Every finding on record at Ayden Healthcare of Greenville

Based on medical record review, observation, staff interview, and policy review, the facility failed to perform incontinence care in a clean and sanitary manner. This affected one (Resident #14) of one resident observed for incontinence care. The facility census was 74.Findings include:Review of Resident #14's medical record revealed an admission date of 06/15/26. Diagnoses included neuromuscular dysfunction of bladder.Review of the physician orders dated 06/15/26 revealed an order for indwelling urinary catheter care routinely and as needed. On 07/24/26, there was an order for Enhanced Barrier Precautions (EBP) every shift due to indwelling urinary catheter.Review of the care plan dated 07/13/26 revealed Resident #14 had a catheter and was at risk for complications for infection, sepsis, and skin decline. Interventions included to change every 30 days and as needed, monitor and/or document for pain or discomfort due to catheter, monitor and report to medical provider for signs or symptoms of urinary tract infection.Observation and interview on 08/05/26 at 1:44 P.M. revealed Certified Nursing Assistant (CNA) #124 was going to perform catheter and incontinence care for Resident #14. CNA #124 entered Resident #14's room, washed her hands and applied gloves. CNA #124 went over to the dresser, opened the drawer, with her gloved hands and pulled out a wash basin. CNA #124 then went to the bathroom door and used her gloved hands to open the door. CNA #124 went into the bathroom and prepared soapy water for care. CNA #124 continued with the same gloved hands and moved Resident #14's blankets away from her peri-area. CNA #124 pulled Resident#14 pants down with her gloved hands. CNA #124 continued to use her gloved hands and used a soapy washcloth to provide peri-care. CNA #124 realized Resident #14 had a bowel movement present. CNA #124 used her same gloved hands to turn resident on her left side. CNA #124 used a different soapy washcloth to provide care to Resident #14 buttocks to remove the bowel movement. CNA #124 used a clean washcloth to rinse resident's buttocks and a clean towel to dry resident's buttocks. CNA #124 continued with the same gloved hands and positioned Resident #14 on her back and used the same gloved hands to clean the indwelling catheter in a motion away from the body. Once catheter care was complete, CNA #124 pulled Resident #14 pants up, removed the dirty adult brief off the bed, covered Resident #14 up and assisted the resident onto her right side, while wearing the same gloves. CNA #124 confirmed she did not change her gloves during peri-care, bowel movement care, and catheter care. CNA #124 confirmed her gloves should have been changed after touching the dresser drawer, after providing bowel movement care and after providing peri-care. CNA #124 confirmed her gloves should have been changed prior to touching the resident's clothes after providing incontinence/catheter care.Review of the facilities Perineal or Peri Care policy dated 04/28/25 revealed perineal care is to be provided to clean the perineum, provide comfort, and decrease risks of infection.This was an incidental finding discovered during the course of the complaint investigation.

Based on observations, staff interviews, and facility policy review, the facility failed to prepare food in a safe and sanitary manner to protect against foodborne illness. This had the potential to affect all 65 residents residing in the facility as the facility did not identify any residents with an order of nothing by mouth. Findings include:Observation of the preparation of puree diets and interview on 12/04/25 at 11:19 A.M. revealed [NAME] #102 cleaning the food processor in the three compartment sink. [NAME] #102 immediately assembled the food processor and added sandwiches without allowing the food processor to air dry prior to placing food in the processor. [NAME] #102 verified she did not allow the food processor to dry before adding food and the inside of the food processor was still wet with sanitizer. Observation on 12/04/25 at 11:25 A.M. revealed the ham and cheese sandwiches stored on the steam table were 125 degrees Fahrenheit (F). [NAME] #102 verified the sandwiches were 125 degrees F and that minimum hot holding temperature should be 135 degrees F. At 11:56 A.M., [NAME] #102 checked the temperature of the ham and cheese sandwich prior to lunch service. [NAME] #102 verified ham and cheese sandwiches were at 132.8 degrees F. Observation on 12/04/25 at 12:02 P.M. revealed [NAME] #121 placing silverware on resident's lunch trays without gloves. Spoons were observed in a plastic container and unorganized. [NAME] #121 was observed touching the mouth-contact surface of other spoons when removing a spoon from the container. Interview with DD #169 verified the spoons were unorganized in the container and reorganized them to prevent contamination. Review of the facility policy titled General Food Preparation and Handling dated 2021 revealed food items will be prepared to conserve maximum nutritive value, develop, and enhance flavor and keep free of harmful organisms and substances.

Based on observations, staff interview, and review of The International Pharmacopoeia guidance, the facility failed to ensure the resident's eye drops that were open were not used beyond four weeks of open date and failed to ensure all eye drops that were opened had an open date. This affected two of three medications cards observed for medication storage. This affected six residents (#12, #23, #27, #46, #54, and #56) reviewed for medication storage. The facility census was 65.Findings include: Observation on 12/02/25 at 9:02 A.M. of the east medication cart revealed artificial tears lubricant eye drop 0.5 ounce (oz) one-eighth full with open dated of 08/27/25 for Resident #12 and latanoprost solution 0.005% one-eighth full no open date with a delivered date of 10/04/25 for Resident #56. Interview on 12/02/25 at 9:11 A.M. with Licensed Practical Nurse (LPN) #122 verified there were no open date on the eye drops for Resident #56 and the bottle was almost empty and the eye drops for Resident #12 was dated 08/27/25. Observation on 12/02/25 at 9:30 A.M. of the north medication cart revealed artificial tears lubricant eye drops half full with an open date of 10/25/25 for Resident #54, artificial tears lubricant eye drops half full with an open date of 10/22/25 for Resident #23, artificial tears lubricant eye drops one-fourth full with an open date of 09/25/25 for Resident #46, erythromycin ointment five milligrams three-fourths full no open date of Resident #46, and ofloxacin drops 0.3% one-fourth full with an open date of 09/10/25 for Resident #27 Interview on 12/02/25 at 9:45 A.M. with LPN #130 verified Resident #54's eye drops had an open date of 10/25/25, Resident #23's eye drops had an open date of 10/22/25, Resident #46's eye drops had an open date of 09/25/25, Resident #46's eye drops were open with no opened date, and Resident #27's eye drops had an open date of 09/10/25. Review of The International Pharmacopoeia, twelfth edition, 2025 revealed multidose ophthalmic drop preparations may be used for up to four weeks after the container is initially opened.

Based on observation and staff and resident interview, the facility failed to ensure resident bed linens were clean. This affected one (#29) out of 19 residents reviewed. The facility census was 65.Findings include: Observation on 12/01/25 at 9:59 A.M. revealed Resident #29's bed was made with sides and end of the bed tucked under mattress. The top white blanket had a large oblong light brown stain approximately 12 inches by six inches with a second light brown oblong stain four inches below approximately six inches by four inches The two stains near the top of the blanket. Interview on 12/01/25 at 9:59 A.M. revealed Resident #29 does not know what the stain was from and does not want to have a stained or dirty bed. Interview on 12/01/24 at 10:02 A.M with certified nursing assistant (CNA) #103 verified the bed was made and there were stains on the blanket and STNA #103 would change out the bedding.

Based on medical record review, review of the facility incident log, staff interview, and policy review, the facility failed to follow the abuse policy related to an injury of unknown origin. This affected one resident (#78) of five residents reviewed. The facility census was 65.Based on medical record review, review of the facility incident log, review of the witness statements, staff interview, and policy review, the facility failed to follow the abuse policy related to an injury of unknown origin. This affected one resident (#78) of five residents reviewed. The facility census was 65.Findings include:Review of the medical record for Resident #78 revealed an admission date of 04/09/24 with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, and hypertension.Review of the discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #78 was dependent on staff for all activities of daily living (ADL).Review of the facility incident log revealed Resident #78 had an incident on 08/08/25 at 7:30 AM. Review of the incident report revealed during morning care, the Certified Nursing Assistant (CNA) staff alerted nursing that Resident #78 had a small amount of blood on her pillow and a knot on the side of her head. Resident #78 was unable to voice a description of what happened.Review of the progress note dated 08/08/25 at 11:43 A.M. per the Assistant Director of Nursing (ADON) #120 revealed during morning care, the CNA staff alerted nursing that resident #78 had a small amount of blood on her pillow and a knot on the side of her head.Interview on 12/04/25 at 9:52 A.M. with the Director of Nursing (DON) revealed she was notified of the incident involving Resident #78 on 08/08/25 during her morning rounds. The DON revealed upon entering Resident #78's room she observed Resident #78 in bed with a small hematoma on the side of her head with small amounts of red drainage. The DON revealed she asked CNA #145 and CNA #179 what occurred but neither CNA was able to provide details at the time.Review of the witness statement dated 08/08/25 CNA #145 revealed she provided care for Resident #78 and when she turned the light on, she observed a little dried blood on her pillow. CNA #145 reported that she asked CNA #179 for assistance with transferring Resident #78 from the bed to her wheelchair using a mechanical lift, CNA #145 showed CNA #179 the bump on Resident #78's head, then notified the nurse. CNA #145 and CNA #179 transferred Resident #78 with the mechanical lift to her wheelchair and CNA #145 brought Resident #78 to the hallway where the DON took over.Review of the witness statement dated 08/16/25 CNA #179 revealed when she went to Resident #78's room to assist CNA #145 with transferring the resident, CNA #145 had already found the hematoma on the resident's head. CNA #179 further revealed she then assisted CNA #145 with transferring Resident #78 from the bed to her wheelchair by operating a mechanical lift.Interview on 12/04/25 at 11:33 AM with CNA #179 revealed she observed the hematoma on Resident #78's head after entering the room to assist CNA #145 transferring with the mechanical lift. CNA #179 revealed she had not assisted CNA #145 transfer Resident #78, she believed Licensed Practical Nurse (LPN) #127 assisted her with care and transferring that morning.Interview on 12/04/25 at 11:51 AM with LPN #127 revealed she was the nurse assigned to care for Resident #78 on 08/08/25. LPN #127 denies assisting any CNAs with transferring the resident on that day. LPN #127 further revealed she was notified that Resident #78 had a bump on her head and blood on her pillow, but she did not immediately assess the resident because the DON was handling the incident.Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised 10/2024, revealed staff should report all incidents/allegations immediately to the Administrator or designee. If an injury is observed/suspected, staff should not move the resident until he/she has been assessed by a nurse supervisor for possible injuries. A nurse should perform an initial assessment of the resident. Additionally, documentation in the nurses' notes should include the results of the resident's assessment, notification of the physician and the Resident Representative, and any treatment provided. Additionally, an injury is classified as an injury of Unknown Source when all the following conditions are met: 1. The source of the injury was not observed by any person; AND 2. The source of the injury could not be explained by the resident; AND 3. The injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Additionally, all incidents and allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and all injuries of unknown source must be reported immediately to the Administrator or designee.This deficiency represents non-compliance investigated under Complaint Number 2603410.

Based on medical record review, facility incident log, staff interview, and facility policy review, the facility failed to report an injury of unknown origin to the state surveying agency. This affected one resident (#78) of five residents reviewed. The facility census was 65.Based on medical record review, review of the facility incident log, staff interview, and policy review, the facility failed to report an injury of unknown origin to the state surveying agency. This affected one resident (#78) of five residents reviewed. The facility census was 65.Findings include:Review of the medical record for Resident #78 revealed an admission date of 04/09/24 with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, and hypertension.Review of the discharge Minimum Data Set (MDS) dated [DATE], Resident #78 was dependent on staff for all activities of daily living (ADLs).Review of the facility incident log revealed Resident #78 had a hematoma incident on 08/08/25 at 7:30 AM. Review of the incident report revealed during morning care, Certified Nurse Assistant (CNA) staff alerted nursing that Resident #78 had a small amount of blood on her pillow and a knot on the side of her head. Resident #78 was unable to voice a description of what happened.Interview on 12/04/25 at 8:19 AM with the Director of Nursing confirmed the facility did not report the incident to the State Surveying Agency.Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised 10/2024 revealed an injury is classified as an Injury of Unknown Source when all the following conditions are met: 1. The source of the injury was not observed by any person; AND 2. The source of the injury could not be explained by the resident; AND 3. The injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Additionally, all incidents and allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and all injuries of unknown source must be reported immediately to the Administrator or designee. If any form of abuse is alleged or serious bodily injury is identified related to any other reportable incident (e.g., Injury of Unknown Source or allegation of Neglect involving serious bodily injury,) the Administrator or his/her designee will notified Ohio Department of Health (ODH) immediately, but not later than two (2) hours after the allegation is made or the serious bodily injury identified. This deficiency represents non-compliance investigated under Complaint Number 2603410.

Based on medical record review, staff interviews, review of the facility's incident investigation, and policy review, the facility failed to complete a thorough investigation into a resident's injury of unknown source when the resident obtained a hematoma with bleeding to her head. This affected one (Resident #78) of five residents reviewed for abuse, misappropriation, neglect, and injury of unknown origin. The facility census was 65.Findings include:Review of the medical record for Resident #78 revealed an admission date of 04/09/24 with diagnoses including chronic obstructive pulmonary disease, and type two diabetes mellitus. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 was dependent on staff for all activities of daily living (ADLs). Review of the nursing progress notes dated 08/08/25 written by Assistant Director of Nursing (ADON) #120 revealed during morning care, Certified Nursing Assistant (CNA) staff alerted nursing that Resident #78 had a small amount of blood on her pillow and a knot on the side of her head. The interdisciplinary team (IDT) considered that the bar from the Hoyer lift struck the resident on the side of the head during transfer into bed. Review of the facility incident log revealed Resident #78 had a hematoma incident on 08/08/25 at 7:30 AM. During morning care, CNA staff alerted nursing that Resident #78 had a small amount of blood on her pillow and a knot on the side of her head. Resident #78 was unable to voice a description of what happened. Review of CNA #145's witness statement dated 08/08/25 revealed she changed and dressed her lower extremities. Then turned on the light and noticed little dried and red blood on her pillow. After noting the blood, she saw CNA #179 in the hallway and they looked at the bump together and told the nurse. Then CNAs #179 and CNA #145 transferred Resident #78 by Hoyer to her chair. Review of Licensed Practical Nurse (LPN) #156's statement dated 08/08/25 revealed Resident #78 rested well through the night and at 5:23 A.M., LPN #156 administered her scheduled lorazepam (treats anxiety). Resident #78 opened her eyes and mouth and took the medications without problems. No signs or symptoms of distress. Review of CNA #179's witness statement dated 08/16/25 revealed when she went to Resident #78's room to assist CNA #145 with transferring the resident, CNA #145 had already found the hematoma on the resident's head. CNA #179 further revealed she then assisted CNA #145 with transferring Resident #78 from the bed to her wheelchair by operating a Hoyer lift. CNA #179 verified the date of her statement was correct during an interview on 12/04/25 at 11:33 A.M. Review of undated statement by CNA #140 revealed on 08/07/25, CNA 140# waited until Resident #78's husband left to put Resident #78 back to bed. Resident #78 was a two-persons assist to transfer to bed. CNA #105 and herself put in bed at 9:30 P.M. There was nothing wrong with Resident #78 at this time, completed two hours checks throughout the night. At 6:00 A.M., no blood was seen on pillow or resident. The facility's investigation was not completed timely. The facility did not complete a thorough investigation to determine what caused the injury of unknown origin. The incident investigation for Resident #78 revealed staff provided inconsistent accounts regarding when the resident's scalp hematoma was first identified, who was present during transfers, and whether the required two-person assistance was provided. The resident required mechanical lift transfers; however, staff were unable to consistently confirm they followed established procedures for safe transfer and supervision. The facility determined the Hoyer bar was what caused the injury prior to having all staff statements. There was no witness statement from CNA #105 who assisted with the transfer on 08/07/25 at 9:30 P.M. and the IDT considered the injury occurred when being transferred into bed. The investigation did not show if the Hoyer lift was already in the room when CNA #179 entered the room, where it was placed when CNA #179 entered the room, and if the Hoyer had any blood on it and/or any blood noted elsewhere to indicate how the injury of unknown was obtained. There was no statement from Resident #78's husband to determine if he saw any injuries on Resident #78's forehead when he left at 9:30 P.M. on 08/07/25. Interview on 12/04/25 at 9:52 AM with the Director of Nursing (DON) revealed she was notified of the incident involving Resident #78 on 08/08/25 during her morning rounds. The DON revealed upon entering Resident #78's room, she observed Resident #78 in bed with a small hematoma on the side of her head with small amounts of red drainage. The DON revealed she asked CNA #145 and CNA #179 what occurred but neither CNA was able to provide details at that time. The DON revealed she investigated the incident and had initially thought CNA #145 must have transferred Resident #78 with the Hoyer by herself. Interview on 12/04/25 at 11:33 A.M. with CNA #179 revealed she observed the hematoma on Resident #78's head after entering the room to assist CNA #145 transferring with the Hoyer lift. CNA #179 revealed she did not assist CNA #145 transfer Resident #78, she believed Licensed Practical Nurse (LPN) #127 assisted her with morning care and transferring that morning. Interview on 12/04/25 at 11:51 A.M. with LPN #127 revealed she was the nurse assigned to care for Resident #78 on 08/08/25. LPN #127 denies assisting any CNAs with transferring the resident on that day. LPN #127 revealed she was notified Resident #78 had a bump on her head and blood on her pillow, but she did not immediately assess the resident because the DON was handling the incident. Review of the facility's Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 10/2024 revealed the facility's policy was to investigate all alleged violations which included injuries of unknown source. The investigation must be completed within five working days. The investigation protocol included the person investigating the incident should generally take the following actions: interview the resident, the accused, and all witnesses. Witnesses generally include any who witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents and family members) and employees who came in close contact with the resident the day of the incident. If there are no direct witnesses, the interviews may be expanded. For injuries of unknown origin, the investigation generally involves talking with staff working on both the shift on duty when the injury was discovered and prior shifts as well. All interviews should be documented. This deficiency represents non-compliance investigated under Complaint Number 2603410.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident care plan addressed their dental needs. This affected one (Resident #55) out of 19 residents reviewed for care planning. The facility census was 65.Findings Include:Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease without dyskinesia, mild protein calorie malnutrition, human immunodeficiency virus disease, type two diabetes mellitus, and adult physical abuse. Review of Resident #55's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required supervision with eating. Resident #55 was dependent with oral hygiene, toileting, showering, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair transfers, toilet transfers, and tub transfers. Resident #55 was noted with mouth pain, facial pain, discomfort or difficulty with chewing. Review of a progress note dated 10/15/25 at 2:53 P.M. revealed Resident #55 complained of a tooth ache in the right lower jaw line. Hospice was notified and Resident #55 was started on amoxicillin 875/125 milligrams (mgs) give one tablet every 12 hours for a bacterial infection for 10 days. Review of the dental visit dated 11/05/25 revealed Resident #55 was seen by the dentist, and a referral was sent for extractions. Review of the care plan on 12/03/25 revealed Resident #55 did not have a care plan to address his dental needs, mouth pain or need for extractions. Interview with the Administrator on 12/03/2025 at 10:21 A.M. verified Resident #55 needed teeth extractions due to dental pain. The Administrator verified Resident #55 did not have a care plan for his dental needs, mouth pain or need for extractions. Review of the policy titled Care Planning dated August 2021 revealed the care plan was based on the resident's comprehensive assessment and was developed by the interdisciplinary team.

Based on interview, record review, and policy review, the facility failed to provide appropriate oral care. This affected one (Resident #62) of two residents reviewed for dental care. The facility census was 65. Based on medical record review, staff interview, and policy review, the facility failed to provide appropriate oral care. This affected one (#62) of two residents reviewed for dental care. The facility census was 65. Findings Include: Review of the medical record for Resident #62 revealed an admissions date of 03/31/15 with diagnoses including hemiplegia and hemiparesis following cerebral infraction affecting left dominant side and muscle weakness.Review of the Minimum Data Set (MDS) for Resident #62 dated 10/07/25 revealed the resident was cognitively intact and required assistance with activities of daily living. Further review revealed Resident #62 does not exhibit the behavior of rejection of care. Review of the medical record revealed Resident #62 was seen by the dentist on 10/17/25. The notes revealed recommendations for staff to assist the resident with brushing twice daily. Review of the oral care log for Resident #62 revealed that on the following days the resident was offered oral care once 09/02/25, 09/04/25, 09/05/25, 09/07/25, 09/08/25, 09/10/25, 09/13/25, 09/14/25, 09/15/25, 09/23/25, 09/26/25, 09/28/25, 10/01/25, 10/02/25, 10/03/25, 10/07/25, 10/09/25, 10/10/25, 10/12/25, 10/13/25, 10/14/25, 10/17/25, 10/23/25, 10/29/25, 10/30/25, 10/31/25, 10/05/25, 10/10/25, 11/17/25, 11/20/25, and 11/30/25.Interview on 12/01/25 at 9:51 A.M. with Resident #62 verified the resident is unable to brush his teeth without staff assistance. Resident #62 stated that staff do not brush his teeth daily and that it was usually only done on days that he gets his showers.Interview on 12/04/25 at 9:38 A.M. with the Director of Nursing verified that there was not documentation of Resident #62 being offered oral care twice daily on the above dates. Review of the facility policy titled, Activities of Daily Living (ADL), Supporting dated August 2021, revealed appropriate care and services will be provided to residents who are unable to carry out ADLs independently.

Based on record review, observation, and staff and resident interview, the facility failed to provide an activities program that supported residents in their choice of activities. This affected one resident (#57) of two residents sampled for activities. The facility census was 65.Based on medical record review, review of the activity participation document, staff and resident interview, and policy review, the facility failed to provide an activities program that supported residents in their choice of activities. This affected one resident (#57) of two residents sampled for activities. The facility census was 65.Findings Include:Record review for Resident #57 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: malignant neoplasm (cancer) of the bladder, COVID-19, chronic heart failure, chronic obstructive pulmonary disease, Parkinson's disease, type 2 diabetes mellitus, and chronic kidney disease.Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had intact cognition, evidenced by a Brief Interview for Mental Status (BIMS) score of 13. Resident #57 required substantial to maximum assistance with chair-to-chair transfer and dressing, and was dependent with footwear and transitioning from sitting to standing.Review of the care plan dated 08/17/25 for Resident #57 revealed the following care-planned items and interventions: Resident #57 was at risk for alteration in activity, with interventions to monitor for changes in activity participation, provide 1:1 activities as needed, provide items for self-directed activities, encourage the resident to experience and learn new activities, and assess and reassess activity interests as indicated.Interview with Resident #57 on 12/01/25 at 10:41 A.M. revealed the resident stated the facility did not provide enough activities. The resident further stated they would like to attend bingo but were not invited.Review of activity participation documentation for October 2025 and November 2025 for Resident #57 revealed the resident was marked as unavailable 71 times and refused 15 times. Documented activities the resident participated in included independent current events, independent active socializing, and independent active television.Interview with the Administrator on 12/03/25 at 3:30 P.M. verified Resident #57 was marked as unavailable on the activity participation documentation. The Administrator further verified Resident #57 was on hospice and was almost always in the facility. Additionally the Administrator was unable to explain why the resident was marked as unavailable for activities.Review of the policy titled Activities, dated 09/2020, revealed activities were to be offered based on individual resident preferences and needs. The policy further stated residents were encouraged, but not required, to participate in activity programming and that activity participation was documented in the medical record.

Based on observation, interview, and record review, the facility failed to follow the menu for residents on a puree diet. This had the potential to affect three residents (#9, #12, and #54) who receive a puree diet . The facility census was 65. Findings include:Review of the lunch menu for 12/04/25 revealed residents on a puree diet should receive pureed tomato soup with crackers, pureed ham and cheese sandwiches, and pureed cantaloupe. Observation of the lunch service on 12/04/25 at 11:56 A.M. revealed the residents on a puree diet were being served tomato soup, pureed ham and cheese sandwiches, and cottage cheese. Interview on 12/04/25 at 12:10 P.M. with Dietary Director #169 verified the residents on a puree diet were served regular tomato soup without crackers and apple sauce instead of pureed cantaloupe. Review of the facility policy titled Texture and Consistency- Modified Diets dated 2021 revealed texture modification diets would be followed and changes should not be made without a written order.

Based on observation, staff interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance, and facility policy review, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) for residents who were in Enhanced Barrier Precautions (EBP). This affected one (Resident #3) of two residents reviewed for EBP. The facility census was 65. Findings include: Record review revealed Resident #3 was admitted on [DATE]. Diagnoses included active primary progressive multiple sclerosis, and epilepsy (seizures). Review of the weekly wound assessment dated [DATE] revealed Resident #3 had a pressure ulcer (wound from constant pressure to the skin) stage IV (pressure ulcer with bottom extending to the muscle or bone) on the sacrum (tailbone). The active physician orders for Resident #3 for December 2025 reveled an order for EBP due to wound and indwelling catheter. Observation of Certified Nursing Assistant (CNA) #164 on 12/03/25 at 12:53 P.M. revealed CNA #164 coming out from behind Resident #3's curtain without a gown on. During an interview on 12/03/25 at 12:53 P.M., CNA #164 stated they just finished changing Resident #3's brief and performing peri-care. CNA #164 verified the two CNAs did not wear a gown. CNA #164 confirmed they should have been wearing a gown due to the EBP. Review of the policy titled Enhanced Barrier Precautions (EBP) dated 04/01/24 revealed for residents for whom EBP are indicated, EBP is employed when performing high contact resident care activities including changing briefs. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP is an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status.

Based on observation, record review and interview, the facility failed to ensure a resident's call light was in working order. This affected one (#55) of 24 residents reviewed for call lights. The facility census was 65. Findings include:Review of Resident #55's medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease without dyskinesia and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was moderately cognitively impaired and was dependent on staff with toileting, personal hygiene, and transfers. Review of the fall care plan dated 10/30/25 revealed Resident #55 was at risk for falls. Interventions included to ensure the call light was in reach. Observation of Resident #55's room on 12/01/25 at 10:28 A.M. revealed Resident #55's call light was not functioning or turning on in the room, hallway, or nursing station. Interview on 12/01/25 at 10:28 A.M. with Maintenance Director #155 verified Resident #55's call light was not functioning or turning on in the room, hallway, or nursing station. Review of the facility's call light policy dated August 2021 revealed staff should notify maintenance if call lights were not functioning.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure the physician was updated regarding a wound change affecting Resident #10. The facility also failed to ensure wound treatments and assessments were obtained timely affecting two (#10, #13) of three reviewed for wounds. The facility census was 63.1.Review of medical record for Resident #10 revealed an admission date of 04/16/25. Diagnoses included malignant neoplasm of mouth, tracheostomy and gastrostomy tubes, and skin graft to the right forearm. The resident was discharged on 05/09/25 to the hospital and did not return.Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 10 indicating impaired cognition. Resident #10 was dependent on eating and required maximum assistance for toileting hygiene, bed mobility and moderate assistance for transfers. Resident #10 was documented to be frequently incontinent of bowel and occasionally incontinent of urine and was noted to have a surgical wound. Review of Resident #10's care plan contained no reference to the resident having a surgical wound and contained no information regarding Resident #10's dressing changes.Review of the physician orders to start 04/19/25 revealed Resident #10's right forearm surgical graft site was to be cleansed daily with normal saline, covered with xeroform followed by a nonadherent surgical dressing and wrapped with rolled bandage. The right arm was then to be wrapped with a Coban wrap (an adherent wrap used to secure and protect primary dressing).Review of the weekly nurse skin assessments revealed Resident #10 had a surgical graft site to the right forearm, however the assessments contained no description of the graft site.Review of a wound assessment note completed by the wound nurse dated 05/02/25 revealed Resident #10 had a right forearm surgical skin graft, the wound measured 5.2 centimeters (cm) by 2.6 cm. The wound description stated the wound had a pink base with scattered slough.Review of the 05/08/25 hospital documentation revealed Resident #10 was sent to the Emergency Department (ED) for altered mental status changes. Resident #10 was documented as alert and oriented to person at the time of arrival in the ED. The ED assessment revealed a wound to the right forearm with purulent drainage. The right forearm wound was cleansed and redressed. Resident # 10 was given an oral antibiotic and returned to the nursing facility with an antibiotic prescription. The ED discharge summary revealed Resident #10 was diagnoses with cellulitis of the right arm and altered mental status changes.Interview on 07/01/25 at 1:32 P.M. with Wound Nurse Licensed Practical Nurse (WNLPN) #101 revealed she had been off on medical leave and had not assessed Resident #10's wound until 05/02/25. WNLPN #101 verified the right forearm wound had a pink base with scattered slough during her assessment. WNLPN #101 verified previous wound assessments completed by nursing contained measurements but no description of the wound. WNLPN #101 stated she had not communicated with the physician regarding her assessment of Resident #10's right forearm wound. Interview on 07/02/25 at 1:12 P.M. with the Director of Nursing (DON) revealed the facility wound physician had not seen Resident #10 and added, the wound physician had seen a limited number of residents because the facility had obtained another wound company, and that company was scheduled to start in a few weeks. The DON verified the treatment and monitoring for Resident #10's wound were grouped together as one task on the Treatment Administration Record. The DON explained the expectation there should be a task for completing the wound care treatment ordered and another task for monitoring the wound site for signs and symptoms of infection. The DON verified Resident #10's progress notes and the weekly skin assessments did not contain a description of the wound and acknowledged it would be difficult to know if there were changes to a wound without such information. The DON also verified WNLPN #101 was not wound certified, however, stated WNLPN #101 did have wound care experience because she rounded with the wound physician. Interview on 07/02/25 at 3:26 P.M. with Physician #115 revealed he was unaware the wound physician had not seen Resident #10 and further stated the staff had not contacted him with any concerns regarding Resident #10's wounds. 2. Review of medical record for Resident #13 revealed admission date of 11/14/21 with diagnoses including diabetes mellitus type II, morbid obesity, depression and chronic obstructive pulmonary disease.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Resident #13 required supervision for meals and was dependent upon staff for bed mobility, transfers and toileting hygiene.Review of the 06/30/25 skin assessment completed by Registered Nurse (RN) #106 revealed documentation of a stage two pressure area to Resident #13's left buttocks. The assessment documented the area was not new. The documentation contained no measurements or any further description of the wound. Review of the current physician orders on 06/30/15 and 07/01/25 revealed no dressing treatment order for the left coccyx wound.Observation on 07/01/25 at 2:42 P.M. of care by Certified Nursing Assistant (CNA) #108 for Resident #13 revealed CNA #108 had a bordered dressing on her left buttock. CNA #108 removed the soiled dressing in preparation of providing incontinence care. An approximate 2.5 cm by 2.0 cm area was observed with no obvious discoloration to the surrounding skin. Interview on 07/01/25 at 9:59 A.M. with RN #106 revealed she had been informed Resident #13 had an open area to her coccyx during her 06/30/25 shift. She stated during her skin assessment she observed a border dressing covering the wound. RN #106 stated, she peeled the dressing back to assess the wound and then reattached the dressing. RN #106 verified she did not measure the area, stating after her assessment she contacted WNLPN #101 to ensure she was aware of the wound. RN #106 stated WNLPN #101 had informed her she was.Interview on 07/01/25 at 1:44 P.M. with WNLPN #105 denied she had been informed of a new skin concern for Resident #13. WNLPN #105 stated Resident #13 had areas of concerns on her coccyx in the past but they had resolved.A second interview on 07/01/25 at 4:05 P.M. with WNLPN #105 revealed she had assessed Resident #13's left buttock wound and believed the area to be moisture associated skin damage, Physician #115 was notified of the new area and treatment orders were received. Interview on 07/02/25 at 1:12 P.M. with the Director of Nursing (DON) revealed CNA's have been educated not to remove a dressing during incontinence care. She shared it was the expectation the CNA to provide incontinence care and then get the nurse to remove the dressing, clean the area if needed and replace the dressing. The DON explained this would reduce the risk of contamination.Review of the facility policy titled Wound Care, revised 04/28/25 provided guidelines for the care of wounds to promote healing and stated the resident's care plan should assess any special needs of the resident.This deficiency represents non-compliance investigated under Complaint Number 1383066.

Based on record review, observation, staff interview and policy review the facility failed to ensure proper infection control practices were followed during incontinence care. This affected one (#13) of three residents reviewed for incontinence care. The facility census was 63.Review of medical record for Resident #13 revealed an admission date of 11/14/21 with diagnoses including diabetes mellitus type II, morbid obesity, depression and chronic obstructive pulmonary disease.Review of the quarterly Minimum Data Set (MDS) assessment for Resident #13 dated 04/09/25 revealed a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. Resident #13 required supervision for meals and was dependent upon staff for bed mobility, transfers and toileting hygiene.Observation on 07/01/25 at 2:42 P.M. of incontinence care by Certified Nursing Assistant (CNA) #108 for Resident #13 revealed CNA #108 donned required personal protective equipment (PPE) prior to entering the room, Resident #13 was found lying on her back in bed. CNA #108 unfastened the incontinence product and used a wipe to cleanse her peri area. Resident #13 had also been incontinent of stool. CNA #108 disposed of the wipe and assisted Resident #13 onto her left side. A soiled bordered dressing was observed on the left buttock. CNA #108 peeled the dressing off with her right hand and disposed of it in a clear trash bag. A shallow open area, approximately quarter-sized was observed. CNA #108 proceeded to grab a wipe from the package and cleanse the resident of stool. Using her right-hand CNA #108 wiped stool from resident and was observed to fold the wipe with her left hand and wiped the resident again before disposing the soiled wipe into the clear trash bag. CNA #108 then obtained another wipe from the package and was observed to wipe stool from resident #13's buttocks, fold the wipe with her left hand and then wipe over the open area on the left buttock. Just prior to the completion of care, CNA #108 wiped both the anal area and open left buttock wound in one motion with the same wipe before disposing of the wipe. CNA #108 then asked Resident #13 to return to her back and explained she would find the nurse to reapply the dressing. CNA #108 then removed her gloves, disposed of them in the trash bag, and removed the bag from the can. CNA #108 tied the trash bag and proceeded into the hallway where she opened the door to the soiled utility room and disposed of the trash bag. CNA #108 stepped back into the hall and then into Resident #13's room beside the soiled utility room and applied hand sanitizer. Interview with CNA #108 immediately after this observation, verified the dressing removed from Resident #13's left buttock had been soiled, but was intact when she removed it. CNA #108 also verified she did not perform hand hygiene immediately after care, prior to leaving Resident #13's room as she should have and further verified hand hygiene was completed after she returned to Resident #13's room after disposing of the soiled items into the soiled utility room.Interview on 07/02/25 at 1:12 P.M. with the Director of Nursing (DON) revealed CNA's have been educated not to remove a dressing during incontinence care. She shared it was the expectation the CNA to provide incontinence care and then get the nurse to remove the dressing, clean the area if needed and replace the dressing. The DON explained this would reduce the risk of contamination. The DON also verified hand hygiene should be completed immediately after providing care and prior to leaving a resident's room. Review of the facility policy, Incontinence Care, revised 04/28/25 documented if a resident was incontinent of feces at the time of the care, enclose the feces in a fold of incontinent product using toilet tissue, then cleanse, rinse and dry area thoroughly and remove soiled gloves and perform hand hygiene.This deficiency represents non-compliance investigated under Complaint Number 1383066.

Based on medical record reviews, staff interview, and policy review, the facility failed to ensure psychotropic medications had appropriate documentation for medical use and failed to ensure as needed (PRN) psychotropic medications had a date for re-evaluation of use or duration of use dates. This affected two (#05 and #16) residents out of three residents reviewed for medication administration. The facility census was 60. Findings include: 1. Review of the medical record for Resident #05 revealed an admission date of 01/15/25 with medical diagnoses of dysphagia, tremors, dementia, osteoarthritis, and adult failure to thrive. Review of the medical record for Resident #05 revealed an admission Minimum Data Set (MDS) assessment, dated 01/31/25, indicated Resident #05 was cognitively intact and required partial/moderate staff assistance for eating, substantial/maximum staff assistance for transfers, and was dependent upon staff for toilet hygiene and bathing. Review of the medical record for Resident #05 revealed a physician order dated 04/14/25 for Lorazepam (antianxiety medication) 0.5 milligram (mg) one tablet by mouth every 12 hours as needed (PRN) for anxiety. The order did not indicate a date for re-evaluation of use or duration use dates. Review of the medical record revealed the Lorazepam order was changed on 05/05/25 to 0.5 mg one tablet by mouth every 12 hours PRN for 14 days. Review of the medical record for Resident #05 revealed the April Medication Administration Record (MAR) which indicated Resident #05 received Lorazepam daily on 04/14/25 to 04/20/25, daily 04/22/25 to 04/26/25, and 04/28/25. Review of Resident #05's May MAR revealed Lorazepam was administered daily 05/01/25 to 05/05/25. 2. Review of the medical record for Resident #16 revealed an admission date of 03/07/25 with medical diagnoses encephalopathy, hypotension, Alzheimer's disease, and atrial fibrillation. Review of the medical record revealed a discharge date of 04/30/25. Review of the medical record for Resident #16 revealed an admission MDS assessment, dated 03/17/25, which indicated Resident #16 was never/rarely understood and had cognitive impairment. Review of the MDS indicated Resident #16 required supervision with eating, partial/moderate staff assistance with transfers, substantial/maximum staff assistance for bathing and bed mobility and was dependent upon staff for toilet hygiene. Review of the MDS indicated Resident #16 received antipsychotic medication daily. Review of the medical record for Resident #16 revealed a physician order dated 03/14/25 for Haloperidol (antipsychotic medication) 5 mg one tablet by mouth every eight hours PRN for agitation. The order did not indicate a date for re-evaluation of use or duration of use dates. Review of the medical record for Resident #16 revealed the March 2025 MAR revealed documentation to support Resident #16 received Haloperidol daily on 03/14/25 to 03/16/25, 03/18/25, 03/22/25, 03/23/25, 03/26/25 to 03/30/25. Further review revealed the April 2025 MAR which indicated Resident #16 received Haloperidol daily on 04/01/25, 04/02/25, 04/07/25 to 04/10/25, 04/17/25, and 04/22/25 to 04/24/25. Review of the medical record for Resident #16 revealed a pharmacy Medication Regimen Review, dated 03/17/25, recommended to re-evaluate the use of Haloperidol 5 mg one tablet by mouth every eight hours PRN to see if the medication was still needed and to consider adding a 14 day stop date. The review was signed by the physician on 04/29/25 with a note which stated the resident was discharging on 04/30/25 and would review if repeat admission. Interview on 04/29/25 at 3:26 P.M. with Director of Nursing (DON) confirmed Resident #05's order for Lorazepam was changed from routine to PRN on 04/14/25 because Resident #05 was having difficulty waking up in the morning. DON confirmed Resident #05's order dated 04/14/25 for Lorazepam 0.5 mg one tablet by mouth every eight hours PRN did not have a re-evaluation of use date or duration of use dates. DON also confirmed Resident #16's Haloperidol was ordered PRN and did not have a re-evaluation of use date or duration of use dates. DON confirmed Resident's Medication Regimen Review, dated 03/17/25, was not reviewed or signed by the physician until 04/29/25. DON also confirmed Resident #16's indication for use of haloperidol was agitation and Resident #16 did not have a medical diagnosis for use of the medication. Review of the facility policy titled, Unnecessary Medications, dated 04/28/25, stated the facility's policy that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary meds. The policy stated the attending physician would assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regimen would be reviewed on an ongoing basis, taking into consideration the following elements: dose, duration of use, indications and clinical need for medication, and adequate monitoring for efficacy and adverse consequences, preventing, identifying, and responding to adverse consequences. The policy also stated the resident's medical record would show adequate indications for the medication's use and the diagnosed condition for which it was prescribed.

Based on medical record review, observations, staff interviews, and policy review, the facility failed to properly measure pressure ulcers and ensure treatments were completed as ordered. This affected one (#36) resident out of three residents reviewed for adequate wound care and services. The facility census was 60. Findings include: Review of the medical record for Resident #36 revealed an admission date of 08/21/2020 with medical diagnoses of multiple sclerosis (MS), myelodysplastic syndrome, quadriplegia, anxiety, and schizophrenia. Review of the medical record for Resident #36 revealed a quarterly Minimum Data Set (MDS) assessment, dated 02/17/25, which indicated Resident #36 had severely impaired cognition and was dependent for all activities of daily living. The MDS indicated Resident #36 had a Stage IV pressure ulcer which was present upon admission. Review of the medical record for Resident #36 revealed a weekly wound assessment, dated 05/01/25, which indicated Resident #36 had a pressure ulcer to her coccyx which measured 6.1 centimeters (cm) by 5.6 cm by 0.4 cm and the wound was stable. The assessment stated the wound was beefy pink and area was improving. No other documentation noted to the description of the pressure ulcer was present. The wound assessment was completed by Wound Care Clinician (WCC) #285. Review of the medical record for Resident #36 revealed a physician order dated 07/16/24 to cleanse area to right buttock/sacrum with normal saline, pat dry, apply zinc to wound bed, cover with calcium alginate with silver, cover with abdominal (ABD) pad, do not apply tape and to change daily and as needed. Review of the medical record revealed a physician order dated 05/07/25 to cleanse area to right buttock/sacrum times two with normal saline, pat dry, apply zinc to wound bed, cover with calcium alginate with silver, cover with abdominal (ABD) pad, do not apply tape and to change daily and as needed Observation with interview on 05/07/25 at 9:49 A.M. of Resident #36's wound care by Licensed Practical Nurse (LPN) #247 and LPN #242 revealed LPN #242 positioned Resident #36 on her left side. LPN #247 washed her hands and applied gloves and gown prior to wound care. LPN #242 removed Resident #36's old dressing which revealed a small amount of serosanguinous drainage. LPN #242 removed gloves, washed hands, and applied new gloves. The observation revealed Resident #36 had two distinct wounds to her right buttock/sacrum area. A wound was observed to be located on Resident #36's upper right buttock which was oblong in shape, about 3 cm long and 1 cm wide with a red wound bed and small amount of yellowish substance noted in wound bed. The observation also revealed a second wound noted posterior and lateral to the oblong wound. The second wound was circular in shape, about 3 cm long by 3 cm wide with red wound bed and a small amount of yellow substance noted in wound bed. Observation revealed LPN #247 cleansed Resident #36's circular wound with normal saline, applied zinc to the wound bed, covered with calcium alginate with silver, and covered with ABD pad. The ABD pad also covered the oblong wound. LPN #247 was observed to remove her gloves and wash her hands after discarding all soiled supplies. Interview with LPN #247 confirmed Resident #36 had two distinct wounds to her right buttock/sacrum area and that she did not complete treatment to the oblong wound located on the right upper buttock. LPN #247 stated the wound documentation for Resident #36 did not indicate a second pressure ulcer to her right buttock/sacrum area, so she only completed treatment to the circular wound located posterior and lateral to oblong wound. Interview on 05/07/25 at 1:27 P.M. with WCC #285 confirmed Resident #36 did not see a wound physician per family request and the facility staff completed weekly wound measurements and treatment orders. WCC #285 stated Resident #36 admitted to the facility with multiple pressure ulcers and the pressure ulcer to right buttock/sacrum had been present since admission. WCC #285 confirmed Resident #36 had two distinct pressure ulcers to right buttock/sacrum area, but the weekly wound assessment indicated the measurements for the entire area containing both pressure ulcers. WCC #285 confirmed the weekly wound assessment did not contain descriptions of each of Resident #36's pressure ulcers to right buttock/sacrum. WCC #285 stated she was not aware that staff were only completing treatment to one of Resident #36's pressure ulcers but confirmed the pressure ulcers have been stable. Review of the facility policy titled, Pressure injury treatment, revised 04/28/25, stated residents with pressure injuries would be treated with consistent treatment protocols to aid in the healing process. The policy stated residents with pressure injuries would have an individualized treatment program that provides the appropriate treatment to facilitate healing and that assesses and addresses comorbid conditions in a systematic manner. This deficiency represents non-compliance investigated under Complaint Number OH00164283.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure medications were available for administration. This affected one (#10) resident out of the three residents reviewed for medication administration. The facility census was 60. Findings include: Review of the medical record for Resident #10 revealed an admission date of 02/11/25 with medical diagnoses of heart disease, diabetes mellitus, atrial fibrillation, depression, and bipolar disorder. Review of the medical record for Resident #10 revealed an admission Minimum Data Set (MDS) assessment, dated 02/11/25, which indicated Resident #10 was cognitively intact and required supervision with eating, partial/moderate staff assistance with toilet hygiene and bed mobility, and substantial/maximum staff assistance with bathing and transfers. Review of the medical record for Resident #10 revealed a physician order dated 02/12/25 for Venlafaxine (antidepressant) extended release (ER) 150 milligram (mg) one tablet by mouth daily for depression. Observation with interview on 05/06/25 at 7:55 A.M. revealed Registered Nurse (RN) #236 prepared Resident #10's medications for administration. The observation revealed RN #236 was not able to locate Resident #10's Venlafaxine ER 150 mg dose due that morning in the medication cart, in medication overflow, or in the facility emergency box. Interview with RN #236 confirmed Resident #10's Venlafaxine ER 150 mg tablet was not available for administration. Review of the facility policy titled, Administering Medications, reviewed 04/28/25, stated medications shall be administered in a safe and timely manner, and as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00164459.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure insulin injector pens were dated when opened. This affected one (#09) resident out of three residents reviewed for medication administration. The facility census was 60. Findings include: Review of the medical record for Resident #09 revealed an admission date of 02/15/25 with medication diagnoses of gas gangrene, chronic osteomyelitis of right ankle/foot, diabetes mellitus (DM) , peripheral vascular disease, and hypertension. Review of the medical record for Resident #09 revealed an admission Minimum Data Set (MDS) assessment, dated 02/20/25, which indicated Resident #09 was cognitively intact and required set-up assistance with eating, partial/moderate staff assistance with showers, and substantial/maximum staff assistance with toilet hygiene, bed mobility, and transfers. The MDS indicated Resident #09 received six days of insulin injections. Review of the medical record for Resident #09 revealed a physician order dated 04/14/25 for Insulin Lispro pen to inject 10 units subcutaneous (SQ) daily for DM and an order dated 04/15/25 for Insulin Glargine SQ solution to inject 35 units SQ daily for DM. Observation on 05/06/25 at 8:08 A.M. revealed Registered Nurse (RN) #236 prepare Resident #09's medications for administration. RN #236 primed Insulin Glargine injection pen with two units of insulin and then set the pen to 35 units. RN #236 then primed Insulin Lispro injection pen with two units then set the pen to 10 units. Observation revealed neither insulin injection pen indicated a date the pens were opened. Observation revealed RN #236 administer insulin injections to Resident #09 as ordered. Interview on 05/06/25 at 8:10 A.M. with RN #236 confirmed she administered Insulin Glargine and Insulin Lispro to Resident #09 via injection pens and neither injection pen indicated a date in which the pens were opened. Review of the facility policy titled, Administering Medications, reviewed 04/28/25, stated medications shall be administered in a safe and timely manner, and as prescribed. The policy stated the expiration/beyond use date on the medication label must be checked prior to administration. When opening a multi-dose container, the date opened shall be recorded on the container.

Based on review of contractor services invoices, interview with outside contractor service, and staff interview, the facility failed to remain solvent by paying all contractors for their services. This had the potential to affect all 67 residents residing in the facility. The current census is 67. Findings include: Review of the facility's contract with the extermination services revealed the exterminators were scheduled to provide services for the facility monthly and treat for any infestations. The contract was for 12 months of service beginning February 2024. Further review revealed the facility had no invoices for the contractor after 08/20/24. Interview on 12/26/24 at 12:08 P.M., with the Receptionist #100, from the exterminator contracted service company, revealed as of August 2024, the facility had an unpaid balance and the extermination service were no longer providing any treatments to the facility due to nonpayment. Interview on 12/26/24 at 10:30 A.M., with Licensed Social Worker, (LSW) #1, revealed when Resident #12 was admitted from the hospital on 09/25/24, returned to the hospital and the readmitted to the facility on [DATE]. Per LSW #1, the resident's personal belongings were bagged up and taken to a contained area outside of the facility. LSW #1 stated due to the facility owing money to the contracted exterminator there had been no extermination services provided to eradicate the bed bugs from Resident #12's personal items. Interview on 12/26/24 at 3:35 P.M., with the Administrator verified the extermination services had not been paid by the facility since August 2024. Per the Administrator the facility planned to pay the invoices and have the exterminator resume their contracted services. The Administrator verified there had been no extermination services provided to the facility since August 2024. This deficiency represents non-compliance discovered during the complaint investigation for Complaint Numbers OH00160209 and OH00159874.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on open and closed medical record review, review of hospital records, review of an emergency medical service (EMS) report, review of the facilities self-reported incident (SRI), staff interviews, review of witness statements, physician interview, review of the American Heart Association website, and review of facility policy, the facility failed to timely notify the physician of a significant change of condition for one resident (Resident #75). This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when Resident #75 experienced low blood pressure, with no notification to the physician of the abnormal level resulting in hospitalization and subsequent death. This affected one (Resident #75) of four residents reviewed for change in condition and death. The facility census was 71. On [DATE] at 5:53 P.M., the Administrator and the Director of Nursing (DON) were notified via phone that Immediate Jeopardy began on [DATE] at 1:00 P.M. when former Licensed Practical Nurse (LPN) #200 failed to notify a physician regarding a significantly low blood pressure level for Resident #75. Resident #75 ' s blood pressure on [DATE] at 11:45 A.M. was ,d+[DATE] millimeters of mercury (mmHg) (normal levels are above 90 systolic and above 60 diastolic). Documentation of the next blood pressure was not obtained until 4:15 P.M. when LPN #72 obtained Resident #75 ' s blood pressure levels at ,d+[DATE] mmHg. No attempts were made to contact a physician regarding the low blood pressure from 11:45 A.M. to 4:15 P.M. On [DATE] at 4:30 P.M., LPN #72 notified Medical Director (MD) #500 of the change in condition and contacted the EMS. The EMS arrived at the hospital at 5:17 P.M. and Resident #75 expired at the hospital on [DATE] at 10:07 P.M. Although the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficiency was corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 4:30 P.M., the DON was made aware by LPN #72 that Resident #75 was sent out to the hospital and later deceased . On [DATE], the DON reviewed Resident #75 ' s medical record and identified that LPN #200, who was Resident #75 ' s attending nurse on [DATE], had not notified the physician of resident ' s change in condition. On [DATE] at approximately 7:00 P.M., the DON notified MD #500 and reviewed the findings with him. On [DATE] at approximately 9:45 A.M., LPN #200 was suspended pending the completion of the investigation. On [DATE] at approximately 10:00 A.M., the DON notified Director of Clinical Services (DCS) #550 and DCS #550 gave directives for auditing like residents, auditing notification of physician, education to be given to all licensed nurses and nurse aides, auditing change of condition of all residents, auditing that nurse assessments being completed and physician notification made as applicable. On [DATE] at approximately 10:15 A.M., and continued [DATE], State tested Nursing Assistants (STNA) and licensed nurses were verbally educated on nursing assessment, reporting of resident refusal of care and decline/change in condition, physician notification of resident decline/change in condition, and documentation standards by the DON. A group/formal in-service was scheduled to be conducted on [DATE] by the DON. On [DATE] at approximately 11:15 A.M., DCS #550 arrived at the facility and assisted with the review of documentation, interviewing employees, and meeting with MD #500 via phone. Investigation ongoing; nurse in question (LPN #200) remains suspended pending conclusion of investigation. On [DATE], the DON reviewed all residents on North Hall, to identify any resident that was acutely ill and could suffer serious outcome. Medical records were reviewed to validate that all residents had been assessed and to identify any resident that may have warranted the physician being notified. On [DATE], an impromptu Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, MD #500, the DON, Human Resource Director (HRD) #350, and DCS #550 regarding Resident #75, and the lack of physician notification by LPN #200 on [DATE]. MD #500 did not have any further recommendations. On [DATE] and ongoing daily, the DON and/or the Assistant DON (ADON) or designee, will continue to review the 24-hour shift change report as well as the 24-hour clinical report to identify residents that may have had a change in condition. For those residents identified as having a change in condition, the DON/ADON/designee will monitor that residents are being assessed and physician notified as appropriate. Monitoring will occur five times a week for four weeks and then randomly thereafter, the DON/ADON/designee will conduct rounds on all units to identify residents that may have a change in condition. If any residents are identified as declining in condition, a review of the medical record documentation will be conducted to validate assessment by a nurse and the physician has been notified if appropriate. Audit results will be submitted to the QAPI committee on an ongoing basis, as needed, for further recommendations. On [DATE], an in-service was conducted by the DON on chain of command, walking rounds, reporting to nurse, vital signs, reporting any resident refusals of care and significant change, and documenting all incidents with all nursing staff including STNAs and all licensed nurses and was completed on [DATE]. On [DATE], the medical records for three additional residents (#14, #59 and #85) were reviewed for changes in condition and/or death, with no concerns noted. Interview on [DATE] at 3:20 P.M. with Residents # 09, #14 and #59, who had condition changes, revealed no concerns regarding the staff care and treatment pertaining to timely nurse assessments. Observation on [DATE] at 2:48 P.M. revealed STNA #62 obtaining and reporting vitals of residents on the Main Unit to LPN #65. On [DATE] at 8:30 A.M., from 1:38 P.M through 3:10 P.M., interviews with LPN #65, LPN #90, LPN #70, Registered Nurse (RN) #80, STNA #50, STNA #55, STNA #60, and STNA #62, stated they received education on notification of changes and re-assessing residents. Findings Include: Review of the closed medical record for Resident #75 revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The resident expired at the hospital on [DATE]. Diagnoses for Resident #75 include malignant neoplasm of rectum with colon resection surgery on [DATE], diabetes, morbid obesity, chronic kidney disease, and heart failure. The resident was a Full Code status. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and required partial assistance for mobility, and extensive assistance for toileting and bathing. Review of handwritten nurses ' notes, listed as late entry for [DATE], former LPN #200 documented on [DATE] at 8:00 A.M. Resident #75 took all of her medication. At 11:30 A.M., therapy staff notified former LPN #200 that Resident #75 ' s blood pressure was low, respirations were 18 breaths per minute, and oxygen saturation was 91 percent (%) with the electronic vitals machine. Therapist #100 stated therapy would not be delivered due to the resident stating she did not feel good. At 11:45, the former LPN #200 documented blood pressure was completed with manual equipment and the value was ,d+[DATE] mmHg. The resident was sleeping at 12:30 P.M. and at 1:20 P.M. the resident was sleeping. Another late entry dated [DATE] at 1:55 P.M revealed former LPN #200 passed onto the second shift nurse, LPN #72, that Resident #75 was starting to decline due to her blood pressure measuring ,d+[DATE] mmHg and to keep an eye on her as Resident #75 wasn ' t feeling well. Review of nursing progress notes in the Electronic Medical Record (EMR), dated [DATE] at 9:53 P.M., revealed the second shift nurse, LPN #72, was called to Resident #75 ' s room when the resident refused incontinence care multiple times. Upon rolling the resident on her side, the resident vomited coffee ground emesis and had loose bloody stool. The resident ' s respirations were 28 breaths per minute and the pulse was 54 beats per minute (bpm). The resident refused medication. MD #500 was notified and ordered the resident sent to hospital via EMS. After the EMS call was completed, the resident was reassessed with respirations of 7 breaths per minute, with labored breathing. The EMS arrived, resumed care, and transported the resident to the hospital. There were no nursing notes in the EMR on [DATE] on the first shift by former LPN #200. Review of Resident #75 ' s clinical vital log documentation dated [DATE] at 10:36 P.M. by LPN #72, revealed Resident #75 ' s blood pressure was ,d+[DATE] mmHg, pulse 54 beats per minute, respirations 28 breaths per minute, blood sugar 95 milligrams per deciliter, and oxygen saturation 90 % on room air. Previous blood pressure included on admitted d [DATE] was ,d+[DATE] mmHg, on [DATE] was ,d+[DATE] mm/Hg, on [DATE] was ,d+[DATE] mmHg, on [DATE] was ,d+[DATE] mmHg, on [DATE] was ,d+[DATE] mmHg and on [DATE] was ,d+[DATE] mm/Hg. There were no vital signs recorded for Resident #75 by the first shift former LPN #200. Review of the EMS report dated [DATE] revealed the EMS was contacted at 4:39 P.M. on [DATE], arrived at 4:47 P.M., and transported Resident #75 to the hospital at 5:15 P.M. The report revealed, upon arrival at the facility, Resident #75 was unresponsive with a blood pressure of ,d+[DATE] mmHg with pulse of 36 beats per minute and oxygen saturation of 81 %. The resident had sinus bradycardia, was mottled and diaphoretic. The resident had rapid breathing and was unable to verbally respond. An attempt to insert a intravenous line was unsuccessful, and the resident was transported to the hospital. Resident #75 was taken to the emergency room , became pulseless and was intubated. The resident expired. Review of the hospital emergency room documents dated [DATE] at 6:20 P.M. revealed Resident #75 arrived at the emergency roiagnom on [DATE] at 5:17 P.M. and expired at 10:07 P.M. The resident arrived with a diagnosis of hypotension, cardiac dysthymia and full cardiac arrest. The resident was intubated and had no cardiac activity. The resident was 12 days post-surgery for rectal cancer with decline in responsiveness over past several days. Review of an investigation statement dated [DATE] by first shift STNA #30 revealed on [DATE] she reported to former LPN #200 multiple times on the day shift that Resident #75 was refusing care, meals, and vitals. The former LPN #200 was not observed to check on Resident #75 during the shift. Review of an investigation statement dated [DATE] by first shift LPN #70 revealed on [DATE] at 1:00 P.M. she heard STNA #30 report to former LPN #200 that Resident #75 was refusing care. LPN #70 suggested to former LPN #200 that Resident #75 needed assessed. Former LPN #200 continued sitting at the nurses station and was not noted to assess Resident #75. Review of an investigation statement dated [DATE] by STNA #40 revealed she took STNA #30 into Resident #75 ' s room to provide care and attempt to obtain vitals. The blood pressure was not reading, and former LPN #200 was notified. Former LPN #200 did not notably respond to two additional times during the shift of STNA #40 ' s concerns of Resident #75 ' s care refusals and pain. The second shift STNA #45 was notified of Resident #75 ' s refusals of care during shift change at 2:00 P.M. Review of an investigation statement dated [DATE] by second shift STNA #45 revealed on [DATE] she received shift report at 2:00 P.M. from STNA #30. STNA #30 reported Resident #75 refused care, meals and had reported the information to former LPN #200 throughout the day. STNA #30 had stated former LPN #200 had not checked on the resident after being notified several times of Resident #75 ' s refusals. At 2:30 P.M., STNA #45 told second shift LPN #72 of Resident #75 ' s refusals. LPN #72 stated she had not been notified by former LPN #200 of Resident #75 ' s refusals. At 4:15 P.M., LPN #72 assisted STNA #45 with incontinence care of Resident #75 when the resident began vomiting and had loose stools. The EMS was called, and the EMS transported Resident #75 to the hospital. Review of the written investigation statement dated [DATE] by former LPN #200 revealed she was called to Resident #75 ' s room by Therapist #100 due to the resident was short of breath and had low blood pressure. The resident stated she did not feel good. Therapist #100 reported she was unable to get a good blood pressure with the electronic vital machine. Former LPN #200 documented that she obtained vitals with manual equipment on a handwritten late entry nurse ' s note and could not recall the exact blood pressure value and respirations were 16. Former LPN #200 told Therapist #100 the therapy session could not be provided due to the resident stated she did not feel well and had low blood pressure. She documented the resident went to sleep and was resting comfortably the remainder of the shift with no nausea or vomiting. The resident had refused the lunch meal. Former LPN #200 reported vitals and the resident condition to second shift LPN #72 because former LPN #200 felt the resident was declining. Review of the investigation statement dated [DATE] and physical therapy documentation dated [DATE] at 1:56 P.M., Therapist #100 revealed the visit with Resident#75 on [DATE] noted Resident #75 ' s blood pressure was obtained of a value of ,d+[DATE] mmHg. Therapist #100 reported the low blood pressure to former LPN #200. Former LPN #200 responded she was going to finish her medication pass and would reassess the blood pressure with manual equipment. Therapist #100 noted former LPN #200 directed no therapy to be provided due to decline in medical status. Review of an investigation statement dated [DATE] by second shift LPN #72 verified the nurses' notes entered on [DATE] at 9:53 P.M., LPN #72 revealed upon arrival of the shift starting at 2:00 P.M. on [DATE], former LPN #200 reported Resident #75 had refused care and may be declining but thought Resident #75 was doing OK. At 3:30 P.M., STNA #45 reported Resident #75 had been refusing incontinence care and needed care. Resident #75 resisted and then permitted LPN #72 and STNA #45 to provide incontinence care. The resident had coffee ground vomiting and loose bloody stool. Review of facilities SRI, submitted by the facility Administrator on [DATE], revealed LPN #72 reported former LPN #200 did not assess Resident #75. Former LPN #200 was terminated due to failure to maintain honest and accurate records of services as well as inefficiency, lack of productive effort or other unsatisfactory work performance. Review of the investigation statement of LPN #65 revealed on [DATE] on second shift report at 2:00 P.M, former LPN #200 reported to LPN #72, Resident #75 ' s blood pressure was ,d+[DATE] mmHg, and the resident was declining. At 4:20 P.M., LPN #72 reported to LPN #65, EMS had been called as Resident #75 was vomiting, and had diarrhea. LPN #65 called former LPN #200. Former LPN #200 reported Resident #75 had not vomited, had no diarrhea, and verified the blood pressure was ,d+[DATE] mmHg. Interview on [DATE] at 10:43 A.M, the DON verified the investigation of Resident #75 ' s change of condition, resulting in hospitalization and death, was not acted upon by former LPN #200. Former LPN #200 did not notify the physician during the first shift of [DATE] when blood pressure was verified at ,d+[DATE] mmHg at 11:45 A.M. The investigation revealed STNAs #30 and #40 notified former LPN #200 throughout first shift of Resident #75 ' s refusal of care, meals and general decline in condition. The DON verified Therapist #100 had notified former LPN #200 of the resident ' s low blood pressure and general weakness at 11:35 A.M. The DON verified former LPN #200 did not document progress notes of Resident #75 ' s conditional changes or vitals obtained during the first shift of [DATE]. The DON stated former LPN #200 documented, with inaccurate dates, and late entry documentation on [DATE] during the investigative interview. The handwritten late entry documentation was not contained in Resident #75 ' s medical record. The DON verified the former LPN #200 was suspended during the investigation and employment terminated on [DATE]. The DON verified former LPN #200 was terminated due to lack of documentation of Resident #75 ' s assessment, recording of blood pressure in the medical record, did not respond to notification from STNAs #30 and #40 of resident condition change, had inaccurate late entry documentation and did not use facility nurses reporting documentation on the second shift nursing report. The DON stated the nurse written shift report could not be located during the investigation to confirm or deny Resident #75 ' s blood pressure was communicated to the second shift nurse. The DON verified the second shift LPN #72, reporting to work at 2:00 P.M., did not assess Resident #75 until 3:30 P.M. Interview on [DATE] at 11:05 A.M. with MD #500 revealed discussion with Resident #75 ' s Emergency Physician on [DATE] that Resident #75 was most likely having a cardiac event during the day of [DATE]. MD #500 stated he was not notified until 4:35 P.M. by second shift LPN #72 of the low blood pressure, vomiting, loose stools and general change in condition. MD #500 stated the first shift nurse, former LPN #200, should have contacted him when the low blood pressure of ,d+[DATE] mmHg was first assessed at 11:45 A.M., in addition to refusal of meals and general not feeling well. Interview on [DATE] at 11:18 A.M., LPN #70 verified she had suggested to former LPN #200 to assess Resident #75 after STNA #30 had reported the resident ' s refusal of care. Former LPN #200 was not observed to act immediately to assess the resident. Interview on [DATE] at 11:40 A.M. with second shift LPN #65 verified she had heard former LPN #200 give shift report to second shift LPN #72 including blood pressure of ,d+[DATE] mmHg and a general decline in condition of Resident #75. LPN #65 verified the blood pressure value and decline in condition was sufficient assessment information to notify the physician immediately. LPN #65 verified LPN #72 did not report having contacted MD #500 and EMS until 4:20 P.M. Interview on [DATE] at 12:07 P.M. with second shift nurse LPN #72 verified she received written shift report from former LPN #200 which did not have blood pressure values and there was no vital or progress record in the EMR from former LPN #200. LPN #72 revealed former LPN #200 stated the resident was in decline but was stable. The verbal clinical report contained no blood pressure values. LPN #72 verified she started her medication pass and did not assess Resident #75 until STNA #45 reported Resident #75 needed assessment due to refusal of care and general decline. During incontinence care, Resident #75 started vomiting and had loose stool, with a blood pressure of ,d+[DATE] mmHg, pulse 54 beats per minute and respirations of 27 breaths per minute. EMS was contacted at about 4:15 P.M and the respirations had decreased to 6 breaths per minute. LPN #72 stated she should have made resident visual rounds at the start of her shift to ensure the residents on her assignment had been assessed accurately. Interview on [DATE] at 1:20 P.M., Therapist #100 verified she had obtained Resident #75 ' s blood pressure on [DATE] at about 12:30 P.M. and the blood pressure was ,d+[DATE] mmHg. Therapist #100 verified she reported immediately to former LPN #200 the low blood pressure value. Former LPN #200 directed no therapy be provided due to the condition change. Former LPN #200 stated she would obtain a blood pressure with manual equipment. Therapist #100 stated she did observe former LPN #200 taking Resident #75 ' s blood pressure with manual equipment about 15 minutes later. Interview on [DATE] at 1:30 P.M., former LPN #200 verified Resident #75 took her medications without difficulty at the 8:00 A.M. medication pass. Former LPN #200 denied STNAs #30 and #40 reported the resident had refused care, refused meals, refused vitals and had a general decline. She stated around 12:00 P.M. Therapist #100 notified her of Resident #75 ' s low blood pressure with the electronic vital machine of ,d+[DATE] mmHg and pulse of 70 beats per minute. The resident had reported not feeling well, wanted to be left alone and sleepy. Former LPN #200 stated she obtained a blood pressure 15 minutes later with manual equipment and the blood pressure was ,d+[DATE] mmHg at around 1:00 P.M. Former LPN #200 stated since the resident ' s admission on [DATE], the resident had been lowly motivated, and spent much time in bed. She stated she checked on Resident #75 at 1:50 P.M and the resident was sleeping so she did not obtain new vitals. Former LPN #200 stated the low blood pressure changes, refusal and general decline had not concerned her enough to contact MD #500. She stated she had reported, in written shift report and verbally, the blood pressure of ,d+[DATE] mmHg to second shift LPN #72. Since Resident #75 ' s blood pressure was assessed at approximately at 1:00 P.M., and former LPN #200 ' s shift ended at 2:00 P.M, former LPN #200 stated the second shift nurse, LPN #72, should have followed up on Resident #75 ' s decline. Review of former LPN #200 ' s personnel record revealed a date of hire of [DATE] and termination date of [DATE]. The termination was described by the DON as failure to maintain honest and accurate records of service provided, inefficiency, lack of proactive effort or other unsatisfactory work performance. Former LPN #200 was suspended on [DATE] during the investigation which ended on [DATE]. The disciplinary termination notice was signed by the DON on [DATE] and former LPN #200 refused to sign. Review of the facility policy titled Change in a Resident's Condition, dated February 2021 revealed the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been a change in resident condition. This includes a significant change in the resident ' s mental condition, refusal of treatment, or a major decline in the resident's status which will not normally resolve itself without intervention by staff. According to the American Heart Association at www.heart.org, titled Understanding Blood Pressure Readings, a blood pressure reading of systolic less than 90 and diastolic less than 60 is considered hypotensive and a clinical abnormal value. This deficiency represents non-compliance investigated under Complaint Number OH00148885.

Based on medical record review, staff interview, policy review and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to accurately assess Resident #25's risk factors for pressure ulcer skin breakdown to ensure an individualized care plan was developed/implemented to prevent skin breakdown, failed to ensure nursing staff conducted Resident #25's skin assessments as ordered and failed to ensure Resident #25's pressure ulcer dressings were changed per physician's order. This resulted in Actual Harm when staff failed to develop/implement a individualized careplan for Resident #25 to prevent skin breakdown to the resident's lower extremities, failed to ensure nursing staff conducted two weekly skin assessments as physician ordered and Resident #25 subsequently developed avoidable Deep Tissue Injuries (DTI's) to the bilateral heels and to the right lateral (outer) foot. Additionally, the facility failed to conduct an accurate skin assessment for Resident #50 who was previously identified as having pressure ulcers, which placed the resident at risk for potential harm. This affected two (#25 and #50) out of three residents reviewed for pressure ulcers. Facility census was 73. Findings include: 1. Review of Resident #25's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #25 was discharged to the hospital on [DATE]. Review of the comprehensive admission Minimum Data Set (MDS) assessment, dated 04/30/19 revealed Resident #25 was cognitively intact and had no rejections of care or services. The resident required extensive assistance of two staff members for bed mobility, transfers, toileting and personal hygiene. Resident #25 required supervision with eating. Further review revealed resident was not ambulatory during the look back period. Two unstageable (inability to see the wound bed) pressures ulcers and two DTI (purple or maroon area of discolored intact skin due to damage of underlying soft tissue) were coded on the MDS that were not present on admission. Resident #25 was coded as receiving physical, speech and occupational therapy during the look back period. Review of Resident #25's comprehensive plan of care dated 04/18/19 documental the resident had potential impairment for skin integrity of the bilateral lower extremities related to [MEDICAL CONDITION]. Interventions included avoid scratching and keep hands and body parts from excessive moisture, keep fingernails cut short, encourage good nutrition good nutrition and hydration in order to promote healthier skin, identify/document potential causative factors and elevate where possible. Additionally, the resident needed cushioning to protect the skin while in chair, the resident needs pressure relieving/reducing mattress to protect the skin while in bed, use a draw sheet or lifting device to move resident, and use caution during transfer and bed motility to prevent striking arms, legs and hands against any sharp or hard services. Review of the Residents #25's Admission Nursing Observation Assessment form dated 04/18/19 at 9:21 P.M. for completed by Licensed Practical Nurse (LPN) #100 revealed no pressure areas were noted on the body at the time of admission. Further review revealed the resident had two plus [MEDICAL CONDITION] (measurement of fluid) in both lower extremities that was present at the time of admission. Review of Resident #25's pressure ulcer risk (Braden) assessment dated [DATE] at 9:41 P.M. revealed the resident identified as low risk for the development of pressure ulcers. Review of Resident #25's physician progress notes [REDACTED]. Resident #25 has had four [MEDICAL CONDITION] per the resident in the past. Blood sugar levels are out of control with sugars in the four hundred range. The physician noted Resident #25 was noncompliant with diet. Review of treatment record (TAR) for the month of (MONTH) 2019 revealed Resident #25 had a weekly skin assessment scheduled for 04/20/18 and 04/27/19 on the for the 6:00 A.M. to 2:00 P.M. shift. Further review of the TAR and the medical record revealed the weekly skin assessments scheduled for 04/20/19 and 04/27/19 were not completed as ordered. Review of the nursing notes for dated 04/27/19 at 7:00 P.M. revealed an aide alerted the nurse when he/she removed Resident #25's socks a large amount of clear fluid sprayed out of both heels. The left heel had a large avulsed (a tearing away of skin) area measuring eight centimeters (cm) by eleven cm. The right heel was open with darker areas on right lateral (outer edge) of the foot, measuring six cm by 15 cm. The primary physician was notified and treatments were ordered to all areas. Review of a physician order dated 04/27/19 documented a new treatment instructing staff to cleanse both heels and pat dry, apply Vaseline gauze and wrap with Kerlix (gauze roll type dressing to secure treatment in place) every day and as needed (PRN). Additional order dated 04/27/19 instructed staff to ensure Resident #25's heels were floated off the mattress when in bed. Review of the TAR from 04/28/19 and 04/29/19 revealed there was no documented evidence by nursing staff that Resident #25's dressings to both feet were changed as ordered. Review of the physician's wound monitoring documents dated 04/29/19 revealed Resident #25 had a unstageable DTI (site one) wound to the right heel measuring six cm by five cm by no measurable depth; an unstageable DTI on right lateral foot (site two) measuring two cm by nine cm by no measurable depth; and a unstageable DTI of the left heel (site three) measuring 10.0 cm by eight cm by 0.1 cm depth. The wound bed for site one and site two were not described. The wound bed for site three was not visible due to fluid filled blister present. Review of physician order dated 04/29/19 revealed an order instructing staff to cleans Resident #25's right and left heels with soap and water, pat dry and apply skin prep (liquid dressing) every day for 30 days. Additional orders for the left foot revealed to cleanse the left heel with wound cleanser, pat dry and apply calcium alginate dressing and wrap with Kerlix every day for 30 days. There were no orders limiting Resident #25's mobility. Review of the revised plan of care dated 04/29/19 revealed Resident #25 had a pressure ulcer to the right heel, left heel, right lateral foot, left lateral foot, anterior right ankle, anterior left ankle and had the potential for further pressure ulcer development related to new shoes and impaired mobility. Interventions include administer treatments as ordered and monitor for effectiveness, do not put shoes on resident at this time, educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, elevate feet on pillow, heel lift boots to both feet, inform the resident/family/caregivers of any new area of skin breakdown, monitor nutritional status. Serve diet as ordered, monitor intake and record, the resident requires pressure relieving/reducing mattress on bed, cushion to chair, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate(drainage). On 08/20/19 at 9:30 A.M. with Registered Nurse (RN) #26 verified Resident #25's care plan documented the presence of new shoes; however, there was no other documentation related to new shoes in Resident #25's medical record. Interview on 08/20/19 at 2:50 P.M. with RN #26 verified Resident #25 had orders for weekly skin assessments. RN #26 further confirmed Resident #25's weekly skin assessment dated [DATE] and 04/27/19 for the 6:00 A.M. to 2:00 P.M. shift were not completed as ordered. Interview on 08/20/19 at 3:09 P.M. with RN #101 verified Resident #25's risk assessment for pressure ulcers completed on 04/18/19 was coded incorrectly indicating a low risk when it should have been assessed and coded as being at high risk for pressure ulcer development. RN #101 further verified the weekly skin assessments that were scheduled for 04/20/19 and 04/27/19 on the 6:00 A.M. to 2:00 P.M. shift were not completed as ordered. RN #101 verified intervention to float Resident #25's heels off bed were not in place until the discovery of the wounds on 04/27/19 and that Resident #25 was admitted with [MEDICAL CONDITION] to the lower extremity. RN #101 confirmed Resident #25 developed DTI's to the bilateral heels and to the right lateral foot. RN #101 further confirmed the intervention to suspend Resident #25's heels were not implemented until after the pressure ulcers developed on 04/27/19. RN #101 confirmed Resident #25's dressings were not changed as ordered on [DATE] and 04/29/19. 2. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of plan of care for Resident #50 with an initiation date of 09/07/16 and a revision date of 08/14/19 revealed the resident was at risk for alteration in skin integrity related to a history of pressure ulcers. Interventions included [MEDICATION NAME] to both lower legs as ordered, barrier cream to peri area/buttocks as needed, collaborate care with Hospice, encourage fluids, encourage to reposition as needed; use assistive devices as needed, float heels as able, podiatrist care as needed, therapy evaluation & treatment per physician orders. Review of significant change MDS assessment for Resident #50 dated 05/03/19 revealed the resident is cognitive intact. Resident #50 required extensive assist for bed mobility, transfers, dressing, toileting and personal hygiene. Further review of the MDS revealed two unstageable pressure ulcers on both heels. Review of most recent quarterly MDS assessment dated [DATE] for Resident #50 revealed intact cognition. Resident #50 required extensive assist for bed mobility, transfers, dressing, toileting and personal hygiene. Further review of the MDS revealed one stage three pressure and one stage four pressure ulcer. Review of Braden scale dated 03/03/19 for Resident #50 revealed resident was at low risk for the development of pressure ulcers. Review of weekly skin assessment for Resident #50 dated 04/27/19 documented no pressure areas at this time. Review of nursing notes for Resident #50 dated 05/01/19 revealed the discovery of a blister on the the resident's right heel and the left heel that was reddened. The physician was notified and new orders were obtained. Review of a physician orders date 05/01/19 for Resident #50 documented a new treatment instructing staff to cleanse the right heel with wound cleanser, pat dry, apply [MEDICATION NAME] and change every three days. Additional orders dated 05/01/19 documented new orders for left heel, cleanse the left heel with soap and water, pat dry, apply [MEDICATION NAME] and change every three days. Review of wound evaluation and weekly management summary for Resident #50 dated 05/06/19 documentated an unstageable DTI to the left heel measuring 0.4 cm by 0.4 cm by depth that was unmeasurable and unstageable DTI of the right heel that measures 2.5 cm by 2.5 cm by depth not measurable due to blood filled blister present. Review of weekly skin assessment for Resident #50 dated 05/10/19 revealed a skin assessment was completed and the resident had no pressure ulcers. Review of wound evaluation and weekly management summary for Resident #50 dated 05/13/19 documentated unstageable DTI to the left heel measuring 0.7 cm by 0.7 cm by depth that was unmeasurable and unstageable DTI of the right heel that measures 2.3 cm by 2.6 cm by depth not measurable due to blood filled blister present. Interview on 08/20/19 at 3:09 P.M. with RN #101 confirmed Resident #50 had pressure ulcers at the time of the weekly skin assessment dated [DATE]. RN #101 confirmed the weekly skin assessment dated [DATE] reflected the resident had no pressure ulcers; however, this assessment was not conducted accurately as the resident did have DTI's to the bilateral heels. Review of the facility policy titled Skin Assessment and Documentation dated 08/01/19 revealed the purpose of the policy is to provide guidelines for the proper procedures for qualified nursing staff to observe a Resident ' s skin condition; collect designated information and document correctly. The policy indicated the pressure ulcer risk assessment will be completed on admission, re-admission, quarterly, annual and anytime there is a significant change to the condition of the resident. The care plan will include interventions to prevent skin breakdown and interventions to treat actual breakdown when indicated. Address these areas with problems and goals when the comprehensive care plan is completed or sooner if needed. A weekly skin assessment must be completed by the nurse and documentation of completion of the assessment is required by initialing the TAR. The staff will document any finds from the weekly skin assessment in the nurse's notes or on the weekly skin assessment form. Review of information from the NPUAP revealed a DTI is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The NPUAP indicated to use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible (but within 8 hours after admission) and based on the identified risk factors a care plan should be developed and implemented. Further review of the NPUAP revealed the facility should assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanter's, elbows and beneath medical devices. The NPUAP also indicated to ensure that the heels are free from the bed and to use heel offloading devices or [MEDICATION NAME] foam dressings on individuals at high-risk for heel ulcers. This deficiency substantiates Master Complaint Number OH 304 and Complaint Number OH 265.