #71's missing phone. Interview on 05/04/26 at 9:59 A.M. with Regional Director of Operations (RDO) #700 confirmed CNA #600 had possession of Resident #71's phone. Interview on 05/04/26 at 10:25 A.M. with Assistant Director of Nursing (ADON) #150 confirmed Resident #71's phone that was reported missing was found at CNA #600's house. Review of the facility policy titled Lost and Found undated revealed the facility should assist all personnel and residents in safeguarding their personal property. 2. Review of the medical record for Resident #12 revealed an admission date of 10/10/19 with diagnoses including morbid obesity, unspecified dementia, and myositis. Review of the pharmacy packing slip for Resident #12 dated 07/15/25 revealed 30 oxycodone five milligram (mg) tablets were delivered to the facility but were not registered as received at the facility. 3.Review of the medical record for Resident #40 revealed an admission date of 04/13/19 with diagnoses including polyosteoarthritis, anxiety disorder, and inflammatory polyarthropathy. Review of the pharmacy packing slip for Resident #40 dated 07/15/25 for revealed 30 hydrocodone five-325 mg tablets were delivered to the facility but were not registered as received at the facility. 4.Review of the medical record for Resident #62 revealed an admission date of 03/06/25 with diagnoses including anxiety disorder, major depressive disorder, and essential hypertension. Review of the pharmacy packing slip for Resident #62 dated 07/15/25 for revealed 30 oxycodone five mg tablets were delivered to the facility but were not registered as delivered at the facility. Review of a police report dated 07/16/25 revealed the facility reported a theft of residents' narcotic medications. Review of an email from the facility to the pharmacy dated 07/24/25 revealed the facility had a narcotic diversion at the facility affecting Residents #12, #40, #62. Resident #12 had 30 oxycodone tablets missing, Resident #40 had 30 hydrocodone tablets missing, and Resident #62 had 30 oxycodone tablets missing. Interview on 05/04/26 at 10:27 A.M. with the Director of Nursing (DON) verified the narcotics and the sign in sheets for Residents #12, #40, #62 dated 07/15/25 revealed the sheets and medications were not turned in by Registered Nurse (RN) #550 and the medications were not at the facility. The DON stated they suspected RN #550 took the medications as they were delivered. Interview on 05/04/26 at 12:13 P.M. with the DON confirmed three narcotic cards in total were missing: Resident #12 was missing 30 oxycodone tablets, Resident #40 was missing 30 hydrocodone tablets, and Resident #62 was missing 30 oxycodone tablets. The DON confirmed the facility was able to substantiate Resident #12, #40, and #62's medications had been misappropriated. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated October 2023 revealed residents had the right to be free from abuse, neglect, exploitation and misappropriation of resident property. This deficiency represents noncompliance investigated under Complaint Numbers 2583908 and 2566783.

Based on record review, interviews, and policy review the facility failed to conduct care conferences with residents or resident representatives on a routine basis. This affected five residents (Residents #02, #57, #21, #54, and #03) of 21 residents reviewed for care conferences. The facility census was 68.Findings include:1. Review of the medical record of Resident #02 revealed an admission date of 06/17/25. Diagnoses included nontraumatic subarachnoid hemorrhage, type II diabetes mellitus, other psychoactive substance use, septic pulmonary embolism, chronic kidney disease stage III, neuromuscular dysfunction of bladder, major depressive disorder, generalized anxiety disorder, and drug induced constipation. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, did not reject care, did not wander, and had an indwelling catheter. Further record review for Resident #02 revealed a quarterly MDS assessment dated [DATE], a quarterly MDS assessment dated [DATE], a quarterly MDS assessment dated [DATE], and a quarterly MDS assessment dated [DATE]. There were only two care conferences documented on 03/18/26 and 04/16/26. During an interview on 04/29/26 at 12:32 P.M., Licensed Practical Nurse (LPN) #190 stated care conferences should be conducted quarterly in conjunction with MDS assessments. LPN #190 confirmed Resident #02 had documentation of only two care conferences dated 03/18/26 and 04/16/26. 2. Review of the medical record of Resident #57 revealed an initial admission date of 03/22/21 and a readmission date of 03/02/26. Diagnoses included fracture of lower end of left femur, polyneuropathy, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral infarction, muscle weakness, acute kidney failure, major depressive disorder, anxiety disorder, psychotic disorder with hallucinations, and opioid dependence. Review of the most recent quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact.Further record review for Resident #57 revealed a MDS assessment dated [DATE], a quarterly MDS assessment dated [DATE], a quarterly MDS assessment dated [DATE], a quarterly MDS assessment dated [DATE], an annual MDS assessment dated [DATE], and a quarterly MDS assessment dated [DATE]. There were only two care conferences documented on 01/08/25 and 01/21/26. During an interview on 04/29/26 at 12:32 P.M., LPN #190 verified Resident #57 only had two documented care conferences on 01/08/25 and 01/21/26.3. Review of the medical record of Resident #21 revealed an initial admission date of 09/02/22 and a readmission date of 10/26/24. Diagnoses included chronic obstructive pulmonary disease, type II diabetes mellitus, cognitive communication deficit, Wernicke's encephalopathy, cerebrovascular disease, altered mental status, unspecified, and unspecified protein-calorie malnutrition. Review of the most recent significant change MDS assessment dated [DATE] revealed the resident was severely cognitively impaired.Further record review for Resident #21 revealed a quarterly MDS assessment dated [DATE], an annual MDS assessment dated [DATE], a quarterly MDS assessment dated [DATE], a quarterly MDS assessment dated [DATE], a significant change MDS assessment dated [DATE], and a significant change MDS assessment dated [DATE]. There were only two care conferences documented on 01/28/26 and 04/22/26. During an interview on 04/28/26 at 9:18 A.M., Resident #21's representative stated she was contacted once for a care conference.During an interview on 04/29/26 at 12:32 P.M., LPN #190 verified there were only two care conferences documented on 01/28/26 and 04/22/26 for Resident #21.4. Review of the medical record of Resident #54 revealed an admission date of 02/18/26. Diagnoses included type II diabetes mellitus, muscle weakness, cognitive communication deficit, dysphasia, major depressive disorder, adjustment disorder with mixed disturbance of emotions and conduct, unspecified mood disorder, and anxiety disorder. Review of the most recent admission MDS assessment dated [DATE], revealed the resident was cognitively intact. Further record review for Resident #54 revealed there were no documented care conferences.During an interview on 04/29/26 at 12:32 P.M., LPN #190 verified there were no documented care conferences for Resident #54.5. Review of the medical record of Resident #03 revealed an initial admission date of 02/17/22 and a readmission date of 02/03/26. Diagnoses included sepsis, personal history of transient ischemic attack, cognitive communication deficit, chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity, major depressive disorder, dementia, pressure ulcer of unspecified cite, chronic kidney disease stage III.Review of the most recent significant change MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired.Further record review for Resident #03 revealed a quarterly MDS assessment dated [DATE], a quarterly MDS assessment dated [DATE], a quarterly MDS assessment dated [DATE], an annual MDS assessment dated [DATE], and a significant change MDS assessment dated [DATE]. There were only two care conferences documented on 01/14/26 and 02/18/26. During an interview on 04/30/26 at 10:57 A.M., LPN #190 stated care conferences should be held along with the MDS assessment. LPN #190 confirmed Resident #03 had documentation of only two care conferences dated 01/14/26 and 02/18/2626.Review of a facility policy titled Care Conferences with a revised date of 01/20 revealed, Care conferences will be scheduled to include the resident, resident representative, and interdisciplinary team as soon as possible after admission, routinely, and with a change in condition.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure staff provided the necessary level of supervision for safe smoking. This affected three (Residents #50, 13, and #24) of four residents reviewed for smoking safety. The facility also failed to ensure the environment was free of accident hazards. This affected one (Resident #52) of one resident reviewed for accident hazard. The facility also failed to ensure a resident's fall was thoroughly investigated, fall interventions were implemented to reduce and/or eliminate future falls. This affected one (#15) of the four residents reviewed for falls. The facility total census was 68.Findings include: 1.Review of the medical record for Resident #50 revealed an admission date of 03/28/26 with diagnoses including toxic encephalopathy, type two diabetes, polyneuropathy, and delusional disorder. Review of the smoking assessment for Resident #50 dated 03/28/26, revealed the resident was a smoker and must follow facility smoking policy. There were no additional interventions documented. Review of the Minimum Data Set (MDS) assessment for Resident #50 dated 04/04/26, revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs.) Review of the care plan for Resident #50, revealed the resident was at an increased risk of injury related to smoking. Interventions included keeping the resident's smoking items at the nurses' station. Observation on 04/28/2026 at 9:45 A.M., revealed Resident #50 was in the first-floor common area with a cigarette in his mouth. The Director of Nursing (DON) approached Resident #50 and noted he also had a lighter on his person. The DON was able to obtain smoking products from the resident. During an interview on 04/28/26 at 9:50 A.M., the DON verified Resident #50 had a cigarette in his mouth and he also had a lighter in his possession. The DON confirmed Resident #50 was not supposed to keep his smoking materials. 2. Review of the medical record for Resident #13 revealed an admission date of 08/04/25 with diagnoses including schizophrenia, schizoaffective disorder, Parkinson's, bipolar disorder, and nicotine dependence. Review of the smoking assessment for Resident #13 dated 03/30/26, revealed the resident was listed as a non-smoker. Review of the MDS assessment for Resident #13 dated 04/03/26, revealed the resident was moderately cognitively impaired. Resident #13 required and required staff assistance with ADLs. Review of the care plan for Resident #13, revealed the resident was at an increased risk of injury related to smoking. Interventions included keeping smoking items at the nurses' station. Observation on 04/28/2026 at 9:47 A.M., revealed Resident #13 was on the first-floor hallway with a cigarette in his mouth and a lighter in his hand. During an interview on 04/28/25 at 9:48 A.M., the DON verified that Resident #13 had his smoking products on his person. During an interview on 04/28/2026 at 11:56 AM., the DON confirmed Resident #13 had stopped smoking when the smoking assessment was completed but had since started smoking again. DON #197 verified that there should have been a new assessment completed when Resident #13 started smoking again. 3. Review of the medical record for Resident #24 revealed an admission date of 06/22/25 with diagnoses including encephalopathy, chronic obstructive pulmonary disease, respiratory failure, anxiety disorder and nicotine dependence. Review of the care plan for Resident #24 dated 02/05/26, revealed it did not include any information regarding the resident's smoking status. Review of the MDS assessment for Resident #24 dated 02/06/26, revealed the resident had moderately impaired cognition and required substantial assistance with ADLs. Review of the smoking evaluation for Resident #24 dated 04/13/26, revealed the resident used vape products and the resident did not have the fine motor skills needed to securely hold tobacco or other smoking items. Observation on 04/28/26 at 9:59 A.M. revealed there was a pack of cigarettes with 11 cigarettes remaining and a lighter in Resident #24's room on the bedside table. During an interview on 04/28/26 at 10:00 A.M., Licensed Practical Nurse (LPN) #161 confirmed the pack of cigarettes with 11 cigarettes in the pack and a lighter in Resident #24 room and on the bedside table and should be locked behind nursing station. LPN #161 stated Resident #24 required supervision with smoking and Certified Nursing Assistants (CNAs) sat outside with the resident when he was smoking. Observation on 04/29/26 at 7:40 A.M., revealed there was a lighter and cigarettes in Resident #24's room on the bedside table. During an interview on 04/29/26 at 7:40 A.M., CNA #185 confirmed the lighter and cigarettes in Resident #24's room and on Resident #24's bedside table and stated the smoking materials should be locked behind the nurses' station. Observation on 04/29/26 at 9:34 A.M., revealed Assistant Director of Nursing (ADON) #150 removed the cigarettes and lighter off the bedside table out of Resident #24 room. During an interview on 04/29/26 at 9:35 A.M., ADON #150 confirmed Resident #24 had cognitive impairment and his cigarettes and lighter should be locked up in the nurses' station. ADON #150 also confirmed Resident #24 smoking evaluation dated 04/13/26 was incorrect, because Resident #24 was a smoker. During an interview on 04/29/26 at 10:00 A.M., MDS Coordinator #190 verified Resident #24's care plan did not include a plan for smoking safely. Review of the facility policy titled Smoking Policy dated August 2023 revealed all smoking material, cigarettes, cigars, lighters, etc. will be kept at the nurse station or designated area.4. Record review of Resident #52 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #52 include muscle weakness, anxiety, post-traumatic stress disorder, polyneuropathy, iron deficiency anemia. Review of the MDS comprehensive assessment dated [DATE], revealed the resident had intact cognition and required supervision for Activities of Daily Living skills.During an interview on 04/27/26 at 10:30 A.M., Resident #52 stated she obtained a scratch on her toe due to accidently kicking the heater cover off in the middle of the night while she was sleeping. The resident stated she had reported the heater covering being off and there had been no intervention from the staff to fix the heater or prevent her foot from coming in contact with the exposed metal. Observations on 04/27/26, 04/29/26, 04/30/26 and 05/04/26 at random times between 9:00 A.M. and 2:30 P.M. revealed Resident #52's room heater cover was removed, exposing jagged pieces of metal around the heater. The resident's foot of the bed was positioned approximately four inches from the exposed jagged metal inner workings of the heater. The bed did not have a footboard. Observation of Resident #52's room on 04/29/26 at11:20 A.M. , revealed numerous brown stains under the wall heater and around the resident's bed. During an interview on 04/29/26 at 4:05 P.M., the Director of Nursing (DON) verified the findings in Resident #52's room. 5. Record review of Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #15 include diabetes, malnutrition, muscle weakness, unsteady on feet, repeated falls, heart failure, reflux uropathy, glaucoma and epilepsy. Review of the active Plan of Care dated 08/01/25 revealed Resident #15 was to have nonskid strips at the floor near bed, nonskid material to the wheelchair, and additional nonskid strips to the floor next to bed to extend the length of the bed. Review of Resident #15's falls included dates on 10/28/25, 12/31/25, 01/13/26, 02/05/26, 03/07/26, 04/03/26, 04/11/26 and 04/30/26. Review of physician orders dated 12/02/25 revealed the Resident #15 was ordered to have nonskid strip next to bed as a fall intervention. Review of the MDS comprehensive assessment dated [DATE], revealed the resident had intact cognition and required supervision with Activities of Daily Living skills. Observations on 04/27/26, 04/28/26, 04/30/26 and 05/04/26 at random times revealed Resident #15 did not have nonslip strips on the floor at his bedside, and no anti- slip material in his wheelchair. There were skip floor strips near the toilet area but were missing in areas and not adhered completely to the floor. During an interview on 05/04/26 at 9:36 A.M., the Administrator verified Resident #15 did not have non-slip strips on the floor at his bedside, no anti-slip material in his wheelchair and the floor strip near the toilet area was missing and not adhered to the floor. During an interview on 05/04/26 at 12:38 P.M., the Director of Nursing (DON) verified Resident #15 had multiple falls with interventions to include nonslip strips on the floor at his bedside, and anti-slip material in his wheelchair. The DON verified floors strips needed to be adhered completely to the floor in order to be effective. The DON verified Resident #15 had a recent fall on 04/030/26 and the new intervention was to add additional floor strips to the entire length of the bed. The DON verified the additional strips had not been added since the fall of 04/230/26. The DON stated she expected any new fall interventions to be implemented immediately after a fall, including the fall interventions on 04/30/26. Review of an undated facility documented titled Monitoring Subsequent Falls and Fall Risk provided by the Administrator, revealed staff will monitor resident's response to interventions intended to reduce falling or the risk of falling. If the resident continued to fall, the staff would re-evaluate the situation and decide whether it is appropriate to continue or change current interventions.

Based on observations, staff interviews and record review, the facility failed to follow the planned menu for residents receiving pureed and mechanical soft consistency diets. This affected 12 Residents (#21, #24, #27, #30, #38, #40, #43, #51, #54, #57,#64 and #66) who received a mechanical soft consistency diet and two Residents (#59 and #37) who received puree foods. The facility total census was 68. Findings include: Review of the diet orders on 04/29/26 at 8:10 A.M., revealed Residents #21, #24, #27, #30, #38, #40, #43, #51, #54, #57,#64 and #66 had physician orders for a mechanical soft consistency diet. Resident #59 had orders for a puree diet and Resident #37 had orders for mechanical soft diet with puree meats. Observation on 04/29/26 at 8:15 A.M. of the breakfast meal service revealed the [NAME] #104 served torn pieces of bacon to the residents on mechanical soft diets and no sausage was provided to the residents receiving the puree diet. Review of the spreadsheet at the same time, revealed the mechanical soft diets were ordered to receive sausage and the puree diets were to receive puree sausage. During an interview on 04/29/26 at 8:15 A.M., [NAME] #104 verified he did not serve sausage for the mechanical and puree consistency diets because there was no sausage available.During an interview on 04/29/26 at 9:15 A.M., Diet Manager (DM) #131 verified mechanical soft diets were ordered to receive sausage and the puree diets were ordered to receive puree sausage. DM #131 verified the residents on the puree diet did not receive any puree meat. Review of facility policy titled, Portion Control Guidelines , dated 2005, revealed food portions are written on the menus and recipes. Policy Menu Substitutions dated 2005 revealed all change of the menu must provide equal nutritive value. This deficiency represents non-compliance investigated under Complaint Number 2986547.

Based on staff interviews and record review, the facility failed to maintain a record of food substitutions. This affected all 67 residents who received food from the kitchen. Resident #5 did not receive food from the kitchen. The facility total census was 68. Findings include:Observation on 04/29/26 at 8:15 A.M. of the breakfast meal service revealed the [NAME] #104 served torn pieces of bacon to the residents on mechanical soft diets. Review of the spreadsheet at the same time, revealed the mechanical soft diets were to receive sausage and the puree diets were to receive puree sausage During an interview on 04/29/26 at 8:15 A.M., [NAME] #104 verified he did not serve sausage for the mechanical and puree consistency diets because there was no sausage available. [NAME] #104 verified he substituted bacon for sausage for the mechanical soft diet and did not obtain or consult the Diet Manager for the food substitution. [NAME] #104 stated he did not know if bacon was a substitute for sausage and did not know how to record the substitution on a substitution log. During an interview on 04/29/26 at 9:15 A.M., Diet Manager(DM) #131 verified the mechanical soft diets were to receive sausage and the puree diets were to receive puree sausage. DM #131 verified there were no substitution logs available for the years of 2025 and 2026, and the [NAME] #104 did not request confirmation of the substitution from DM #131 or Registered Dietitian (RD) #600. DM #131 was unsure if bacon was an equal substitution for sausage. Review of the food substitution record at the same time revealed no food substitution records for years of 2025 and 2026. During an interview on 05/04/26 at 4:29 P.M., RD #600 verified a substitution log should have written changes when the food is substituted. RD #600 stated she had reviewed the April 2026 log with two food substitution entries, but no months prior in 2026 or 2025. RD #600 denied she had been consulted for any food substitution, including the bacon for the sausage on 04/29/26. Review of facility policy titled, Menu Substitutions , dated2005, revealed changes shall be of equal nutritive value and made by the diet manger or dietary professional. All menu changes will be documented using a substitution log reflecting ad ate the items substituted and reason for the substitution. The substitution log will be filed for one year.

Based on observations, interviews and record review, the facility failed to properly prepare and store food, and maintain a sanitary kitchen. This affected all 67 residents who received food from the kitchen. Resident #5 did not receive food from the kitchen. The facility total census was 68. Findings Include: 1. Observation on 04/28/26 at 12:48 P.M. revealed CNA #192 delivered lunch trays to Residents #38, #33, #57, #44, #16, #35, #61, and #14 in their rooms. Continued observation of CNA #192 revealed CNA #192 did not sanitize or wash her hands between delivery of each lunch tray. An interview on 04/28/26 at 12:58 P.M. with CNA #192 confirmed that CNA #192 did not sanitize or wash her hands between delivering lunch trays to the rooms of Residents #38, #33, #57, #44, #16, #35, #61, and #14. Further interview with CNA #192 revealed meal trays are delivered to a resident's room even if the resident isn't present in their room at the time of delivery. CNA #192 reported that residents who smoke are often outside smoking during lunch tray delivery. CNA #192 further reported that residents who are out of their rooms during meal tray delivery may find that their meal is cold by the time residents return to their rooms. 2.Review of the facility provided diet orders, revealed 67 residents received food from the kitchen. Resident #5 received nutrition from a gastric tube and did not receive food from the kitchen. Observations in the kitchen on 04/27/26 at 9:15 A.M. through 9:45 A.M. revealed the following: The ice machine scoop was in a non-draining container with the scoop side in the up position. The garbage disposal had standing brown liquid in the bowl with a strong pungent odor. Two employee handwashing areas had no working hands free dry towel dispenser. The non-in-use meat slicer was not covered. In the dry food storage area, there were five opened containers of foods with no open dates. There were six ceiling light fixtures with no protective covering above the food shelves. In the walk in refrigerator there were six opened containers of sauces with no open dates. The refrigerator fans had a buildup of brown debris. There were three soaked boxes of thawing meat with no catch pan. There were no food and no refrigerator temperatures documented for dates of 04/24/26, 04/25/26 and 04/26/26. In the disposable container and flatware storage room, approximately 10 foot by 30 foot space, the floor planks were separated up to a half inch in multiple places along the floor. At the entrance to the room, there was an approximately five-foot square area of no flooring planks , revealing a subfloor gap of nearly an inch between the subfloor and the planks. There were two vents above the food service line, where food was observed to be prepared, with heavy brown debris. During dishwashing, there was a floor fan blowing towards the dishwashing area with a heavy build up a brown debris. There were three areas in the food service area with gouges, and missing door jams, on the walls , door frames and ceiling. The areas revealed drywall and wood studs with uncleanable surfaces. Interview on 04/27/26 at 9:45 A.M the Diet Manager , (DM) #131 verified the observation of the kitchen. The DM#131 stated the kitchen needed cleaning, repairs and all surfaces need to be cleanable, including the walls, ceiling and floors. DM #131 verified the food and walk in refrigerators temperatures must be documented at each meal. Observation on 04/30/26 at 8:50 A.M. revealed the [NAME] #104 wore gloves and tore up pieces of bacon and biscuits for the mechanical altered diet after touching the counter, lids and other surfaces. [NAME] #104 did not change gloves between tearing up bacon and biscuits for the next mechanical soft diet preparation. Interview on 04/30/26 at 9:50 A.M. , the DM #131 verified the [NAME] #104 did not change the gloves between touching food and touching surfaces, and either a utensil should be used or the gloves should be changed after directly handling food. Observation on 05/04/26 at 2:21 P.M. revealed the following regarding resident food storage in resident designated refrigerators: The 200 unit resident refrigerator had a sign revealed the refrigerator was for resident foods only , foods must be labeled and dated and discarded after two days. In the refrigerator: There was no thermometer to record refrigerator temperature. The ice machine scoop was in a non-draining container with the scoop side in the up position There were four containers of unlabeled and undated food, and an unidentified lunch bag with no name. In the freezer, there were two bags of with no label and no date. The 100: unit resident refrigerator had a sign revealed the refrigerator was for resident foods only , foods must be labeled and dated and discarded after two days. In the refrigerator: There was no temperature log for the months of April or May of 2026. There were three bags of open foods and in containers with no label or date. There was no container of food unsealed with no label or date. Interview on 05/04/26 at 9:36 A.M. the Administrator verified the uncleanable surfaces of the floor, the walls and ceiling areas of the kitchen. Interview on 05/04/26 at 2:21 P.M. with Medical Records staff #167 verified the observation of the resident refrigerators. The Medical Record staff #167 verified the refrigerators should only be for resident food storage and should be labeled and dated with the resident's name and when opened. The refrigerators should have thermometer and a daily record of the temperature. Review of facility policies titled, Food Preparation , dated 2005 , revealed staff must use clean fresh gloves when handing foods; Storage of Perishable Foods, dated 2005, revealed refrigerator items must be labeled and dated, meats thawed on bottom shelf, containers shall be impervious , refrigerator temperatures shall be documented twice a day, all foods covered ; and Storage of Staples ,dated 2005, revealed the storeroom shall be maintained of potential contamination free from dirt. This deficiency represents noncompliance investigated under Complaint Number 2788567.

Based on observation, record review, interview, and policy review, the facility failed to follow precaution procedures for residents with orders for Enhanced Barrier Precautions (EBP). This affected four Residents (#02. #05, #07, and #19) of the five residents reviewed for infection control. The facility also failed to ensure hand hygiene was completed while passing food trays. This affected eight Residents (#38, #33, #57, #44, #16, #35, #61, and #14) The facility census was 68.Findings include:1.Review of the medical record revealed Resident #07 was admitted to the facility on [DATE]. Diagnoses included acute kidney failure, Hodgkin's lymphoma and retention of urine. Review of the physician orders dated 04/09/26 for Resident #07, revealed the resident was ordered to be in EBP due to multiple wounds and having an indwelling (foley) catheter Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #07 was cognitively intact. Observation of Resident #07's room on 04/28/26 at 10:52 A.M. revealed when surveyor knocked on the resident's door, Certified Nursing Assistant (CNA) #200 opened door and stated he was providing personal care for Resident #07. CNA #200 was observed to be wearing gloves and no gown. Observation of Resident #07's doorway revealed no signs indicating the resident was in EBP and there was no cart containing personal protective equipment (PPE) near the room. During an interview on 04/28/26 at 10:54 A.M., CNA #200 verified he was not wearing a gown while providing care for Resident #07 and stated he did not know the resident was in EBP. During an interview on 04/28/2026 at 10:59 A.M., Resident #07 stated the staff only wore gloves when providing care and had never worn a gown. During an interview on 04/28/2026 at 11:04 A.M., MDS Coordinator (MDSC) #190 verified Resident #07 was in EBP and there was no sign or posting indicating the resident was in EBP. MDSC #190 verified there was no cart available with PPE to use near Resident #07's room. Review of the medical record for Resident #19 revealed an admissions date of 10/31/24. Diagnoses included chronic obstructive pulmonary disease (COPD), type two diabetes, and morbid obesity. Review of the MDS assessment dated [DATE], revealed Resident #19 was cognitively intact. Review of the physician orders dated 04/19/26 for Resident #19, revealed the resident was ordered to be in EBP due to extended-spectrum beta-lactamase (ESBL) infection in urine. Observation of Resident #19's room on 04/28/2026 at 9:28 A.M., revealed CNA #200 was in Resident #19's room with gloves on and no gown. There was a sign posted on the resident's door indicating Resident #19 was in EBP. During an interview on 04/28/2026 at 9:32 A.M., CNA #200 verified Resident #19 was ordered to be in EBP, and he was providing care to the resident and not wearing a gown. During an interview on 04/2826 at 9:34 A.M., Licensed Practical Nurse (LPN) #161 verified Resident #19 had an active order for EBP. LPN #162 stated the order for EBP should have been discontinued because it was ordered for a wound that had healed. Observations revealed LPN #161 instructed CNA #200 to remove the EBP sign from the resident's door and stated it was no longer needed. During an interview on 04/28/2026 at 10:14 A.M., Resident #19 stated the staff haven't been using gowns while providing care. During an interview on 04/28/2026 at 11:38 A.M., the Director of Nursing (DON) verified Resident #19 still had an active order for EBP related to infection in his urine and the EBP sign should not have been removed from his door. Observation of Resident #19's room on 04/28/2026 at 1:02 P.M., revealed MDSC #190 prepared and placed a cart with PPE for Resident #19's room. MDSC #190 verified Resident #19 was he was on EBP and did not have the needed PPE at his room. Record review of Resident #05 revealed the resident was admitted to the facility on [DATE]. Diagnoses included esophageal obstruction, malnutrition, dysphagia, anxiety, and chronic obstructive pulmonary disease. Review of physician orders dated 08/01/25 for Resident #05, revealed the resident was ordered to be in EBP related to an indwelling gastric tube (g-tube) placement. Review of the MDS comprehensive assessment dated [DATE], revealed Resident #05 had intact cognition and required partial assistance with Activities of Daily Living (ADL). The resident received nutrition through a g-tube. Observation of Resident #05's room on 04/27/26 at 9:50 A.M., revealed no signs posted indicating the resident was ordered to be in EBP. During an interview on 04/29/26 at 11:05 A.M., the DON verified Resident #05 was ordered to be in EBP related to a physician order dated 08/01/25 and there was no sign posted indicated the resident was to be in EBP until after the surveyor discovered it on 04/27/26. The DON stated the signage was placed on the resident's door on 04/28/26 when the corporate nurse directed the staff to put signage on the resident's door. Review of the medical record for Resident #02 revealed the resident was admitted to the facility on [DATE]. Diagnoses included nontraumatic subarachnoid hemorrhage, type two diabetes mellitus, and major depressive disorder. Review of the most recent MDS 3.0 assessment dated [DATE], revealed Resident #02 was cognitively intact. Review of the physician order dated 02/09/26 for Resident #02, revealed the resident was ordered to have the foley catheter changed every thirty days. Observation on 04/29/26 at 10:28 A.M., revealed CNA #174 and CNA #400 were assisting with a dressing change then utilized a Hoyer (mechanical) lift to get Resident #02 out of the bed and into wheelchair. CNA #174 and CNA #400 stated the resident was in EBP and verified they wore gloves and no gown. CNA #174 stated they only used a gown when emptying the catheter bag. CNA #400 stated they do not wear gowns when doing any personal care for the resident. Observation of incontinence care on 04/30/26 at 8:14 A.M., revealed CNA #154 provided catheter care and incontinence care for Resident #02 with no gown in place. CNA #154 verified Resident #02 was in EBP, and no gown was worn during the care. CNA #154 stated no gowns were worn for catheter care unless the resident had an infection. CNA #154 verified an EBP sign was posted on the resident's door indicated for staff to wear gloves and gown for high contact activities including providing hygiene, changing briefs, and device care for urinary catheter. 5. Observation on 04/28/26 at 12:48 P.M., revealed Certified Nursing Assistant (CAN) #192 delivered lunch trays to Residents #38, #33, #57, #44, #16, #35, #61, and #14 in their rooms. CNA #192 did not complete any hand hygiene between delivery of each lunch tray. During an interview on 04/28/26 at 12:58 P.M., CNA #192 confirmed she did not sanitize or wash her hands between delivering lunch trays to the rooms of Residents #38, #33, #57, #44, #16, #35, #61, and #14. Review of the policy titled, Enhanced Barrier Precautions, dated 04/01/24, revealed a gown and gloves were to be utilized for high contact resident care activities including dressing, bathing, transferring, providing hygiene, changing briefs and device care. EBP was indicated for residents with indwelling medical devices. Review of the policy titled, Infection Prevention and Control Program, dated 04/28/25, revealed a resident with an infection or communicable disease shall be placed on transmission-based precautions (TBP). This deficiency represents non-compliance investigated under Complaint Number 2588878.

Based on observations and staff interviews, the facility failed to ensure the essential kitchen equipment was in working condition. This affected all 67 residents who received food from the kitchen. Resident #5 did not receive food from the kitchen. The facility total census was 68.Findings include:1.Review of a bid to replace the kitchen stove dated 03/20/25, provided by Administrator, revealed the most current bid for the stove replacement.Observations on 04/27/26 through 05/05/26 from 8:00 A.M through 4:00 P.M. revealed the kitchen stove was not fully functional. Of the six top burners, one burner was able to heat food. The grill top was nonoperational. During an interview on 04/29/26 at 9:05 A.M., [NAME] #104 verified his breakfast meal was to start at 8:30 A.M. but he could not get the meal completed on time with the stove not working fully. During an interview on 04/29/26 at 9:15 A.M. Diet Manager, (DM) #131 verified the stove burners did not fully function and the grill was not operational. DM #131 verified some foods had to be altered to a less fresh form, such as grilled cheese because the grill was not working. There was no known plan or active bid to replace the stove.During an interview on 05/04/26 at 10:00A.M., the Administrator verified the stove was not working properly and the most current bid for the replacement of the stove expired on 03/20/25. There were no current stove bids or approval for a new stove. 2. Review of the dishwasher temperature and sanitizing chemical testing logs for each meal of March and April 2026 listed the wash temperatures of 150 degrees Fahrenheit (F) or 160 degrees F and rinse temperatures of 150 degrees F, 155 degrees F or 160 degrees F, and sanitizer chemical reading at 50 parts per million (PPM). The May 2026 water temperature log listed the wash temperatures of 150 degrees F and 150 degrees F and rinse temperature of 155 degrees F and 160 degrees F. There were no dinner water temperatures and no sanitizer testing recorded for 05/01/26 through 05/03/26. Observation of the dishwasher on 05/04/26 at 9:50 A.M. with DM #31, revealed the water temperature gauges for the rinse and wash cycle were not operational and were stuck at 130 degrees F for the wash temperature and 150 degrees F for the rinse cycle. The dishwasher plate listed the dishwater as a low temperature machine requiring a wash cycle at 140 degrees F and rinse cycle at 120 degrees F. The dishwasher required a sanitizing chemical to reach sanitation levels.During an interview on 05/04/26 at 9:50 A.M., DM #131 verified the dish machine gauges were not operational and the dishwasher required a sanitizer, which should be completed and recorded. The DM #131 verified the water temperatures were not obtained with any other temperature device, the temperature logs of March, April and May of 2026 were not accurate, and sanitizing testing was not completed for May 2026. Review of facility policy titled, Food Safety and Sanitation , dated 2021, revealed all regulations will be followed in order to assure a safe ad sanity food service department. This deficiency represents non-compliance investigated under Master Complaint Number 2992266 and Complaint Number 2788567.

Based on observations, staff interviews and policy review, the facility failed to maintain a clean, comfortable and homelike environment. This affected all 22 residents (#01, #02, #03, #05, #09, #11 #12, #13 #14 #28, #35 #48, #51 #52, #53, #57, #58 #66, #69 #90, #94 and #95) residing on the 200 B hall. The facility total census was 68.Findings include:Based on observations, and interviews, the facility failed to maintain a clean comfortable homelike environment. This affected all 23 residents residing on the 200 B hall, (rooms numbers 201,202, 203, 204,205,206,207,208,209,210,211,212,213 and 214). The facility total census was 68 .Review of the facility census revealed there were 23 residing on the 200 unit B hallway. Observation on 04/027/26 through 05/04/26 at random times revealed all the residents residing on 200-unit B hallway had room entry doors and door trim with removed and peeling paint on surfaces. There was an approximate 12 foot length by 12 inch section of flooring near the nursing station with dark ,blackened built up. The entry corners and floor transition strips of each resident room had heavy blackened buildup of debris. In the hallway, near room [ROOM NUMBER], the wall guard near the floor splintered and had jagged edges of approximately six by three inches. The area was at walking and wheelchair height from the floor. The elevator had three sections of approximately eight foot in length of splintered and missing railing covers. entryway of the facility had carpeting with a heavy debris built up. The area had wallpaper removed and cove basing removed. The two ceiling lights had no covering. Interview on 05/04/26 at 9:36 A.M. the Administrator and Maintenance Director, (MD) , #109 verified the elevator, entry area, hallway and room entry areas of residents residing on the 200 unit B hallway was in of repair. The MD #109 verified the entry area and door conditions had been in disrepair for nearly two years. Review of facility policy titled, Quality of Life Homelike Environment , undated, revealed residents are provided a safe, clean, comfortable and homelike environment. This deficiency represents non-compliance investigated under Master Complaint Number 2992266 and Complaint Numbers 2796154, and 2788683.

Based on medical record review, review of personnel files, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to report possible staff to resident abuse to the state agency. This affected one (Resident #62) of three residents reviewed for abuse. Based on medical record review, review of facility SRIs, staff interview, and review of the facility policy, the facility failed to report allegations of resident to resident abuse to the state agency in a timely manner. This affected one (Resident #19) of three residents reviewed for abuse. The facility census was 68 residents. Findings include: 1. Review of the medical record for Resident #62 revealed an admission date of 03/06/25 with diagnoses including anxiety disorder, major depressive disorder, and essential hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #62 dated 03/14/26 revealed the resident had moderately impaired cognition and required staff assistance with activities of daily living (ADLs.) Review of the personnel filed for Certified Nursing Assistant (CNA) #500 revealed it included a letter dated 03/28/26 written by Receptionist #125 dictated by Resident #62 alleging the CNA had sexually abused her almost every night and she had feared him for almost three months. Review of the facility SRIs revealed there was no report made to the state agency regarding Resident #62's allegation of abuse per CNA #500. Interview on 05/04/26 at 1:01 P.M with the Administrator confirmed the facility had not reported Resident #62's allegation of abuse to the state agency due to the resident's history of making false allegations. Interview on 05/04/26 at 3:29 P.M. with the Administrator confirmed Receptionist #125 had turned in the letter which included Resident #62's allegation of abuse per CNA #500 to him on 03/29/26. 2. Review of the medical record for Resident #9 revealed an admission date of 02/21/23 with diagnoses including hemiplegia affecting left side, diabetes, heart failure, depression, bipolar disorder. Review of the MDS assessment for Resident #9 dated 04/17/26 revealed the resident had intact cognition and required moderate assistance with ADLs. Review of the SRI for Resident #9 dated 04/24/26 revealed the resident was involved in an incident with another resident on 04/22/26. Interview on 05/04/26 at 1:03 P.M. with the Administrator verified the resident-to-resident incident between Resident #9 and another resident was discovered on 04/22/26 but was not reported to the state agency until 04/24/26. The Administrator stated allegations of potential and suspected abuse should be created within two hours of discovery if the abuse involved serious injury and within 24 hours for all other allegations. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated October 2023 revealed staff should report all incidents and allegations of abuse immediately to the Administrator or designee. The facility would notify the state agency immediately, but not later than two hours after the allegation is made or the serious bodily injury identified. This deficiency represents noncompliance investigated under Complaint Number 2734919.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide an accessible private area for residents to make phone calls This affected two (Residents #9 and #13) of two residents reviewed for phone privacy. The facility census was 68 residents. Findings include: Review of the medical record for Resident #9 revealed an admission date of 02/21/23 with diagnoses including hemiplegia affecting left side, diabetes, bipolar disorder, polyneuropathy, and vascular disease. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 04/17/26 revealed the resident had intact cognition and required moderate assistance with activities of daily living (ADLs.) Review of the medical record for Resident #13 revealed an admission date of 08/04/25 with diagnoses including schizoaffective disorder, anxiety disorder, Parkinson disease, and below the left knee amputation. Review of the MDS assessment for Resident #13 dated 04/03/26 revealed the resident had intact cognition and required supervision with ADLs. Observations on 04/27/26 through 05/05/26 revealed there was a desk phone at the nurses' station which did not allow for privacy during phone calls. Interview on 04/27/26 at 9:45 A.M. with Resident #13 confirmed he did not have a room phone or a personal cell phone, and he had to make personal calls at the nurses' station. Resident #13 stated when he made personal calls to family, staff did not provide him with privacy. The resident denied he had been offered a portable phone to make private phone calls. Interview on 05/05/26 at 9:10 A.M. with Resident #9 confirmed she did not have a room phone or a personal cell phone, and she had to make personal calls at the nurses' station. Resident #9 stated when she made personal calls to family, staff did not provide her with privacy. The resident denied she had been offered a portable phone to make private phone calls. Interview on 05/05/26 at 9:14 A.M. with Unit Manager (UM) #150 verified the only phone available for residents on the 200 unit was the desk phone at the nurses' station which did not allow for privacy during phone calls. Review of facility policy Resident Rights undated revealed the residents had the right to reasonable access to a telephone for private communications.

Based on medical record review, staff interview, and policy review, the facility failed to issue residents the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) after the facility initiated discharge from Medicare part A services. This affected two (Residents #83 and #84) of three residents reviewed for beneficiary notices. The facility census was 68 residents. Findings include: 1. Review of the medical record for Resident #83 revealed an admission date of 11/03/25 with diagnoses including Marfan syndrome, seizure disorder, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment for Resident #83 dated 12/18/26 revealed the resident was cognitively impaired. Review of the Notice of Medicare Non-Coverage (NOMNC) for Resident #83 revealed Medicare Part A Services ended on 12/05/25 for the resident. The facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted, and Resident #83 decided to remain in the facility. There was no documentation of the facility's issuance of a SNF ABN to Resident #83. 2. Review of the medical record for Resident #84 revealed an admissions date of 11/10/25 with diagnoses including nontraumatic intracerebral hemorrhage, type two diabetes, and cognitive communication deficit. Review of the MDS assessment for Resident #84 dated 02/13/26 revealed the resident was cognitively impaired. Review of the NOMNC for Resident #84 revealed Medicare Part A Services ended on 12/03/25 for the resident. The facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted, and Resident #84 remained in the facility. There was no documentation of the facility's issuance of a SNF ABN to Resident #84. Interview on 04/29/2026 at 10:50 A.M. with Minimum Data Set Coordinator #190 verified that the facility had not issued SNF ABN notices to Resident #83 and #84 nor the residents' representatives when Medicare Part A Services ended. Review of the facility policy titled Best Practice Medicare Non-Coverage Part A/B dated 02/23/24 revealed if a resident remained in the facility after the last traditional Medicare A covered day, a SNF ABN notice was to be given to the resident and/or the resident's representative.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure privacy was provided during care. This affected one (Resident #7) of three residents reviewed for resident rights. The facility census was 68 residents. Findings include:Review of the medical record for Resident #7 revealed an admission date of 04/08/26 with diagnoses including acute kidney failure, Hodgkin's lymphoma, and persistent mood disorder. Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 04/15/26 revealed the resident was cognitively intact and required substantial assistance with toileting. Observation on 04/29/26 at 7:40 A.M. revealed Certified Nursing Assistant (CNA) #185 was providing toileting assistance for Resident #7 in the resident's room. The door to Resident #7's room was open to the hallway, and the CNA exposed the resident's bottom as the aide washed the resident and applied a clean incontinence brief. Interview on 04/29/26 at 7:45 A.M. with CNA #185 confirmed she had not provided visual privacy to Resident #7 during care, and she should have shut the resident's door prior to providing care. Review of the facility policy titled Resident Rights dated December 2016 revealed employees should treat all residents with kindness, respect, and dignity.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to honor resident choices regarding bathing. This affected one (Resident #19) of three residents reviewed for resident rights. The facility census was 68 residents. Findings include: Review of the medical record for Resident #19 revealed an admission date of 02/17/26 with diagnoses including transient cerebral ischemic attack, chronic obstructive pulmonary disease, type two diabetes, and morbid obesity. Review of the Minimum Data Set (MDS) assessment for Resident #19 dated 02/27/26 revealed the resident was cognitively intact and required partial/moderate assistance with bathing and substantial/maximal assistance with shower transfers. Review of the shower sheets for Resident #19 dated 03/02/26 to 04/30/26 revealed there were 11 shower sheets with three marked for bed baths and two marked as refused. Interview on 04/28/26 at 10:20 A.M. with Resident #19 confirmed he preferred to take showers as opposed to taking bed baths but he had been told by staff on several occasions that he had to have a bed bath because he require a Hoyer lift for showers. Interview on 04/30/26 at 9:30 AM with Certified Nursing Assistant (CNA) #159 verified Resident #19 required a Hoyer lift transfer for showers. CNA #159 also verified there had been times when Resident #19 did not receive a shower per the resident's preference and had to receive a bed bath instead because the facility did not have enough staff available to safely use the Hoyer lift. Review of the facility policy titled Resident Rights dated December 2016 revealed residents had the right to self-determination and participation.

Based on record review, observation, staff and physician interview, review of a self-reported incident (SRI), review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, and review of the facility policy, the facility failed to monitor and identify residents with weight loss and failed to ensure appropriate nutritional interventions were recommended and implemented to prevent severe weight loss and adverse outcomes. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death on [DATE] when Resident #61, who was at nutritional risk related to a body mass index (BMI) (A measure of body fat based on height and weight. A healthy range is 18.5 to 24.9) of 15.8 (indicating underweight), diagnosis of muscular dystrophy, and decreased ability to feed self, was not weighed from [DATE] through [DATE]. There was a lack of nutritional interventions to attempt to obtain Resident #61's weight while Resident #61 had decreased meal intakes from [DATE] to [DATE]. Subsequently on [DATE], Resident #61 was admitted to the hospital with hypoglycemia secondary to poor oral intake and weighed 65 pounds which was a severe weight loss of 36.6 percent (%). The Immediate Jeopardy continued on [DATE], when Resident #14 was identified with a severe unplanned weight loss of 16.87 % in a six-month period, developed an unstageable pressure ulcer on [DATE] to her left foot and the resident's nutritional needs and plan of care were not reassessed and/or revised as of [DATE]. This affected two residents (#61 and #14) of three residents reviewed for change in condition. The facility identified a total of nine residents as being at nutritional risk. The facility census was 60. On [DATE] at 2:35 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Operations (RDO) #930 were notified Immediate Jeopardy began on [DATE] when Resident #61 had a severe unplanned weight loss of 35.6 percent (%) over approximately five and one-half months, from [DATE] to [DATE], and the weight loss was not identified and monitored ultimately leading to the resident being admitted to the hospital with hypoglycemia secondary to poor oral intake. Additionally, they were notified the Immediate Jeopardy continued on [DATE] when Resident #14 experienced a significant weight loss of 5.8 % in a one-month period of time and Registered Dietitian (RD) #920 and Dietetic Technician (DT) #925 failed to reassess the nutritional needs of the resident and failed to ensure appropriate nutritional interventions were implemented to prevent severe weight loss. Furthermore, Resident #14 developed a facility-acquired unstageable pressure ulcer with eschar (dry, back hard necrotic tissue) and slough (dead, yellowish tissue) to the resident's left foot and continued to lose weight over time subsequently experiencing a severe 16.87 % weight loss over a six-month period. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], Resident #61 was transferred to the hospital and never returned. On [DATE], Resident #14 was assessed by the DON. The resident did have an in-house, acquired pressure ulcer to the left foot identified on [DATE]. Interventions for the in-house, acquired pressure ulcer were implemented on [DATE]. No other negative outcomes were noted. Resident #14 had an expert evaluation on [DATE] by Medical Director (MD) #935 in an attempt for the resident to receive hospice care for the weight loss, and no other concerns were noted. On [DATE], all residents were audited by the DON for any residents that had a significant weight loss according to the facility's policy. Any resident with a significant weight change, according to the policy, will be provided immediate interventions for weight loss. On [DATE], skin sweeps for all residents in the facility were completed with Wound Physician (WP) #940 and Assistant Directors of Nursing (ADONs)/Licensed Practical Nurses (LPNs) #725 and #815 with no new skin areas noted. On [DATE], the DON was educated by Regional Director of Clinical Operations (RDCO) #945 on the following: Weights and documentation of weights must be completed in a timely manner, monthly weights are to be completed by the fifth of each month, reweights are to be completed by the seventh of each month and weekly weights are to be completed by the date determined based on the admitted . On [DATE], ADON/LPNs #725 and #815 were educated by the DON on the following: Weights and documentation of weights must be completed in a timely manner, monthly weights are to be completed by the fifth of each month, reweights are to be completed by the seventh of each month and weekly weights are to be completed by the date determined based on the admitted . On [DATE], all nurses and State tested Nursing Assistants (STNAs) in the facility were educated by the DON/Designee on the following: Weights and documentation of weights must be completed in a timely manner, monthly weights are to be completed by the fifth of each month, reweights are to be completed by the seventh of each month and weekly weights are to be completed by the date determined based on the admitted . The facility does not utilize agency staff. All as needed (PRN) staff and/or staff off work will receive education per the DON/Designee prior to working a shift. On [DATE], all nursing staff were educated by the DON/Designee regarding if any resident refuses to be weighed, it will be documented in the progress notes. On [DATE], all nursing staff were educated by the DON/Designee to notify MD #935 of any resident refusing to be weighed. On [DATE], the DON was educated by the Administrator that all weights must be reviewed in the ongoing weekly risk meeting attended by the DON, LPNs (#725 and #815), Social Worker (SW) #950, Minimum Data Set (MDS) Nurse #850, and Therapy Manager #845. RD #920 will identify residents at increased nutritional risk or weight changes for discussion by the Interdisciplinary Team (IDT) at the weekly meeting. Results will be shared with MD #935 and with the Quality Assurance Performance Improvement (QAPI) Committee. On [DATE], the Administrator and DON reviewed the policy on weight management and there were no changes made. On [DATE], to monitor ongoing compliance, all residents at increased nutritional risk and/or significant weight changes will be weighed weekly for six weeks. The DON/Designee will audit the weights weekly for six weeks to ensure there is no significant weight change without interventions or notification of MD #935. The DON/Designee will audit residents who refused to be weighed weekly for six weeks. The DON/Designee will attempt to reweigh any resident and document the second attempt. Any negative findings will be immediately corrected and reviewed in the weekly risk meeting and the monthly QAPI meeting. The next QAPI meeting will be held on [DATE], and the QAPI committee will determine the need for ongoing monitoring. On [DATE], RD #920 and DT #925 were educated by the RDCO #945 on the process for obtaining weight information and communicating with the DON and the IDT regarding residents with identified nutritional concerns and/or unplanned weight changes. On [DATE], RD #920 assessed Resident #14 and reviewed and updated Resident #14's nutritional care plan and interventions. On [DATE], RD #920 reviewed all residents in the facility and compiled a list of residents at increased nutritional risk and/or significant weight change. RD #920 reviewed and update the care plans of residents at increased nutritional risk and/or significant weight change. RD #920 identified eight additional residents (#01, #13, #04, #10, #37, #20, #29, and #33) at nutritional risk and reviewed and updated their care plans and implemented interventions. On [DATE], between 11:58 A.M. and 12:37 P.M., Registered Nurse (RN) #105, LPN #725, and STNAs #385, #435, and #480, verified they were educated on the process for obtaining and documenting resident weights and how to respond if a resident refused to be weighed. All staff members interviewed were knowledgeable of the content of each education provided by the facility. On [DATE], the surveyor completed review of the medical records for Residents #20, #33, and #37, identified as being at nutritional risk, and revealed no concerns related to monitoring for weight changes. The resident's assessments were current and accurate, and care plans were initiated and updated with appropriate interventions to prevent weight loss/change. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of the medical record for Resident #61, revealed a readmitted [DATE] with diagnoses including, but not limited to, muscular dystrophy, multiple sclerosis (MS), and cardiomyopathy. Review of the facility weight records for Resident #61, revealed the resident was 67 inches tall and his weight on [DATE] was 100.1 pounds, weight on [DATE] was 100.0 pounds, and weight on [DATE] was 101.0 pounds. There were no subsequent weights documented for the resident. Review of the nurse's progress notes from [DATE] to [DATE] for Resident #61, revealed there were no weights or refusals to be weighed documented for the resident. Review of the nutritional progress note dated [DATE] for Resident #61 authored by RD #920, revealed the resident had a low BMI of 15.8 indicating the resident was underweight. The most current weight available for the resident was 101 pounds obtained on [DATE]. Resident #61 consumed 50 to 75 % at meals and was noted with meal refusals. The resident was at nutritional and hydration risk due to refusal of food, medications, care, and a low BMI. No new recommendations were made. Review of the Minimum Data Set (MDS) assessment 3.0 dated [DATE] for Resident #61, revealed the resident was cognitively impaired and required extensive assistance of two staff with bed mobility and transfers and extensive assistance of one staff with eating. Review of section-K (swallowing/nutrition) revealed the resident was 67 inches in height and no weight was recorded for the resident and weight loss was not assessed. Review of the nutritional progress note dated [DATE] for Resident #61 authored by DT #925, revealed the most current weight available for the resident was the weight of 101 pounds obtained on [DATE]. DT #925 made no new nutritional recommendations. Review of the care plan updated on [DATE] for Resident #61, revealed the resident was at risk for altered nutritional status as evidenced by being underweight related to diagnosis of muscular dystrophy and was dependent on staff for feeding. Resident has a low BMI with a need to avoid weight loss. The residents by mouth (PO) intakes were variable with suboptimal intake and a need for supplementation. The goal of the care plan was the resident will maintain or gain weight as per the nutritional plan. Interventions included: honor food preferences by providing select menus, obtain laboratory (labs) as ordered and notify physician of the results, provide additional calories/protein at meals per patient preference, provide supplements as ordered, review weights and notify the physician of significant weight change, and provide total assistance with feeding. Review of the nutritional progress note dated [DATE] for Resident #61 authored by RD #920, revealed the most current weight available for the resident was the weight of 101 pounds obtained on [DATE]. RD #920 made no new nutritional recommendations. Review of MD #935 physician's progress note dated [DATE] for Resident #61, revealed the resident's appetite varied, and the resident was getting nutritional supplements. Resident #61 had a thin build, and the staff reported no changes. No weight loss was noted, and the resident's assessment/plan included malnutrition and a plan to encourage oral diet and supplements. However, review of the physician orders and care plan for Resident #61, revealed there were no nutritional supplements ordered for Resident #61 from [DATE] until [DATE]. Review of the physician orders dated [DATE] for Resident #61, revealed orders for the resident to receive a regular diet, mechanical soft texture with thin liquids, Protein liquid 30 milliliters by mouth daily at 9:00 A.M. for wound healing and Ensure Plus supplement (a high calorie supplement) three times daily with meals. Review of the meal intake records dated [DATE] to [DATE] for Resident #61, revealed the resident refused four meals during the time period and his intake was variable from 25 to 100 %. Review of the nutritional progress note dated [DATE] for Resident #61 authored by RD #920, revealed the most current weight available for the resident was the weight of 101 pounds obtained on [DATE]. RD #920 made the recommendation to increase resident's liquid protein supplement to twice daily and made no changes to the resident's care plan. RD #920 documented the resident's weight was stable. Review of the nurse progress note for Resident #61 dated [DATE] at 7:42 P.M., revealed the resident called nine-one-one (911) due to complaints of nausea. Resident #61 had refused staff's offer for an as needed (PRN) Zofran (medication for nausea and vomiting) when EMS arrived. Review of the hospital's admitting history and physical dated [DATE] at 11:58 P.M. for Resident #61, revealed criminal neglect was suspected, and the nurse was going to contact adult protective services. Resident #61 was bedridden with severe contractures related to muscular dystrophy and was unable to feed himself. The resident complained on admission that facility had not fed him since last Thursday due to the nursing home staff refused to feed him and his admitting diagnoses were failure to thrive and hypoglycemia (low blood glucose levels). Lab results showed the resident's blood sugar upon arrival at the hospital was 48 (low). Review of the MDS assessment 3.0 dated [DATE] for Resident #61, revealed the resident was discharged with a return not anticipated (DRNA) and review of Section-K, revealed the resident was 67 inches in height and no weight was recorded and weight loss was not assessed. Review of the hospitalist's (hospital physician) progress note dated [DATE] at 4:04 P.M. for Resident #61, revealed the resident's body weight upon admission to the hospital was 65.6 pounds with a BMI of 10.24 (underweight). Resident #61 was admitted to the hospital with hypoglycemia secondary to poor oral intake and the resident's blood sugars improved after receiving intravenous (IV) dextrose (sugar). The physician did not see any major acute medical problems requiring continued hospital stay, but the hospital needed to determine alternate placement for the resident. Review of the hospital's dysphagia evaluation dated [DATE] for Resident #61, revealed the resident presented to the hospital with failure to thrive and hypoglycemia with blood sugars in the forties and it appeared as if resident had not been receiving good care. The resident reported he was on a regular solid diet with thin liquids at the facility. The resident required one-on-one feeding and reported the facility staff had not fed him since last Thursday. Review of the SRI created on [DATE], revealed the facility investigated an allegation of neglect for Resident #61 based upon reading the hospital notes and determined the facility was not able substantiate neglect. Interview on [DATE] at 1:14 P.M. with RD #920, verified the last recorded weight the facility had for Resident #61 was obtained on [DATE] for 101 pounds. RD #920 confirmed the facility had an ongoing problem obtaining and recording the resident's weights. RD #920 confirmed she visited the facility on a monthly basis and DT #925 visited the facility on a weekly basis. RD #920 indicated Resident #61 frequently refused meals and care. RD #920 confirmed she did not make any recommendations for the significant weight loss when she assessed him on [DATE], [DATE], and [DATE] because she had not been informed of any weight loss for the resident. Interview on [DATE] at 1:25 P.M. with DT #925 confirmed the last recorded weight the facility had for Resident #61 was obtained on [DATE]. DT #925 confirmed she did not make any nutritional recommendations for Resident #61 when she assessed him on [DATE] because as far as she knew, his weight was stable at 101.0 pounds. DT #920 indicated Resident #61 had a low BMI and frequently refused meals and care. Interview on [DATE] at 2:04 P.M. with the Administrator and the DON confirmed the facility investigated an allegation of neglect for Resident #61 and reported the allegation as part of the facility submitted SRI dated [DATE] based on reading the hospital notes for Resident #61 dated [DATE] and [DATE]. The DON confirmed Resident #61 was not a diabetic and the facility had no recent blood sugars for the resident, and hospital notes indicated resident's blood sugar was 48 upon arrival to the emergency room . The DON confirmed she was aware the resident's admitting weight at the hospital was 65 pounds which represented a 36-pound weight loss and a 35.6 % weight loss from his last recorded weight at the facility. The DON confirmed the resident did not return to the facility, and they were notified he was placed at a different facility. The DON further indicated Resident #61 had a history of refusal of care and meals at times, but confirmed the facility had no documentation of the resident's refusal of the monthly weights for March through [DATE]. Interview on [DATE] at 2:37 P.M. with Dietary Manager (DM) #465, verified Resident #61 received a regular diet mechanical soft texture with thin liquids. DM #465 confirmed she was unaware of the resident's meal intakes or weights, but the kitchen sent trays to the nursing floor for the resident on a daily basis. Interview on [DATE] at 10:34 A.M. with the DON, revealed it was the STNAs responsibility to obtain the monthly weights by the fifth day of each month and the nurses should record the weights in the resident's electronic medical record (EMR) in the weight section for RD #920 and DT #925 to review during their visits to the facility. Interview on [DATE] at 12:50 P.M. with STNA #385, revealed Resident #61 was always very thin and very contracted and required total assistance of staff with feeding and even with providing a liquid supplement. STNA #385 indicated the resident occasionally refused meals but would usually accept a liquid supplement. STNA #385 confirmed the STNAs documented meal intakes and refusals of meals in the EMR. STNA #385 confirmed the STNAs obtained weights when requested by the nurses. STNAs would hand-write the weights on paper for the nurses to record in the EMR. If a resident refused to be weighed, the STNAs would note the refusal on paper and also report it verbally to the nurse. STNA #385 confirmed she did not recall Resident #61 refusing weights for her and she could not recall the last time she had weighed him. STNA #385 confirmed the resident had been at the facility for years and had always looked thin, but in June of 2023 he looked even thinner than usual which she had mentioned to the nurses. Interview on [DATE] at 1:07 P.M. with STNA #780, revealed Resident #61 could not feed himself and staff had to even hold his Ensure supplement for him. STNA #780 confirmed Resident #61 was very thin and was not a big breakfast or lunch eater but would usually accept dinner when she tried to feed him. STNA #780 confirmed STNAs were responsible to get weights when assigned by the nurses and would hand-write them on a paper to give to the nurses to record in the EMR. STNA #780 confirmed she had not been asked to obtain a weight for Resident #61 during his stay at the facility, but he looked extremely thin in June of 2023, the last time she cared for him. Interview on [DATE] at 2:58 P.M. with the DON, confirmed she found a handwritten list of weights in the ADONs office which was now assigned to LPN #815. Resident #61's name was on the handwritten list and under April, May and [DATE] was marked for refused under the space where his monthly weight should be. The DON confirmed the list was found on [DATE] and the information had not been entered into the EMR or shared with the attending physician, RD #920, or DT #925. Interview on [DATE] at 3:18 P.M. with ADON/LPN #815, for the second floor, indicated she had been employed by the facility since the end of [DATE]. LPN #815 confirmed she and the DON were looking through papers in her office on [DATE] and found the handwritten list of weights for the second floor for April, May, and [DATE]. LPN #815 confirmed she was aware the list of weights was in her office. LPN #815 confirmed she was new to the facility and only knew Resident #61 briefly before he was discharged from the facility. LPN #815 confirmed Resident #61 was extremely thin and had to be fed by staff and she was unaware of him refusing to be weighed. Interview on [DATE] at 12:29 P.M. with the DON confirmed the facility held weekly risk meetings which RD #920 and DT #925 did not attend, but they sent her a list of the residents with increased nutritional risk or weight loss concerns. The DON confirmed they had sent no information regarding concerns for Resident #61's nutritional status or weight and/or refusal of weights in May or [DATE]. Interview on [DATE] at 2:06 P.M. with MD #935 confirmed Resident #61 was severely debilitated due to diagnosis of Muscular Dystrophy and required total assistance of staff with feeding and activities of daily living although resident frequently refused care and refused to be evaluated. MD #935 confirmed Resident #61 was not diabetic and did not have orders to have his blood sugar monitored and was unaware the resident had been admitted to the hospital on [DATE] with a diagnosis of hypoglycemia. Interview confirmed MD #935 was not notified of the resident's severe weight loss of 35.6 % from 101.0 pounds on [DATE] to his next recorded weight of 65 pounds on [DATE] upon admission to the hospital. The facility did not notify him of resident refusals of weight, nor was it documented in the resident's record. MD #935 confirmed he was the Medical Director for the facility and attended the quarterly QAPI meetings, but he never heard the facility staff discuss concerns with obtaining and monitoring resident weights. 2. Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure, with hypoxia anxiety disorder, dysphagia, bipolar disorder, and polyosteoarthritis. Review of the weight record for Resident #14 documented in the EMR, revealed the resident weighed 247.8 pounds on [DATE], 246 pounds on [DATE] and 231.6 pounds on [DATE]. The medical record had no documented evidence of any subsequent weights for the resident. Review of the nutrition progress note dated [DATE] for Resident #14 authored by DT #925, revealed the resident's [DATE] weight was 231.6 pounds which represented a significant weight loss of 14.4 pounds from the previous month's weight of 246.0 pounds. This was a 5.9 % loss and DT #925 requested a reweight be obtained to confirm the weight loss. There was no evidence a reweight was obtained and no new interventions implemented and or nutrition recommendations for the 5.9 % weight loss from [DATE] to [DATE]. Review of the physician orders dated [DATE] for Resident #14, revealed the resident was ordered to receive a regular diet, pureed texture, and thin consistency liquids. Review of the nutritional progress note dated [DATE] for Resident #14 authored by DT #925 revealed the most current weight available for the resident was the weight of 231.6 pounds obtained on [DATE]. The resident was on a regular puree diet with thin liquids and was to have one-on-one feeding assistance during meals. The resident's intakes were poor, and she was consuming ,d+[DATE] % of meals and her BMI was 34.2 (obese stage). The note revealed the resident's weight for [DATE] was not available. DT #925 made recommendations for an appetite stimulant and house shakes (supplement) three times daily due to resident's nutrition and hydration risk related to diagnosis, pureed diet texture, and poor intake. Further review of the medical record revealed the house shakes three times daily were not implemented until three months later on [DATE] and there was no documented evidence the recommendation for an appetite stimulant was considered and/or implemented. Review of the care plan updated [DATE] for Resident #14, revealed the resident was at nutritional risk related to COPD, dysphagia, anxiety, obesity (BMI greater than 30), intakes less than 50 %, and mechanically altered diet related to dysphagia. Interventions included the following: assess resident for signs and symptoms of aspiration, assist resident with meals as needed, follow dysphagia guidelines as ordered, elevate head of bed as ordered, honor food preferences as able, monitor for signs and symptoms of dehydration, obtain weights as ordered, and provide diet as ordered. Review of the physician progress note dated [DATE] for Resident # 14, revealed the resident had increased confusion and required increased assistance with ADLs including needing to be fed. Review of the physician progress note dated [DATE] for Resident #14, revealed the resident was experiencing a decline in condition physically and cognitively and had lost weight recently. The nursing staff asked if resident qualified for hospice due to weight loss and dysphagia. The assessment/plan for the resident's weight loss/malnutrition, indicated the resident did not want a feeding tube and staff should encourage oral diet and supplements. Review of the hospice assessment dated [DATE] for Resident #14, revealed the nurse assessed the resident for appropriateness of hospice services per the order/request of the resident's physician. The assessment revealed the resident was appropriate for hospice services due to diagnoses of cerebrovascular disease, dysphagia, and weight loss. The note revealed the assessment of weight loss for Resident #14 was based on the most current available weight of 231.6 pounds obtained on [DATE]. Additional record review revealed the resident was never admitted to hospice due to MD #835 noting the resident was cognitively impaired and was not able to make decisions and when the family was consulted, they didn't want to be involved in the resident's care. The facility was in the process of obtaining a court ordered guardian. Review of the MDS assessment 3.0 dated [DATE] for Resident #14, revealed the resident was cognitively impaired and required extensive assistance of one to two staff with ADLs. Resident #14 required extensive assistance of one staff with eating. Review of Section K of the MDS, revealed the resident was 69 inches tall, and no weight was recorded for the resident and weight loss was not assessed. Review of the social service progress note dated [DATE] for Resident #14, revealed the resident was declining and unable to make decisions for herself but might be appropriate for hospice. Social services contacted the resident's emergency contact regarding hospice services without success. Review of the physician progress note dated [DATE] for Resident #14, revealed the resident had dysphagia and continued on a puree diet and had to be fed by staff. The resident's appetite was poor, and the resident had lost some weight recently. Staff should encourage oral diet and supplements. The assessment/plan for the resident's weight loss/malnutrition, indicated the resident refused a feeding tube and staff to encourage oral diet and supplements. Review of the nurse progress note dated [DATE] for Resident #14, revealed an STNA notified the nurse of an area to the resident's left plantar foot. Skin preparation was applied, and the resident was added to the wound physician rounds. Review of the wound physician progress note dated [DATE] for Resident #14, revealed the resident had a newly identified unstageable pressure ulcer (obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage III or Stage IV pressure injury will be revealed) with onset date of [DATE] on the left plantar foot which measured 2.5 centimeters (cm) in length by 2.2 cm in width with the wound bed obscured by 70 % eschar and 30 % slough. Observation of wound care for Resident #14 on [DATE] at 12:49 P.M. per LPN #815, revealed the resident was resting on a pressure reduction mattress with padding to the footboard. Observation revealed the resident had a dime-sized pressure ulcer to her left plantar foot with minimal amount of slough observed to wound bed. Observation of the lunch meal for Resident #14 on [DATE] at 1:04 P.M., revealed the resident was served a puree diet in her room and fed by STNA #455 with the head of her bed elevated. Resident #14 was totally dependent on staff for feeding and was not able to participate in a meaningful interview due to cognitive impairment. The resident consumed approximately 75% of the meal. Interview on [DATE] at 1:25 P.M. with DT #925 confirmed the last recorded weight the facility had for Resident #14 was obtained on [DATE] and she requested a reweight to confirm the significant weight loss in the one-month time period. DT #925 confirmed when she assessed Resident #14 on [DATE], the facility had not obtained a re-weight. DT #925 confirmed she had not assessed Resident #14's nutritional status since that time and heard the resident was going to be signing up for hospice. DT #925 confirmed she made recommendations for Resident #14 to be started on an appetite stimulant medication and to receive house shakes three times daily due to the presumed weight loss. DT #925 was unsure if her recommendations had been implemented. DT #925 was unaware Resident #14 had a pressure ulcer. Interview on [DATE] at 2:58 P.M. with the DON confirmed she found a handwritten list of weights in the ADON's office which was now assigned to LPN #815. Resident #14 was on the handwritten list and the following weights were listed for Resident #14: [DATE] was 221.0 pounds, [DATE] weights were 215.6 pounds and 211.4 pounds, and June weight was 206.0 pounds. The DON confirmed the list was found on [DATE] and the information had not been entered into the EMR or shared with the attending physician, RD #920 or DT #925. The DON confirmed the facility had not yet obtained a [DATE] weight for Resident #14. Interview on [DATE] at 3:18 P.M. with LPN #815, confirmed she and the DON were looking through papers in her office on [DATE], and found the handwritten list of weights for the second floor for April, May, and [DATE]. LPN #815 confirmed she had not been aware the list of weights was in her office. LPN #815 confirmed she was new to the facility and had a start date in June of 2023. LPN #815 confirmed Resident #14 was overweight but had a poor appetite and had to be fed a puree diet by staff. LPN #815 confirmed Resident #14 developed an in-facility acquired unstageable pressure ulcer to her left foot on [DATE] and was receiving daily treatments for the ulcer. Review of a facilities hand-writ [TRUNCATED]

Based on record review, observation, staff interview, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin and failed to timely identify a resident's pressure ulcer until it reached an advanced stage which resulted in actual harm to Resident #14 who was admitted to the facility without pressure ulcers and developed an unstageable pressure ulcer to the left plantar foot. This affected one (Resident #14) of three residents reviewed for pressure ulcers. The facility census was 60. Findings include: Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure (CRF) with hypoxia, anxiety disorder, bipolar disorder, and polyosteoarthritis. Review of the care plan dated 05/02/19 for Resident #14, revealed the resident had a potential for impairment to skin integrity related to incontinence, impaired mobility, and hypertension. Interventions included the following: educate resident/family/caregivers of causative factors and measures to prevent skin injury, identify/document potential causative factors and eliminate/resolve where possible, incontinence care as needed, assist to turn/reposition at least every two hours as needed, report any reddened or open areas, obtain blood work as ordered, and pressure relieving devices to the bed. Review of the pressure ulcer risk assessment dated [DATE] for Resident #14, revealed the resident was at risk for the development of pressure ulcers. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #14, revealed the resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADLs.) Resident #14 was assessed as not having the presence of pressure ulcers. Review of the weekly skin checks dated 06/21/23 and 06/28/23 for Resident #14, revealed there were no pressure ulcers noted. Review of the nurse's progress note dated 06/30/23 for Resident #14, revealed a State tested Nursing Assistant (STNA) notified the nurse of an area to the resident's left plantar foot. Skin preparation was applied, and the resident was added to the wound physician rounds. Review of the wound physician's progress note dated 06/30/23 for Resident #14, revealed the resident had a newly identified unstageable pressure ulcer to the left plantar foot which measured 2.5 centimeters (cm) in length by 2.2 cm in width with the wound bed obscured by 70 percent (%) eschar (dry, back hard necrotic tissue) and 30 % slough (dead, yellowish tissue). The physician noted the wound occurred due to pressure from the footboard on the resident's bed. Review of the wound grid dated 07/02/23 for Resident #14, revealed the pressure ulcer to the resident's left plantar foot measured 3.0 cm in depth and 2.3 cm in width and the pressure ulcer was caused by the bed footboard. Observation of wound care on 07/21/23 at 12:49 P.M. for Resident #14 completed by Licensed Practical Nurse (LPN) #815, revealed the resident was resting on a pressure reduction mattress with padding to the footboard. The observation revealed the resident had a dime-sized pressure ulcer to her left plantar foot with minimal amount of slough observed to the wound bed. Interview with LPN #815 on 07/21/23 at 1:08 P.M., confirmed Resident #14 developed an unstageable pressure ulcer to her left plantar foot related to pressure from the resident's left foot against the metal prong attaching the controls for the low air loss mattress (LLAM) to the footboard of the bed. LPN #815 confirmed the facility put the padding in place to the foot board after the pressure ulcer was identified on 06/30/23. Interview with Director of Nursing (DON) on 07/21/23 at 3:56 P.M., confirmed Resident #14 had skin checks on 06/21/23 and 06/28/23 which indicated resident had no pressure ulcers. The DON confirmed the staff identified an area to resident's left plantar foot on 06/30/23 which was assessed by the wound physician on 06/30/23. The wound physician determined the resident had an unstageable pressure ulcer to her left plantar foot which was covered with slough and eschar and was caused by the footboard. The DON confirmed the facility applied padding to the resident's footboard after the area was identified. The DON confirmed the ulcer was not identified until it had reached an advanced stage. Review of the facility policy titled Skin Care dated June 2023 revealed skin care and skin assessments are provided to the residents. The facility will provide the care necessary to decrease the risk of a resident developing a pressure injury. Skin will be observed upon admission and routinely throughout the resident's stay. Preventative care plans will be developed and implemented. Review of the NPUAP guidelines dated 2014 pages 70-71 at (https://npiap.com/general/custom.asp?page=2014Guidelines) revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. This deficiency represents non-compliance investigated under Complaint Number OH00144214.

Based on record review, observation, staff interview, review of facility policy, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to thoroughly assess and monitor residents for skin breakdown. This resulted in Actual Harm when Resident #31 and #66's pressure ulcers were not identified by the facility until the ulcers were at a Stage III or full thickness skin loss. In addition, the facility failed to initiate timely wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected two (#31 and #66) of three residents reviewed for pressure ulcers. Facility census was 64. Findings include: 1. Review of the medical record for Resident #31 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment for Resident #31 dated 04/08/22 revealed the resident was cognitively impaired and required extensive assistance of two staff with Activities of Daily Living (ADL's). Further review of the MDS revealed Resident #31 was coded as negative for the presence of pressure ulcers but was at risk for the development of pressure ulcers. Review of the care plan for Resident #31 dated 08/11/20 revealed the resident had the potential for impairment to skin integrity related to incontinence and impaired mobility. Interventions included the following: educate resident/family/caregivers of causative factors and measures to prevent skin injury, identify/document potential causative factors and eliminate/resolve where possible, incontinence care as needed, assist to turn/reposition at least every two hours as needed, report any reddened or open areas, obtain blood work and cultures of any open wounds as ordered by the physician, and needs pressure relieving/reducing mattress to protect the skin while in bed. Review of the nurse progress note for Resident #31 dated 04/24/22 revealed staff noted the resident had an open area to the buttock measuring 3.0 centimeters (cm) in length by 0.5 cm in width with a small amount of blood. Agency Nurse #09 cleansed the area with normal saline and left it open to air. The on-call Nurse Practitioner (NP) was notified, and the plan was for Resident #31 to be seen by the wound nurse. Review of the wound assessment for Resident #31 dated 04/27/22 per Registered Nurse (RN) #100 revealed the resident had a Stage III pressure ulcer to the left buttock which was not present upon admission or related to a Leave of Absence (LOA). The wound was assessed as 2.7 cm in length by 1.0 cm in width by 0.1 cm in depth with minimal serosanguinous drainage. Review of the wound assessment for Resident #31 dated 04/27/22 per wound Medical Doctor (MD) #150 revealed the resident had a Stage III pressure ulcer to her left buttock which was assessed as 2.7 cm in length by 1.0 cm in width by 0.1 cm in depth with minimal exudate. MD #150's notes indicated the wound was first identified by the facility on 04/24/22. MD #150's recommendations were for Resident #31 to be placed on a low air loss mattress to aid in wound healing and the recommended treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the April 2022 monthly physician orders for Resident #31 revealed an order dated 04/29/22 for a low air loss mattress due to Stage III pressure ulcer to the left buttock and an order dated 04/30/22 to cleanse pressure ulcer to left buttock with NS, apply wound gel to the wound bed and cover with a DCD once daily. Review of the April 2022 Treatment Administration Record (TAR) for Resident #31 revealed the low air loss mattress was initiated on 04/29/22 and the treatment to the resident's pressure injury was initiated on 04/30/22. Observation on 05/23/22 at 1:50 P.M. of wound care for Resident #31 by RN #100 and Licensed Practical Nurse (LPN) #200 revealed the resident was on a low air loss mattress and had an open and healing Stage III pressure ulcer to her left buttock which was approximately one cm in diameter. Interview on 05/23/22 at 1:50 P.M. with RN #100 confirmed the wound was classified as a Stage III pressure ulcer and was first identified on 04/24/22 by an Agency Nurse #09 and she assessed the wound on 04/27/22. Interview on 05/24/22 at 9:13 A.M. with the Director of Nursing (DON) confirmed Resident #31's pressure ulcer to her left buttock was first identified on 04/24/22 when it was already at a Stage III which is a more advanced stage. The DON further confirmed the treatment order for Resident #31 was not started until 04/30/22. Interview on 05/24/22 at 9:18 A.M. with RN #100 confirmed after she assessed Resident #31's wound on 04/27/22, she cleansed the wound with normal saline, applied wound gel and covered it with a dry dressing. RN #100 confirmed she did not document wound care in the TAR or the nursing notes. RN #100 confirmed the record contained no documentation regarding administration of wound care for Resident #31 on 04/25/22, 04/26/22, 04/28/22, and 04/29/22. 2. Review of the medical record for Resident #66 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, Resident #66 received diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #66 was discharged from the facility on 04/25/22 and did not return to the facility. Review of a significant change MDS assessment for Resident #66 dated 04/12/22 revealed the resident was cognitively impaired, required extensive assistance of two staff with ADL's, was coded as positive for presence of a pressure ulcer not present upon admission to the facility and was at risk for the development of pressure ulcers. Review of the care plan for Resident #66 dated 07/27/20 revealed the resident was at risk for experiencing an alteration in skin related to disease process, and incontinence. Interventions included the following: administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered and monitor for effectiveness, follow facility protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of weekly skin assessments for Resident #66 per licensed nurse dated 01/31/22 and 02/07/22 revealed the resident had no pressure areas and no non-pressure areas. Review of weekly skin assessment for Resident #66 per licensed nurse dated 02/11/22 revealed the resident had a skin tear to the left buttock and no pressure areas. Review of a nurse progress note for Resident #66 dated 02/11/22 revealed a new order was obtained to cleanse a six cm by six cm skin tear to left buttocks daily with NS or wound cleanser, apply Triple Antibiotic Ointment (TAO) and non-adherent dressing. Review of the note for Resident #66 per MD #150 dated 02/16/22 revealed the resident had a skin tear to the left buttocks first observed by staff on 02/11/22 which measured six cm by six cm. Review of the February 2022 TAR for Resident #66 revealed an order dated 02/11/22 was signed off to cleanse skin tear to left buttock with NS or wound cleanser, apply TAO and non-adherent dressing daily once daily. The order to the left buttock was changed on 02/17/22 to cleanse skin tear to left buttocks with NS or wound cleanser, apply Santyl nickel thick and cover with moist gauze and dry sterile dressing daily. Review of the wound assessment for Resident #66 dated 02/16/22 revealed the resident had a Stage III pressure ulcer to the sacrum which was not present upon admission nor related to a LOA. The wound was assessed as 2.1 cm in length by 1.0 cm in width and depth was unable to be determined. Review of the wound assessment for Resident #66 dated 02/16/22 per MD #150 revealed the resident had a Stage III pressure ulcer to her sacrum which was assessed as 2.1 cm in length by 1.0 cm in width with a depth which was unable to be determined. The wound bed was 85 percent (%) slough tissue. MD #150 provided sharp debridement of the wound at the bedside, and it measured 1.8 cm in length by 0.9 cm in width by 0.3 cm in depth post debridement. The physician recommended the wound be treated with enzymatic [MEDICATION(S)] agent, Santyl and that resident be placed on a low air loss mattress. Interview on 05/24/22 at 9:13 A.M. with the DON confirmed Resident #66's pressure ulcer to her sacrum was first identified on 02/16/22 when it was already at a Stage III, which is a more advanced stage. Review of the facility policy titled Prevention of Pressure Injuries dated April 2020 revealed the facility staff should inspect residents' skin on a daily basis when performing or assisting with personal care or ADL's, identify any signs of developing pressure injuries (i.e., non-blanchable [CONDITION(S)]) or for darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency, and should inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). Review of the NPIAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [CONDITION(S)], and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for [CONDITION(S)] (redness of the skin) was the first component of every skin inspection. Skin redness and tissue [CONDITION(S)] resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominence's including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. Further review of the NPIAP revealed a Stage III Pressure Injury is full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This deficiency substantiates Complaint Number OH 500.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, observation, resident interview and staff interview, the facility failed to ensure Resident #30 received adequate assistance with repositioning in the bed to prevent the resident from falling. Actual harm occurred to Resident #30 when she fell off the bed, onto the floor during the changing of bed linens and sustained a questionable subarachnoid hemorrhage within the left frontal region. This affected one (Resident #30) of three residents reviewed for falls. The facility census was 99. Findings include: Record review for Resident #30 revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of a care plan, dated 06/24/18, revealed the resident was at risk for falls related to history of falls. Interventions included to encourage her to transfer and change positions slowly and required two-person assistance. Review of a nurse aide form titled Kardex, dated 06/24/18, revealed she was a fall risk and the facility was to provide assistance to transfer and ambulate as needed assistance with two staff members. Review of an admission Minimum Data Set (MDS) assessment, dated 07/01/18, revealed Resident #30 was cognitively intact. She required extensive assistance for bed mobility and transfers with two-person assistance. Review of progress note, dated 08/19/18 at 2:35 P.M., revealed Resident #30 was found in a sitting position next to her bed and State tested Nurse Aide (STNA) #40 was in the room with the resident. It was documented the STNA was present with the resident and stated she was performing care and turned the resident while she was in bed and the resident rolled out of bed and onto the floor. The resident stated she struck her head on the left side and reported tenderness to touch at left temporal without visual injury. Review of the hospital notes, dated 08/19/18, revealed upon assessment at the hospital, the resident reported she fell out of bed when one staff member had assisted her with care and there should have been two persons assisting her. The note further revealed the examination of a Computed Tomography (CT) scan of the head revealed a questionable subarachnoid hemorrhage within the left frontal region and given the surrounding bony overgrowth this could represent artifact. Review of fall investigation, dated 08/19/18, revealed STNA #40 stated Resident #30 asked for assistance to be changed. She stated she wasn't assigned to her room, but the other three aides were in other rooms and not available at the time. The STNA stated she cleaned the resident and changed the sheet and stated as she was turning to change the sheets and pulled them, and the resident fell out of the bed, onto the floor, and hit her head. Observation of Resident #30 on 09/13/18 at 11:40 A.M. revealed she was lying in a low bed, her call light was within reach, and her room was without clutter. Interview with the Director of Nursing (DON) on 09/13/18 at 11:08 A.M. revealed she wasn't aware the MDS dated on admission 07/01/18 had a two-person assistance for bed mobility. She stated she went directly to the Kardex at the time and it said the resident was a one-person assistance and stated it was changed when the resident returned from the hospital because she was diagnosed with [REDACTED]. When asked for the Kardex that said the resident was a one-person assistance at the time of the fall it could not be found. She further stated STNA #40 no longer worked in the facility. Another interview with the DON on 09/13/18 at 2:30 P.M. verified Resident #30 fell out of the bed but stated she thought the STNA #40 did not roll her but stuffed the sheets under her and when she went to pull the sheets out from under the resident, she fell out of bed opposite of where the STNA was standing. Interview with Resident #30 on 09/13/18 at 11:42 A.M. revealed she remembered the fall and stated the STNA flipped her over, which flipped her out of the bed and hit the left side of head on the corner of the night stand table. She stated she went out to the hospital and had a CT scan and it was determined she had a bleed. She stated she always had two staff members to assist with care since she was admitted to the facility and she stated she told STNA #40 there needed to be two staff members and the STNA insisted she could do the care by herself. She stated if one staff member came to her room she refused the care. She stated the fall was very painful and she stated there was still bleeding in there. She stated she does have some pain in her forehead at times. An attempt to interview STNA #40 on 09/13/18 at 12:26 P.M. during the survey was unsuccessful. Interview with STNA #45 on 09/13/18 at 3:10 P.M. revealed when she changed the sheets for a resident, you make sure the resident was rolled towards you, to keep them safe, if you are providing care by yourself. As a result of the incident, the facility took the following action to correct the deficient practice by 09/06/18: · On 08/20/18, the facility ensured the Kardex's for all residents matched what the functional assistance was for bed mobility for all the residents. · On 08/20/18, the facility ensured care was monitored for those residents who required a two-person assistance while being bathed in bed every day for a week, twice a week for two weeks and then weekly. · On 08/21/18, all 54 licensed nursing staff were in-serviced on fall policy and procedures. This deficiency substantiates Complaint Number OH 944.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on closed medical record review, review of hospital discharge records, and staff interview, the facility failed to ensure one discharged resident was provided adequate supervision to prevent a falling that resulted in a left hip fracture. This involved one (#101) of five sampled residents in a current resident census of 100. Findings include: Review of the closed medical record of Resident #101 revealed the resident was admitted to the facility from the hospital on [DATE]. Prior to the hospitalization the resident had resided at another nursing facility. The resident had been discharged to the hospital for treatment of [REDACTED]. Prior to admission to the nursing facility, licensed practical nurse (LPN) #1 contacted the hospital to obtain pertinent information about Resident #101's cognitive and physical condition, and nursing care needs. LPN #1 documented the resident was alert, very confused, tearful at times, rambled, disorganized, pleasant, had aggressive behavior at the prior nursing facility, was incontinent of bladder and bowel, required one to two staff persons to transfer, was hard to roll in bed, and had a healing stage II pressure sore on her coccyx, as well as a skin tear to her right elbow. The resident was admitted to the nursing facility with [DIAGNOSES REDACTED]. The transportation staff that transported the resident from the hospital to the facility on [DATE] documented the resident as clearly confused, answering all questions inappropriately, alert but disoriented, hallucinating and tearful. According to the resident's hospital transfer sheet completed by a hospital physician and a licensed practical nurse dated 01/04/11, the resident had dementia with behavioral disturbances, was disoriented, confused, at risk for falling and required the physical assistance of two staff to ambulate and to transfer. Further review of the closed medical record revealed hospital nurse's focus notes dated 01/03/11 at 7:30 P.M. and 01/04/11 at 12:17 A.M., documented the resident was in bed with a bed alarm in place. Review of facility nurse's notes by registered nurse (RN) #5 dated 01/04/11 at 5:45 P.M., revealed the resident was admitted to the facility at 5:20 P.M. via ambulance, per the previous nurse, and was up eating supper at that time. At 6:15 P.M., RN #2 documented the resident's blood pressure was 90/60, pulse 62, respirations 18, and axillary temperature was 98.2 degrees Fahrenheit. At 6:30 P.M., RN #2 documented she was called to the resident's room by her roommate (discharged Resident #103) and the roommate stated the resident fell . The notes stated Resident #101 was laying on the right side of the bed (on the floor) on her left side. The notes stated the resident demonstrated increased agitation, anxiety, and had no complaints of pain and was tearful. RN #2 documented she was unable to do full range of motion due to the resident's increased agitation. Neurological evaluations of the resident were initiated at 6:30 P.M. per the neurological evaluation flow sheet. The resident was assisted to bed by three staff members which she tolerated well. Review of nurse's notes by RN #2 dated 01/04/11 at 10:15 P.M. as a late entry for 6:30 P.M., revealed when the resident was found she had on non-skid footwear, her call light was within reach and not on, the wheels of the bed were locked, there was adequate lighting, the resident was unable to answer questions regarding what she was doing at the time of the fall, and no new skin areas were noted. At 6:45 P.M., RN #2 documented the resident's responsible family member was notified of the fall and new fall prevention interventions were put in place including a low bed and mats to either side of the bed. The notes stated the family member told the nurse that she would be coming to the facility to talk to the nurse and complete the admission paperwork. RN #2 then notified the resident's physician at 7:00 P.M. to verify Resident #101's admission orders [REDACTED]. No new orders were received from the resident's physician at that time. Nurse's notes by RN #2 dated 01/04/11 at 7:15 P.M. stated the resident's responsible family member arrived at the facility and went to see the resident and was unable to calm the resident. The family member communicated to RN #2 that she was concerned due to the resident's increased agitation and tearfulness. RN #2 then assessed the resident and noticed she was guarding her left leg. RN #2 again was unable to complete range of motion due to the resident's agitation. RN #2 documented there was no swelling or bruising, but she did observe a small bulge to Resident #101's left thigh. The resident's responsible family member, who was present at the time, was made aware and the resident's physician was notified. Resident #101 was sent out to the emergency room of a local hospital for evaluation. Nurse's notes by RN #2 dated 01/04/11 at 10:45 P.M. stated the emergency room nurse called and reported the resident was admitted to the hospital with [REDACTED]. Nurse's notes by RN #2 dated 01/18/11 at 6:15 P.M. as another late entry for 01/04/11 6:30 P.M., stated Resident #101 had no edema, swelling or bruising noted at the time of the fall on 01/04/11, and there was no shortening or lengthening of either leg noted. The notes stated the resident was giving incoherent answers to questions, swinging at the air and staff when asked if she was hurting, and did not answer yes or no; mumbling incoherently. During interview on 02/08/11 at 10:00 A.M., RN #2 stated the resident was in her bedroom with only her roommate present, and was seated up in bed for her evening meal. RN #2 stated she did not recall if the resident had finished eating or was still eating nor if the meal tray was still in the room on the over bed table when she went in the room. RN #2 stated she was called to the room by Resident #101's roommate when the resident fell . She verified Resident #101 was assisted back to bed after being assessed. She stated the resident offered no specific complaint of pain at that time, that she was very combative and agitated and was not making any sense. She stated the abnormality to the resident's left leg was not evident until after the resident was placed back in bed and was receiving incontinence care and being repositioned by the nurse aides. RN #2 stated a nurse aide reported to her the resident was acting different and she noticed an abnormality to the resident's left leg. RN #2 stated she then went to the resident's room to assess her and subsequently sent the resident to the emergency room per physician's orders [REDACTED]. [REDACTED]. During interview on 02/07/11 at 12:53 P.M., licensed practical nurse (LPN) #1 verified she was the nurse who took report from the hospital nurse regarding Resident #101's cognitive and physical condition and nursing care needs. LPN #1 stated the nurse at the hospital did not communicate any information regarding the resident being at risk for falls, or any fall safety precautions or devices being implemented to deter or prevent falls while at the hospital. Interview with the Director of Nursing (DON) on 02/08/11 at 12:00 P.M. affirmed the transportation documentation, the hospital transfer sheet, and the hospital focus notes accompanied the resident on admission. He stated however, not all the information regarding the resident's risk of falling including behaviors of concern or fall prevention devices in use in the hospital were communicated to LPN #1 when she was given information from the nurse at the hospital prior to the resident's admission. The Administrator stated the information obtained by LPN #1 was what RN #2 had to use at the time the resident was admitted to the facility until assessments could be completed and all admission paperwork could be reviewed. He stated the hospital nurse did not report to LPN #1 the resident attempted to ambulate unassisted or that she used any type of chair, devices, or restraint to deter or prevent the resident from ambulating without assistance. Further interview with the Administrator and DON on 02/08/11 at approximately 1:30 P.M., revealed after Resident #101's fall on 01/04/11 the facility took the following actions: On 01/05/11, all current residents were reassessed for fall risk; On 01/04/11 through 01/07/11, all resident's fall care plans were reviewed and revised; On 01/06/11 and 01/07/11, department heads and administrative nursing staff (DON and personnel from social services, admissions, therapy services, activities, nursing supervisors, and assessment nurses) had a quality assurance meeting and were educated by the Administrator and DON on obtaining thorough and in depth information regarding a potential resident's safety needs when taking report from the hospital to ensure the residents' safety needs would be met from the time of admission or to determine if the facility could meet their safety needs; On 01/10/11 through 01/13/11, all licensed nursing staff, social service staff, admission staff, therapy services staff, and activity staff were inserviced on the need to get thorough and in depth information regarding a potential resident's safety needs when taking report from the hospital to ensure the residents safety need would be met from the time of admission. The admission staff and hospital liaisons are now asking for and doing in depth record reviews prior to admitting a resident; The facility has done ongoing quality assurance monitoring related to falls and resident safety during the daily clinical meeting by the Administrator, DON and Assistant Director of Nursing using specific monitoring tools for admissions and falls. There have been no falls with significant or serious injury since 01/04/11; Review on 02/08/11 of the medical records of two residents admitted less than 14 days ago and since the Resident 101's fall on 01/04/11, revealed both residents had immediate needs fall risk care plans initiated on admission and had experienced no falls since being admitted to the facility; Interview with Admissions Coordinator (AC) #4 on 02/08/11 at 3:06 P.M. affirmed she has been educated on new procedures for obtaining as much information regarding a potential/newly admitted resident prior to them coming to the facility. AC #4 stated she talks with the hospital social worker in depth regarding any potential admission and specifically asks probing questions about the potential resident's safety needs, risk of falling, or history of falling and requests nursing notes from the hospital for the month or so prior to admission. She stated the information is then reviewed by the DON who determines if there is sufficient information or if additional information is necessary prior to the resident being admitted . She stated after all necessary information is obtained then the DON will make an admission determination. If the resident is a fall risk or has a history of falls, the admission referral is taken to the nurses with any specific safety needs, fall risk precautions, or fall prevention devices that will be needed highlighted i.e. low bed with floor mats, so that the needed care and devices are identified prior to admission and are ready for the resident when they arrive; During interview on 02/08/11 at 3:11 P.M., nurse supervisor/LPN #3 verified the information stated by AC #4 when interviewed at 3:06 P.M. LPN #3 stated that when information is provided to the nursing department about a new resident being admitted , the information provided is used to develop and implement an immediate needs plan of care until through assessment and observation of the newly admitted resident is complete. This certification deficiency substantiates Complaint Control Number OH 412.