Every finding on record at Ayden Healthcare of Rosemount Pavilion

Based on observation, interview, and record reviews the facility failed to ensure treatment orders for a resident with a pressure ulcer were implemented timely and appropriately. This affected one resident (#79) of the six residents the facility identified as having pressure ulcers. The facility census was 81. Findings include: Record review for Resident #79 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included open wound of the right knee, atrial fibrillation, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 03/22/26, revealed the resident was assessed to have intact cognition. Review of the care plan, revised 04/02/26, revealed the resident had an alteration in skin. Interventions included to administer treatments as ordered. Review of the Wound Assessment Report, dated 04/20/26 and signed by Nurse Practitioner (NP) #501, revealed Resident #79 was assessed to have Moisture Associated Skin Dermatitis (MASD) to the coccyx. Treatment for the area of MASD was to cleanse with wound cleanser, apply triad cream with collagen particles, and leave open to air twice a day. Review of the Wound Assessment Report, dated 04/27/26 and signed by Nurse Practitioner (NP) #501, revealed Resident #79 was assessed to have a pressure ulcer to the coccyx. Treatment orders for the pressure ulcer were to cleanse the pressure ulcer with wound cleanser, apply a collagen dressing - cut to fit wound bed, and cover with a silicone bordered superabsorber, change every day and as needed. Review of the Wound Assessment Report, dated 05/04/26 and signed by NP #501, revealed Resident #79 continued to have a pressure ulcer present to the coccyx. Treatment orders for the pressure ulcer were to cleanse the pressure ulcer with wound cleanser, apply a collagen dressing - cut to fit wound bed, and cover with a silicone bordered superabsorber, change every day and as needed. Review of the active physicians order, dated 04/13/26, revealed an order for Resident #79's sacrum to be cleansed with wound cleanser, pat dry, apply triad cream with collagen particles and leave open to air every shift for prevention. No order to cleanse the pressure ulcer to Resident #79's coccyx with wound cleanser, apply a collagen dressing - cut to fit wound bed, and cover with a silicone bordered superaborber, change every day and as needed was present. Observation on 05/06/26 at 10:00 A.M. revealed staff were providing incontinence care to Resident #79. The resident had a small wound to her coccyx which did not have a dressing in place when staff assisted the resident to roll over in bed. The wound did not exhibit signs of infection. Interview with Assistant Director of Nursing (ADON) #124 on 05/05/26 at 12:30 P.M. confirmed NP #501 came to the facility weekly to assess resident wounds and provide treatment orders. ADON #124 confirmed the treatment orders for the wound to Resident #79's coccyx had been changed by NP #501 on 04/27/26 but had not been implemented by the facility.This deficiency represents non-compliance identified during the investigation of Complaint 2972768.

Based on observation, interviews, record reviews, and review of facility policy, the facility failed to ensure incontinence care was provided in a timely manner. This affected one resident (#79) out of the three residents reviewed for incontinence care and toileting assistance. The facility census was 81. Findings include:Record review for Resident #79 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included open wound of the right knee, atrial fibrillation, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 03/22/26, revealed the resident was assessed to have intact cognition. The resident was assessed to always be incontinent of bowel and bladder. Review of the care plan, revised 04/02/26, revealed the resident has/at risk for bladder incontinence. Interventions included to apply barrier cream as ordered and to provide peri-care after each incontinent episode. Observation on 05/05/26 at 9:16 A.M. revealed the call light for Resident #79 and Resident #80's room was lit up in the hallway. Staff were busy providing care to other residents in their rooms. Observation on 05/05/26 at 9:24 A.M. revealed the call light for Resident #79 and Resident #80's room continued to be lit up in the hallway. No staff had entered the room since the previous observation. Observation on 05/05/26 at 9:31 A.M. revealed the call light for Resident #79 and Resident #80's room continued to be lit up in the hallway. No staff had entered the room since the previous observations. Observation on 05/05/26 at 9:42 A.M. revealed the call light for Resident #79 and Resident #80's room continued to be lit up in the hallway. No staff had entered the room since the previous observations. Upon knocking and entering the room, Resident #79 was lying in the bed and Resident #80 was sitting up on the side of the bed. Resident #79 confirmed she was needing incontinence care provided by staff as she could not do it herself. Resident #79 confirmed she had placed the call light on once before and Certified Nursing Assistant (CNA) #147 had entered the room and told the resident she would get assistance and return to provide care. Resident #79 confirmed she had placed the call light back on when staff did not return timely and was still waiting for staff to return. Resident #79 confirmed she had not had incontinence care provided since approximately 5:45 A.M. when night shift staff were completing their final rounds. Observation on 05/05/26 at 9:56 A.M. revealed CNA #147 and CNA #166 entered the room and turned off the call light, 40 minutes after the call light was initially observed to be on. CNA #147 confirmed Resident #79 had not had incontinence care provided since day shift had begun at 7:00 A.M. CNA #147 and CNA #166 began providing incontinence care to Resident #79. The resident was observed to have been incontinent of bowel and bladder and the attend was saturated with urine and feces. Interview with CNA #147 and CNA #166 on 05/05/26 at 10:15 A.M. confirmed Resident #79 was able to place her call light on and let staff know when she needed incontinence care provided. They confirmed the resident required assistance from two staff members for care and sometimes it took a while to provide care. Review of the facility policy titled Incontinence Management, reviewed 04/28/25, revealed it was the policy of the facility to promote intact skin, maintain dryness, and respect the residents standard and individualized interventions. Interventions included timely response to the needs of the resident.This deficiency represents non-compliance identified during the investigation of Complaints 2973419 and 2966978.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure infection control measures were appropriately implemented during wound care treatment. This affected one resident (#72) observed for wound care. The facility census was 81. Findings include:Record review for Reisdent #72 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included colostomy hemorrhage, type two diabetes mellitus, and atrial fibrillation. Review of the 5-Day Minimum Data Set (MDS) assessment, dated 03/11/26, revealed the resident was assessed to have intact cognition and to have a surgical wound present with surgical wound care provided. Observation on 05/04/26 at 1:45 P.M. revealed Assistant Director of Nursing (ADON) #117 entered the room of Resident #72 to provide wound care treatment to the residents abdominal wounds. ADON #117 performed hand hygiene and donned (put on) two pairs of gloves, one on top of the other. ADON #117 removed the old (dirty) wound dressing, cleansed the abdominal wounds, and applied skin prep to the skin surrounding the wounds. ADON #117 then removed the outer glove on each hand leaving the inner glove on each hand. ADON #117 did not perform hand hygiene. ADON #117 then measured the abdominal wounds and placed the new dressing on the wounds.ADON #117 then removed the inner gloves on each hand and discarded them, then performed hand hygiene. Interview with ADON #117 on 05/04/26 at 2:20 P.M. confirmed she had donned two pairs of gloves, one on top of the other, prior to performing wound care. ADON #117 confirmed she had removed one pair of the gloves in the middle of the wound care treatment leaving the remaining pair of the gloves on her hands. ADON #117 confirmed she had not performed hand hygiene except before and after the wound care treatment was completed. Review of the facility policy titled Wound Care, reviewed 08/2024, revealed the procedure for wound care was to wash and dry hands, apply exam gloves, remove the old dressing and discard, wash and dry hands thoroughly, apply new gloves, then cleanse wound and apply new dressing. Remove gloves and wash hands thoroughly following the completion of the wound care treatment.This deficiency represents non-compliance identified during the investigation of Complaint 2972768.

Based on observations, interviews, and record reviews, the facility failed to ensure comprehensive, resident centered care plans were developed and implemented. This affected seven residents (#39, #48, #69, #74, #76, #78, and #233) out of the 20 residents whose comprehensive care plans were reviewed during the annual survey. The facility census was 78. Findings include: 1. Record review for Resident #39 revealed the resident was admitted to the facility on [DATE] and had diagnoses include pressure ulcer of the right heel, morbid obesity, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/20/25, revealed the resident was assessed to have intact cognition. The resident was assessed to have one stage three pressure ulcer which was present upon admission to the facility. Review of the active physicians orders for Resident #39 revealed orders for a specialty mattress to bed, house protein supplement two times a day, encourage to float heels, and resident to wear Prevalon boots to bilateral feet while in bed. Review of the care plan, most recently revised on 04/29/25, revealed the resident had actual impairment to skin integrity related to a right heel Deep Tissue Injury (DTI) and Moisture Associated Skin Damage (MASD). Interventions were limited to follow facility protocols for treatment of injury, weekly treatment documentation, and Enhanced Barrier Precautions (EBP) as ordered. Observation on 05/12/25 at 9:45 A.M. revealed Resident #39 was lying in bed on the left side. A specialty mattress was in place on the residents bed which provided pressure relieving measures. Interview with Resident #39 at the time of the observation confirmed the specialty mattress had been in place to the bed for several months. The resident confirmed staff assisted her to elevate her heels off the bed but she was not able to utilize Prevalon boots due to them not staying in place as they were intended to. Interview with the Director of Nursing (DON) on 05/16/25 at 11:00 A.M. confirmed the care plan for Resident #39 only contained generic interventions utilized for several residents with skin alterations and did not contain individualized interventions for the care of the resident. 2. Record review for Resident #48 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Post Traumatic Stress Disorder (PTSD), insomnia, and Parkinson's disease. Review of the quarterly MDS assessment, dated 04/11/24, revealed the resident was assessed to be cognitively intact. Review of the care plan, dated 01/24/25, revealed the resident displayed or had a diagnosis with mental disorder or psychosocial difficulty adjustment, or had a history of trauma/PTSD. The only intervention present was assist resident and family with access to psychiatry and psychosocial services. Interview with the DON on 05/16/25 at 11:00 A.M. confirmed the care plan for Resident #48 did not contain specific information regarding the cause of the residents PTSD, potential triggers for PTSD, or individualized interventions to assist in preventing re-triggering PTSD. 3. Record review for Resident #74 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included acute pain due to trauma, psychoactive substance abuse, and anxiety disorder. Review of the admission MDS assessment, dated 02/04/25, revealed the resident was assessed to have intact cognition. Review of the active care plan for Resident #74 revealed there was no care plan in place related to the residents history of trauma. Interview with Resident #74 ON 05/12/25 at 10:29 A.M. confirmed the residents son had committed suicide and the resident had hallucinations of him walking past the door to her room so she preferred to keep the door shut. The resident confirmed she had traumatic events which had occurred and loud noises such as guns firing, fireworks, and loud bangs set her off so she had headphones which she wore frequently to muffle the noises. Interview with the DON on 05/16/25 at 11:00 A.M. confirmed no care plan had been developed related to the residents history of trauma to include causes of the residents trauma, potential triggers for trauma, or individualized interventions to assist in preventing re-triggering of trauma. 34299 4. Review of the medical record for Resident #69 revealed an admitted [DATE] with diagnoses including unspecified fracture of left lower extremity, generalized anxiety disorder, major depressive disorder, congestive heart failure, atrial fibrillation, diabetes mellitus type two, and hypertension. Review of the physician orders dated 05/25 revealed Resident #69 was ordered the following medications and treatments: blood glucose before meals and at bedtime, notify physician if blood sugar less than 60 or above 400, oxycodone hydrochloride five milligrams (mg) by mouth every six hours for pain, Metoprolol tartrate 50 mg by mouth two times daily for hypertension-hold if systolic blood pressure less than 120 milliliters of mercury (mmHg) or pulse less than 60 beats per minute (bpm), Sertraline hydrochloride 100 mg by mouth once daily for depression, buspirone hydrochloride 10 mg by mouth three times daily for anxiety and Midodrine hydrochloride 10 mg by mouth three times daily for hypotension-hold if systolic blood pressure greater than 120 mmHg. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #69 was cognitively intact with no mood symptoms or behaviors. Resident #69 had impaired range of motion to bilateral lower extremities. Resident #69 required substantial-maximum assistance from staff to complete activities of daily living. Resident #69 was incontinent of bowel and bladder. Resident #69 did not have any pain, falls or skin impairment. Review of the nursing progress notes dated 05/13/25 at 5:28 P.M. the nurse noted a conversation with the Nurse Practitioner (NP) concerning the resident received scheduled Midodrine 10 mg by mouth three times daily related to hypotension and Lopressor 50 mg by mouth two times daily related to hypertension and atrial fibrillation. New orders received to continue the Lopressor as scheduled and change the perimeters to hold the medication if pulse was less than 60 beats per minute. A order to taper the Midodrine off at this time at a slow pace due to risk of arrhythmia if medication was stopped to suddenly. The resident was updated on the orders given. Review of the monthly medication review by the pharmacy revealed a recommendation on 03/04/25, that was signed by physician on 03/08/25: please consider adding parameters to Midodrine hydrochloride 10 mg by mouth three times daily for hypotension and hold if systolic blood pressure was greater than 120 mmHg. Review of the plan care initiated on 05/13/25 revealed Resident #69 had hypotension and atrial fibrillation. The goal stated Resident #69 would be free of signs and symptoms of hypotension through review date. The interventions included: give medications as ordered, monitor for side effects and effectiveness, monitor/document/report to the physician as needed any signs and symptoms of hypotension (dizziness, fainting, syncope, blurred vision, lack of concentration, nausea, fatigue, and or cold clammy pale skin), and obtain and monitor lab/diagnostic work as ordered, report the results to physician and follow up as indicated. Review of the plan of care initiated on 05/13/25 revealed Resident #69 was at risk for alteration in mood and behavior related to anxiety and depression, makes statements to therapy such as I don't need to know how to walk my boyfriend will carry me wherever I want when he gets out of prison, prefers to stay in her room and chooses not to get up out of bed. The goal stated Resident #69 would have reduced number of mood indicators or reduced instances of mood indicators. The interventions included to administer medications per order, encourage loved ones to contact/visit, and observe and report any changes in mental status. The plan of care did not address any cardiovascular diseases such as congestive heart failure or hypertension. Interview with Director of Nursing 05/16/25 at 12:20 P.M. confirmed care plans were not completed to meet all the needs of the resident. 5. Review of the medical record for Resident #76 revealed an admitted [DATE] with diagnoses including dysarthria, neuromuscular dysfunction of bladder, transient ischemic attack (TIA), cirrhosis of liver, benign prostate hypertrophy (BPH), insomnia, viral Hepatitis B, hypertension and major depression. Review of the physician orders dated 05/25 revealed Resident #76 was ordered the following medications and treatments: 16 French indwelling foley catheter with 10 milliliter (ml) balloon to catheter bag drainage system related to neurogenic bladder, change indwelling foley catheter monthly and as needed, monitor urinary output related to foley catheter every shift, irrigate bladder three times per week with normal saline, Furosemide 40 mg by mouth daily for edema, potassium chloride extended release 10 milliequivalents (mEq) by mouth daily as supplement, Trazadone hydrochloride 150 mg by mouth at bedtime related to major depressive disorder, buspirone hydrochloride 10 mg by mouth two times daily for anxiety, Eliquis 5 mg by mouth daily, and enhanced barrier precautions due to foley catheter. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #76 was cognitively intact with little interest or pleasure in doing things, feeling down, depressed and or hopeless, had trouble with sleeping, and feeling tired, feeling bad about self and trouble concentrating 12-14 days of look back period. Resident #76 had no impaired range of motion. Resident #76 required substantial to maximum assistance with toileting and personal hygiene, partial to moderate assistance with transfers and was dependent on the staff for showers and bathing. Resident #76 had an indwelling catheter for urinary output, and was occasionally incontinent of bowel. Resident #76 had no falls or skin impairment. Observations on 05/12/25 at 10:20 A.M., 05/12/25 at 3:46 P.M. and 05/15/25 at 2:38 P.M. revealed Resident #76 seated in the chair in his room with the indwelling foley catheter bag lying on the floor with no dignity bag cover. Interview on 05/12/25 at 3:49 P.M. with Licensed Practical Nurse (LPN) #620 confirmed Resident #76 indwelling foley catheter bag was lying on the floor with no dignity bag. LPN #620 stated Resident #76 likes to drag the bag around on the floor wherever he goes. Review of the plan of care initiated 02/24/25 and revised on 05/14/25 revealed Resident #76 was not compliant with showers/bathing, not letting indwelling foley catheter bag hang, not keeping the cover on his indwelling foley catheter bag and taking medications. The goat stated Resident #76 would verbalize understanding of education. The interventions included: document educational attempts with resident and family related to non compliance, educate resident and family on adverse effects of non compliance, and notify the physician of non compliance. Review of the plan care for Resident #76 initiated 02/24/25 revealed no plan of care related to viral Hepatitis B, cirrhosis of liver, hypertension, depression, dysarthria, edema, blood thinner medication or enhanced barrier precautions. Interview with Director of Nursing 05/16/25 at 12:20 P.M. confirmed care plans were not completed to meet all the needs of the resident. 6. Review of the medical record for Resident #78 revealed an admitted [DATE] with diagnoses including fracture of body of sternum, displaced fracture of olecranon process without extension of right ulna, unspecified fracture of lower end of right femur, major depressive disorder, insomnia, anxiety and severe pain. (all related to motor vehicle accident) Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #78 was cognitively intact with little interest or pleasure in doing things two to six days of look back period, feeling down, depressed or hopeless two to six days of look back period and had no social isolation or behaviors. Resident #78 had impaired range of motion to one side of upper extremities and to both lower extremities. Resident #78 was dependent on the staff for toileting hygiene, and required substantial to maximum assistance of staff for showers/bathing, personal hygiene and transfers. Resident #78 had scheduled pain medication with non pharmacological interventions with almost constant severe pain. Resident #78 was at risk for pressure ulcers, had surgical wounds and wound care. The assessment did not have Resident #78 using a pressure reducing device for chair or bed, turning and repositioning or nutritional interventions. Review of the physician orders dated 05/25 revealed Resident #78 was ordered the following medications: Baclofen 10 milligrams (mg) by mouth three times daily for muscle spasms, Mirtazapine 30 mg by mouth at bedtime for insomnia, Prazosin hydrochloride one mg by mouth at bedtime for hypertension-hold if systolic blood pressure was less than 120 millimeters of mercury (mmHg) or pulse less than 60 beats per minute and notify provider-, Sertraline 75 mg by mouth daily for depression, Fenofibrate micronized 200 mg by mouth daily for hyperlipidemia, buspirone hydrochloride 5 mg by mouth every 12 hours for anxiety, Eliquis 5 mg by mouth two times daily for deep vein thrombosis, Gabapentin 100 mg by mouth three times daily for nerve pain, Hydroxyzine Pamoate 50 mg by mouth three times daily for anxiety, oxycodone hydrochloride 5 mg by mouth give two tablets every six hours for pain, tramadol hydrochloride 50 mg by mouth every six hours for breakthrough pain, monitor for bleeding, and assess residents pain every shift. Review of the psychosocial assessment completed on admission by Social Services #175 dated 03/21/25 revealed Resident #78 was involved in a horrific event-a car accident, reported anxiety and depression and became tearful when talking about his circumstances. Resident #78 was sitting up in bed, alert, oriented, pleasant and cooperative despite pain. Resident #78 reported he did not sleep at all due to his pain last night. Resident #78 became tearful when speaking about his motor vehicle accident. Resident #78 was independent prior and working full time. Psychiatric services offered but resident declined. No further investigation into Resident #78 trauma, triggers or symptoms, or plan to advert the triggers. Review of the progress note dated 05/15/25 at 12:59 A.M. authored by the Nurse Practitioner (NP) revealed Resident #78 was seen for follow up visit. The NP noted Resident #78 was healing from multiple fractures and surgeries after motor vehicle collision. The NP noted Resident #78 diagnoses included insomnia, essential hypertension, acute pain due to trauma, multiple fractures of ribs, unspecified fracture of shaft of right femur and presence of right artificial knee joint. Review of the plan of care initiated on 04/02/25 revealed Resident #78 had potential for alteration in comfort as evidenced by verbalization, facial expression and body language related to multiple recent surgical repairs. The goal stated Resident #78 would display or express signs of comfort by next review date. The interventions included administer medications as ordered, attempt non pharmacological interventions (none listed) and pain assessment per facility policy. Review of the plan of care initiated on 04/02/25, revised on 04/25/25, revealed Resident #78 had potential impairment to skin integrity related to co morbidities and history of multiple surgical incisions. The goal stated Resident #78 would have no complications through review date. The interventions included follow facility protocols for treatment of injury and weekly treatment documentation to include measurement of each skin breakdown, type of tissue and exudate and any other changes. (Plan did not address pressure reducing device to chair and bed or turning and repositioning) Review of the plan of care dated 04/02/25 revealed Resident #78 was at risk for alteration in mood and behavior related to anxiety, depression, little interest or pleasure in doing things and tearful at times. The goal stated Resident #78 would have reduced number of mood indicators or reduced instances of mood indicators. The interventions included to administer medications per order, encourage loved ones to visit and observe and report any changes in mental status. The plan of care for Resident #78 did not address trauma, care of including triggers and interventions, insomnia, muscle spasms, deep vein thrombosis, hypertension or hyperlipidemia. Interview with Director of Nursing 05/16/25 at 12:20 P.M. confirmed care plans were not completed to meet all the needs of the resident. 7. Review of the medical record for Resident #233 revealed an admitted [DATE] with diagnoses including complete amputation of right leg between the right hip and knee, complications of amputation stump, pressure ulcer of sacral area stage four, diabetes mellitus type two, hypotension, and sebhorrheic dermatitis. Review of the physician orders dated 05/25 revealed Resident #233 was ordered the following treatments: apply Dakins solution to a four by four or Keflex roll and use to pack wound with a damp dressing, cover with abdominal pads and secure with medipore tape, negative pressure wound therapy-wound vac type of filler dressing was black foam, wound bed preparation, wound vac pressure settings of 125 milliliters of mercury (mmHg) pressure, continues, change three times weekly. catheter care every shift, cleanse left heel with wound cleanser and apply heel protector to left foot and oxygen at one liter per minute via nasal cannula. Review of the Medicare five day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #233 had cognitive impairment with inattention, disorganized thinking, delusions, and other behavioral symptoms directed towards others. Resident #233 had no impaired range of motion to bilateral upper extremities or bilateral lower extremities and used a wheelchair for mobility. Resident #233 was dependent on the staff to complete activities of daily living. Resident #233 had indwelling foley catheter for urination and was incontinent of bowels. Resident #233 diagnoses included coronary artery disease, diabetes mellitus, complete traumatic amputation at level between right hip and knee, stage four pressure ulcer to sacral region. Resident #233 had frequent mild pain with as needed pain medications. Resident #233 had recent weight loss while not on a prescribed weight loss regimen. Resident #23 had one stage two pressure ulcer on admission, one stage four pressure ulcer on admission, and one unstageable/deep tissue injury upon admission. The assessment did not not Resident #233 had a pressure reducing device for chair or bed and no turning or repositioning. Review of the progress note dated 05/03/25 at 12:59 A.M. authored by Nurse Practitioner (NP) for routine visit revealed Resident #233 had traumatic amputation of the right hip and knee, sacral region stage four pressure ulcer, chronic obstructive pulmonary disorder, diabetes mellitus type two, hypotension, primary osteoarthritis and non ST segment myocardial infarction (NSTEMI). Resident #233 wears oxygen at one to two liters per minute via nasal cannula and has a foley catheter. Review of the plan of care revised 05/13/25 revealed Resident #233 had actual skin impairment to skin integrity related to area to left heel, sacral wound, surgical wound to amputee right lower extremity, and right hip. The goal stated Resident #233 would have no complications through review date. The interventions included the following: enhanced barrier precautions, follow facility protocols for treatment of injury, may see in house wound care as needed, may see local wound care provider, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of the plan of care initiated on 05/08/25 revealed Resident #233 had indwelling foley catheter related to stage four pressure ulcer to sacrum. The goal stated Resident #233 would be free from catheter related trauma through review date. The interventions included position catheter bag and tubing below the level of the bladder and away from the entrance room door, monitor and document intake and output per facility policy, monitor for signs and symptoms of discomfort on urination and frequency, and monitor, document and report to physician any signs and symptoms of urinary tract infection. (pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse and temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status and change in behavior. The plan of care did not address hypotension, NSTEMI, diabetes mellitus type two, osteoarthritis or oxygen use. Interview with Director of Nursing 05/16/25 at 12:20 P.M. confirmed care plans were not completed to meet all the needs of the resident.

Based on record reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected five residents (#36, #48, #69, #74, and #78) out of five residents identified by the facility as having PTSD/trauma. The facility census was 78. Findings include: 1. Record review for Resident #36 revealed the resident was admitted to the facility on [DATE] and had diagnoses including diabetes mellitis type II, cataracts, benign neoplasm of the chorioid, hypertensive retinopathy, dementia, chronic obstructive pulmonary disease, hypertension, neuropathy, contractures, hemiplegia and hemiparesis, congestive heart failure, cerebral infarction, dysphagia, aphagia, epilepsy, post-traumatic stress disorder(08/23/21), chronic pain, atrial fibrillation, anxiety, and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment, dated 03/03/25, revealed this resident was assessed to have severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 99. This resident was assessed to have an active diagnosis of PTSD. Review of the active care plans for Resident #36 revealed no plan of care was in place addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions to reduce the risk of re-traumatization and provide care for PTSD. Further record review for this resident revealed no assessment had been completed to identify the cause of PTSD for Resident #36 and to identify potential triggers which may cause re-traumatization. Interview with the Director of Nursing (DON) on 05/16/25 at 11:26 A.M. verified an assessment of the cause of PTSD and possible triggers for Resident #36 had not been completed and additionally verified there had not been a plan of care implemented for Resident #36 to minimize the risk of re-traumatization. 34299 2. Review of the medical record for Resident #69 revealed an admitted [DATE] with diagnoses including unspecified fracture of left lower extremity, generalized anxiety disorder, major depressive disorder, congestive heart failure, atrial fibrillation, diabetes mellitus type two, and hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #69 was cognitively intact with no mood symptoms or behaviors. Review of the trauma informed care assessment dated [DATE] revealed Resident #69 was asked if anything unusually frightening, horrible or traumatic had happened to her. Resident #69 replied she had been constantly on guard, watchful and felt startled. Resident #69 stated she felt numb, detached from people, activities and or surroundings. Resident #69 was unable to identify any triggers. The plan of care initiated on 05/13/25 did not address Resident #69 trauma or interventions for staff as needed for adverse reactions. Interview on 05/12/25 at 12:20 P.M. with the Director of Nursing (DON) confirmed Resident #69 was not assessed appropriately for trauma informed care and did not have a plan of care that included cause of trauma, triggers and interventions. Interview on 05/12/25 at 2:43 P.M. with Resident #69 revealed her nerves were shot. Resident #69 stated she takes medication but does not feel it is helping. 3. Review of the medical record for Resident #78 revealed an admitted [DATE] with diagnoses including fracture of body of sternum, displaced fracture of olecranon process without extension of right ulna, unspecified fracture of lower end of right femur, major depressive disorder, insomnia, anxiety and severe pain. (all related to motor vehicle accident) Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #78 was cognitively intact with little interest or pleasure in doing things two to six days of look back period, feeling down, depressed or hopeless two to six days of look back period and had no social isolation or behaviors. Review of the psychosocial assessment completed on admission by Social Services #175 dated 03/21/25 revealed Resident #78 was involved in a horrific event-a car accident, reported anxiety and depression and became tearful when talking about his circumstances. Resident #78 was sitting up in bed, alert, oriented, pleasant and cooperative despite pain. Resident #78 reported he did not sleep at all due to his pain last night. Resident #78 became tearful when speaking about his motor vehicle accident. Resident #78 was independent prior and working full time. Psychiatric services offered but resident declined. No further investigation into Resident #78 trauma, triggers or symptoms, or plan to advert the triggers. Review of the plan of care initiated on 4/2/25 revealed no plan of care related to trauma including triggers or symptoms, or plant to advert triggers. Interview on 05/13/25 at 10:27 A.M. with Resident #78 revealed he was driving home from work and was hit head on by a drunk driver. Resident #78 stated his whole life changed in the blink of an eye and he will never be able to run again or climb a tree. Resident #78 became teary eyed and shaky voice talking about it. Resident #78 was traumatized by the incident and will always be disabled. Interview on 05/12/25 at 12:20 P.M. with the Director of Nursing (DON) confirmed Resident #69 was not assessed appropriately for trauma informed care and did not have a plan of care that included cause of trauma, triggers and interventions. 42728 4. Record review for Resident #48 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Post Traumatic Stress Disorder (PTSD), insomnia, and Parkinson's disease. Review of the quarterly MDS assessment, dated 04/11/24, revealed the resident was assessed to be cognitively intact. Review of the care plan, dated 01/24/25, revealed the resident displayed or had a diagnosis with mental disorder or psychosocial difficulty adjustment, or had a history of trauma/PTSD. The only intervention present was assist resident and family with access to psychiatry and psychosocial services. No causes or potential triggers for the residents PTSD were identified. Review of facility assessments for Resident #48 revealed no assessment of the potential causes or triggers of the residents PTSD were present. Interview with the Director of Nursing (DON) on 05/16/25 at 11:00 A.M. confirmed Resident #48 had not been adequately assessed for causes and potential triggers of PTSD to prevent possible re-triggering. 5. Record review for Resident #74 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included acute pain due to trauma, psychoactive substance abuse, and anxiety disorder. Review of the admission MDS assessment, dated 02/04/25, revealed the resident was assessed to have intact cognition. Review of the active care plan for Resident #74 revealed there was no care plan in place related to the residents history of trauma. Interview with Resident #74 ON 05/12/25 at 10:29 A.M. confirmed the residents son had committed suicide and the resident had hallucinations of him walking past the door to her room so she preferred to keep the door shut. The resident confirmed she had traumatic events which had occurred and loud noises such as guns firing, fireworks, and loud bangs set her off so she had headphones which she wore frequently to muffle the noises. Interview with the DON on 05/16/25 at 11:00 A.M. confirmed Resident #48 had not been adequately assessed for causes and potential triggers of PTSD to prevent possible re-triggering.

Based on observation, interview, medical record review, the facility failed to provide Resident #233 with a dignity bag for the indwelling foley catheter. This effected one (Resident #233) of three residents reviewed for indwelling foley catheter. The facility census was 78. Findings include: Review of the medical record for Resident #233 revealed an admitted [DATE] with diagnoses including complete amputation of right leg between the right hip and knee, complications of amputation stump, pressure ulcer of sacral area stage four, diabetes mellitus type two, hypotension, and sebhorrheic dermatitis. Review of the physician orders dated 05/25 revealed Resident #233 had an order for foley catheter care every shift. The physician orders did not include size of foley catheter or when to change it. Review of the Medicare five day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #233 had cognitive impairment with inattention, disorganized thinking, delusions, and other behavioral symptoms directed towards others. Resident #233 was dependent on the staff to complete activities of daily living. Resident #233 had indwelling foley catheter for urination. Review of the plan of care initiated revealed Resident #233 had an indwelling foley catheter related to stage four pressure ulcer to sacrum. The goal stated Resident #233 would be free from catheter related trauma through review date. The interventions included the resident has a foley catheter, position the catheter bag and tubing below the level of the bladder and away from the entrance room door. The staff were to monitor and document intake and output per the facility policy, monitor for signs and symptoms of discomfort with urination, and monitor, record and report to the physician signs and symptoms of urinary tract infection such as pain, burning, blood tinged urine, cloudiness, no or decreased output, deepening of urine color, increased pulse, increased temperature, foul smelling urine, chills, altered mental status, change in behavior and or eating patterns. Observations on 05/12/25 at 3:29 P.M. and 05/15/25 at 8:09 A.M. revealed Resident #233 had indwelling foley catheter. The foley catheter drainage bag was not covered and lying on the floor. Interview on 05/15/25 at 8:10 A.M. with Certified Nursing Assistant (CNA) #101 confirmed Resident #233 foley catheter bag was not covered and lying on the floor. Review of the facility provided policy named Catheter Policy, revised on 04/28/25, did not address covering the indwelling foley catheter bag with a dignity bag to enhance the privacy of the resident.

Based on observations, interviews, and record reviews, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected pressure relieving devices and mechanically altered diets. This affected three residents (#20, #39, and #233) out of the 20 residents whose MDS assessments were reviewed during the annual survey. The facility census was 78. Findings include: 1. Record review for Resident #39 revealed the resident was admitted to the facility on [DATE] and had diagnoses include pressure ulcer of the right heel, morbid obesity, and diabetes mellitus. Review of the quarterly MDS assessment, dated 04/20/25, revealed the resident was assessed to have intact cognition. The resident was assessed to have one stage three pressure ulcer which was present upon admission to the facility. The resident was assessed to not have pressure reducing devices in place to the bed or chair. Review of the facility Equipment Purchase/Rental List revealed a specialty mattress had been obtained for Resident #39 on 10/18/25. Review of the active physicians order, dated 04/28/25, revealed an order for a specialty mattress to be in place on the residents bed. Observation on 05/12/25 at 9:45 A.M. revealed Resident #39 was lying in bed on the left side. A specialty mattress was in place on the residents bed which provided pressure relieving measures. Interview with Resident #39 at the time of the observation confirmed the specialty mattress had been in place to the bed for several months. Interview with the Director of Nursing (DON) on 05/16/25 at 11:00 A.M. confirmed Resident #39 had a specialty, low air loss mattress in place to the bed since 10/18/24. The DON confirmed the MDS assessment dated [DATE] did not accurately reflect the use of a pressure reducing device to the residents bed. 34299 2. Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, hypertension, protein calorie malnutrition, bipolar disorder, dementia, anxiety and hyperlipidemia. Review of a physician order dated 10/13/24 revealed Resident #20 was to receive a fortified foods diet, regular texture and thin liquids. Resident #20 also received a house supplement three times daily. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was cognitively impaired with continuous inattention, disorganized thinking, had delusions and hallucinations and physical/verbal/other behavioral symptoms towards others. Resident #20 had impaired range of motion to bilateral lower extremities and was dependent upon staff to complete activities of daily living. Resident #20 was incontinent of bowel and bladder. Resident #20 had prognosis of life expectancy of less than six months. Resident #20 weight was 90 pounds with no weight loss of five percent in last month or 10 percent or more in six months. Resident #20 had no chewing or swallowing concerns and was not receiving a mechanically altered diet. Review of the nutritional assessment dated [DATE] revealed Resident #20 received fortified foods, regular diet, with double portions and house supplement three times daily. Resident #20 was dependent upon staff to eat her meals, and had no oral status concerns. Review of the plan of care revised 04/25/24 revealed Resident #20 had potential for alteration in nutrition/hydration status related to multiple chronic health issues, advanced age, supplement in place, variable oral intake with the need for fortified foods, a significant weight loss at 30 days, body mass index of less than 23 percent for her age. On 01/29/25 had a significant weight loss in 30 days, on 02/07/24 weight loss trend was more stable, on 02/19/24 significant weight gain following weight loss and on 04/24/24 started hospice care. The goal stated Resident #20 would remain comfortable as evidenced by no signs and symptoms of hunger or thirst through next review. The interventions included to administer medications as ordered, assess and report signs of edema to physician, assess resident for signs and symptoms of aspiration, assist resident with meals as needed, coordinate/collaborate care with hospice services, encourage family to bring in favorite foods from home, honor food preferences as able, monitor for signs and symptoms of dehydration, monitor labs as ordered, obtain food preferences, obtain weights as ordered, offer meal substitutions as needed, provide diet as ordered, provide snacks per facility policy and supplements as ordered. An observation on 05/15/24 at 12:10 P.M. of Resident #20 eating her lunch meal. Resident #20 daughter was in the facility assisting her mother to eat. Resident #20 meal ticket stated she received a mechanical soft diet, fortified foods (mashed potatoes), double portions of protein and thin liquids. Resident #20 food noted on her lunch tray consisted of mechanical soft hamburger meat-double portion of meat, mashed potatoes-fortified, and mixed vegetables. An interview on 05/15/25 at 2:01 P.M. with Dietary Manager #400 revealed Resident #20 received mechanical soft diet, double portions of protein and thin liquids. Dietary Manager #400 stated she received the order on a communication form provided by the nurses. Review of the communication form dated 03/22/25, unable to determine nurse signature, revealed Resident #20 had a diet change to mechanical soft meats. An interview on 05/15/25 at 12:06 P.M. with Registered Nurse (RN) MDS Coordinator #930 revealed she completed all MDS for the facility. RN MDS Coordinator #930 stated she reviewed the 24 hour report and orders every day to compile information and complete the MDS and care plans. RN MDS Coordinator #930 confirmed Resident #20 diet order was not mechanically altered per the MDS dated [DATE]. An interview on 05/15/25 at 2:08 P.M. with Licensed Practical Nurse (LPN) #720 revealed she was not sure what Resident #20 diet order was and she would check the order. On 05/15/25 at 2:13 P.M. LPN #720 confirmed she changed the diet order in the electronic medical record to mechanical soft diet, double portions of protein and fortified mashed potatoes on this date from regular diet, regular texture, fortified foods, and thin liquids. LPN #720 did not state where or who she received the order from. An interview on 05/15/25 at 2:30 P.M. with the Director of Nursing (DON) revealed she would look in to the diet order and where it came from. The DON confirmed there was not any documentation related to diet order change on 03/22/25. 3. Review of the medical record for Resident #233 revealed an admitted [DATE] with diagnoses including complete amputation of right leg between the right hip and knee, complications of amputation stump, pressure ulcer of sacral area stage four, diabetes mellitus type two, hypotension, and sebhorrheic dermatitis. Review of the Medicare five day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #233 had cognitive impairment with inattention, disorganized thinking, delusions, and other behavioral symptoms directed towards others. Resident #233 had impaired range of motion to bilateral upper and lower extremities and was dependent on the staff to complete activities of daily living. Resident #233 used a wheelchair for mobility. Resident #233 had indwelling foley catheter for urination and was incontinent of bowels. Resident #233 had a recent surgery (right above the knee amputation), a stage two pressure ulcer upon admission, a stage four pressure ulcer upon admission, and an unstageable/deep tissue injury upon admission. Resident #233 was provided pressure ulcer care and surgical wound care, however Resident #233 did not have a pressure reducing device for his chair or bed and was not scheduled for turning and repositioning. Review of the wound assessment dated [DATE] at 2:09 P.M. authored by Registered Nurse (RN) #103 revealed Resident #233 presented today with left foot second digit diabetic foot ulcer with partial thickness, measured 0.5 centimeters (cm) by 0.5 cm by 0.1 cm and was stable, left great toe diabetic foot ulcer with full thickness, measured 0.4 cm by 0.5 cm by 0.2 cm and was improving. The left ischial pressure ulcer, stage two, measured 2.4 cm by one cm by 0.2 cm and was improving and stable. The right iliac crest skin tear, partial thickness, measured 1.3 cm by three cm by 0.1 cm. The stage four pressure ulcer, present on admission, to the sacrum measured 17 cm by 13 cm by two cm. All as wound care and assessment was provided by in house wound care provider. Review of the plan of care dated 05/13/25 revealed Resident #233 had actual impairment to skin integrity related to area to left heel, sacral wound, surgical wound for amputation to right lower extremity, and the right hip. The goal stated the resident would have no complications through review date. The interventions included enhanced barrier precautions as ordered, follow facility protocols for treatment of injury, may see in house wound care as needed, to see outside provider for wound care and weekly treatment documentation to include measurement of each area of skin breakdown with width, length, type of tissue and exudate and any other notable changes or observations. Observations on 05/12/25 at 3:29 P.M., 05/14/25 at 10:19 A.M. and 05/15/25 at 8:09 A.M. revealed Resident #233 was lying in bed on a low loss air mattress, had a pressure relieving cushion to his chair, heel protector on left foot, and was positioned on his side. An interview on 05/15/25 at 8:10 A.M. with Certified Nursing Assistant (CNA) #101 confirmed Resident #233 had a specialty air mattress, a pressure relieving cushion to chair, heel protector on left foot and was turned and repositioned. An interview on 05/15/25 at 12:06 P.M. with RN MDS Coordinator #930 revealed she completed all MDS for the facility. RN MDS Coordinator #930 stated she reviewed the 24 hour report and orders every day to compile information and complete the MDS and care plans. RN MDS Coordinator #930 confirmed Resident #233 MDS dated [DATE] did not indicate Resident #233 had a pressure relieving device to bed and or chair and no turning or repositioning.

Based on observation, interviews, and record reviews, the facility failed to ensure fall interventions on resident care plans were reviewed and revised to ensure accuracy. This affected one resident (#48) out of the two residents whose care plans were reviewed for fall interventions during the annual survey. The facility census was 78. Findings include: Record review for Resident #48 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Post Traumatic Stress Disorder (PTSD), insomnia, and Parkinson's disease. Review of the quarterly minimum data set (MDS) assessment, dated 04/11/24, revealed the resident was assessed to be cognitively intact. Review of the care plan, dated 01/14/21, revealed the resident was at risk for falls and potential injury. Interventions included a commode or urinal at bedside. Observation on 05/12/25 at 3:30 P.M. revealed Resident #48 was lying in bed. No commode or urinal were present at the residents bedside. Interview with Licensed Practical Nurse (LPN) #300 on 05/13/25 at 4:38 P.M. confirmed there was not a commode or urinal present at Resident #48's bedside. Interview with the Director of Nursing (DON) on 05/16/25 at 11:00 A.M. confirmed the care plan intervention for Resident #48 to have a commode or urinal present at bedside was no longer appropriate and had been removed from the residents care plan.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure wound care treatments were provided as ordered by the physician. This affected one resident (#15) out of the two residents who were reviewed for non-pressure skin conditions during the annual survey. The facility census was 78. Findings include: Record review for Resident #15 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included diabetes mellitus, chronic kidney failure, and pruritis (itching). Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/07/25, revealed the resident was assessed to have intact cognition. Review of the care plan, most recently revised on 05/12/25, revealed the resident had eczematous areas all over body and skin tears to right wrist and top of forehead. Interventions included treatments as ordered. Review of the active physician order, dated 05/01/25, revealed an order to cleanse left shoulder with soap and water, pat dry, apply Triad cream, and leave open to air daily and as needed. Review of the active physician order, dated 05/01/25, revealed an order to cleanse left arm with soap and water, pat dry, apply Triad cream, and leave open to air daily and as needed. Review of the active physician order, dated 05/01/25, revealed an order to cleanse the right forearm with soap and water, pat dry, apply Xeroform, apply a non-adherent dressing, and wrap with gauze. Change daily and as needed. Further review of the active physicians orders for Resident #15 revealed no orders in place for an Optifoam bandage to be applied to the arm below the right elbow. Observation on 05/12/25 at 9:21 A.M. revealed Resident #15 was lying in bed and had an Optifoam bandage in place to the arm below the right elbow which contained staff initials and a date of 05/10/25. The resident had Kerlix to the right and left lower arms which was hanging loosely by the residents wrists, was saturated with blood, and had tape in place which contained staff initials and a date of 05/10/25. The resident had an Optifoam bandage in place to the left shoulder which was not dated or initialed. Observation of wound care treatment completed by Licensed Practical Nurse (LPN) #185 for Resident #15 on 05/12/25 at 3:15 P.M. revealed LPN #185 removed the old bandages from the left arm, left shoulder, and right arm of Resident #15. LPN #185 then removed old gloves, completed hand hygiene, and put on new gloves. LPN #185 then cleansed the right arm and left arm of Resident #15 with wound cleanser and patted the areas dry. LPN #185 then removed old gloves, completed hand hygiene, and put on new gloves. LPN #185 then applied a clean Optifoam bandage to the residents right arm below the elbow, wrapped the residents right arm with Kerlix and secured it with tape, and wrapped the residents left arm with Kerlix and secured it with tape. LPN #185 then removed gloves, completed hand hygiene, and disposed of old bandages appropriately. Interview with LPN #185 at the time of the observation confirmed the Optifoam bandage to the residents right arm below the elbow and the Kerlix to the residents right and left arms were heavily saturated with dried blood and fresh blood and were dated as being changed last on 05/10/25 (two days prior). LPN #185 confirmed the Optifoam bandage to the residents left shoulder had not been initialed or dated. LPN #185 confirmed dressings were to be dated and initialed by the person completing the dressing change at the time wound care was completed. Interview with LPN #185 on 05/13/25 at 10:35 A.M. confirmed the wound care treatment she had completed for Resident #15 on 05/12/25 was not done as ordered by the physician. LPN #185 confirmed there had not been an order in place for an Optifoam bandage to be applied to the residents right arm below the elbow or to the residents left shoulder. LPN #185 confirmed Xeroform and a non-adherent bandage should have been applied to the residents right arm and the left arm should have had Triad cream applied then been left open to air. Review of the facility policy titled Wound Care, reviewed 04/28/25, revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. Physicians orders for the procedure were to be verified, treatments were to be applied as indicated, then the wounds were to be dressed as ordered. [NAME] tape or dressings with initials, time, and date and apply to dressing.

Based on interview and record review the facility failed to ensure the physician order for pressure ulcer care contained sufficient information to provide adequate care. This effected one resident (Resident #233) of four reviewed for pressure ulcer care. The facility census was 78. Findings include: Review of the medical record for Resident #233 revealed an admitted [DATE] with diagnoses including complete amputation of right leg between the right hip and knee, complications of amputation stump, pressure ulcer of sacral area stage four, diabetes mellitus type two, hypotension, and sebhorrheic dermatitis. Review of the Medicare five day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #233 had cognitive impairment with inattention, disorganized thinking, delusions, and other behavioral symptoms directed towards others. Resident #233 had no impaired range of motion to bilateral upper extremities or bilateral lower extremities and used a wheelchair for mobility. Resident #233 was dependent on the staff to complete activities of daily living. Resident #233 had indwelling foley catheter for urination and was incontinent of bowels. Resident #233 diagnoses included coronary artery disease, diabetes mellitus, complete traumatic amputation at level between right hip and knee, stage four pressure ulcer to sacral region. Resident #233 had frequent mild pain with as needed pain medications. Resident #233 had recent weight loss while not on a prescribed weight loss regimen. Resident #23 had one stage two pressure ulcer on admission, one stage four pressure ulcer on admission, and one unstageable/deep tissue injury upon admission. The assessment did not include that Resident #233 had a pressure reducing device for chair or bed and no turning or repositioning. Review of the physician orders dated 05/25 revealed Resident #233 was ordered the following treatments: apply Dakins solution to a four by four or Kerlix roll and use to pack wound with a damp dressing, cover with abdominal pads and secure with medipore tape, negative pressure wound therapy-wound vac type of filler dressing was black foam, wound bed preparation, wound vac pressure settings of 125 milliliters of mercury (mmHg) pressure, continues, change three times weekly, catheter care every shift, cleanse left heel with wound cleanser and apply heel protector to left foot and oxygen at one liter per minute via nasal cannula. Review of the progress note authored by wound care provider Nurse Practitioner (NP) dated 05/05/25 at 3:16 P.M. revealed Resident #233 wound assessment as follows: wound #1 stage two pressure ulcer present on admission with no odor, measurements were 1.3 centimeters (cm) by 3 cm by 0.1 cm. The wound base was 100 percent epithelial, wound edges attached, peri-wound intact, light amount of serosanguineous exudate. Wound #2 deep tissue injury present on admission, measurements were 3.5 cm by 7 cm by 0 cm. The wound base was 100 percent epithelial,wound edges attached, with no odor. Wound #3 stage four pressure ulcer present on admission with no odor, measurements were 17 cm by 13 cm by 2 cm and tunneling undefined o'clock of 2.2 cm. The wound base was 10 percent epithelial, 50 percent granulation, 30 percent slough and 10 percent eschar. The periwound was intact with heavy amount of serosanguineous exudate, and rated pain at six of 10. The wound care provider debrided the wound to the sacrum. The plan stated to complete medications-labs-imaging procedures, add protein supplement, prostate, multivitamin and vitamin C for wound healing. Apply foam booties and low air loss mattress to the bed to reduce pressure on wounds. All the above was discussed with facility nursing staff. Review of a nursing progress note authored by Licensed Practical Nurse (LPN) #620 dated 05/13/25 revealed Resident #233 had an appointment at local wound care provider center. Resident #233 returned with new order to change sacral wound daily; apply Dakins solution to a four by four or Kerlix roll and use to pack the wound with a damp dressing. Cover with abdominal pad and secure with medipore tape. The order was updated in point click care (electronic health record system) Review of the plan of care revised 05/13/25 revealed Resident #233 had actual skin impairment to skin integrity related to area to left heel, sacral wound, surgical wound to amputee right lower extremity, and right hip. The goal stated Resident #233 would have no complications through review date. The interventions included the following: enhanced barrier precautions, follow facility protocols for treatment of injury, may see in house wound care as needed, may see local wound care provider, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Observations on 05/12/25 at 3:29 P.M., 05/14/25 at 10:19 A.M., and 05/15/25 at 8:09 A.M. revealed Resident #233 had a low air loss specialty mattress to his bed, a pressure reducing cushion to chair and was positioned on his side. Interview on 05/15/25 at 12:35 P.M. with the Director of Nursing (DON) confirmed the physician order for wound was not complete or adequate to provide care for Resident #233 wounds. Also confirmed the wound NP recommendations for protein supplement prostat, Vitamin C and a multivitamin for wound healing was not transcribed to physician orders. The facility did not provide a policy for wound care orders and treatment.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure smoking assessments were accurately completed for residents who smoked at the facility. This affected one resident (#39) out of the two residents reviewed for safe smoking practices during the annual survey. The facility identified 11 residents who were smokers. The facility census was 78. Findings include: Record review for Resident #39 revealed the resident was admitted to the facility on [DATE] and had diagnoses include pressure ulcer of the right heel, morbid obesity, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/20/25, revealed the resident was assessed to have intact cognition. Review of the care plan, initiated on 10/20/24, revealed the resident was at risk for injury related to smoking. Interventions included supervision at all times for smoking and smoking items to be kept at the nurses station. Review of the facility Smoking and Safety assessments, dated 01/13/25 and 04/18/25, revealed the resident was assessed to not smoke. Review of the list of residents who smoked provided by the facility revealed Resident #39 was listed to be a supervised smoker. Interview with Resident #39 on 05/14/25 at 12:35 P.M. confirmed staff assisted her outside to smoke cigarettes usually once a day at 1:00 P.M. The resident confirmed she had smoked cigarettes since being admitted to the facility though not as frequently as she wanted to due to her physical limitations. Observation on 05/14/25 at 1:05 P.M. revealed Resident #39 was outside smoking a cigarette in the designated smoking area with supervision from staff. Interview with the Director of Nursing (DON) on 05/16/25 at 11:00 A.M. confirmed the facility Smoking and Safety assessments for Resident #39 completed on 01/13/25 and 04/18/25 were inaccurate as the resident was a supervised smoker. Review of the facility policy related to smoking, not titled and reviewed most recently in 07/2024, revealed residents in the nursing center who smoke tobacco-cigarettes will be assessed using a smoking assessment. Residents are to smoke in outside designated smoking areas if determined to be a safe smoker as assessed.

Based on observation, interview and record review the facility failed to ensure resident meals were as ordered by the physician. This effected one (Resident #20) of two residents reviewed for nutrition. The facility census was 78. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, hypertension, protein calorie malnutrition, bipolar disorder, dementia, anxiety and hyperlipidemia. Review of a physician order dated 10/13/24 revealed Resident #20 was to receive a fortified foods diet, regular texture and thin liquids. Resident #20 also received a house supplement three times daily. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was cognitively impaired with continuous inattention, disorganized thinking, had delusions and hallucinations and physical/verbal/other behavioral symptoms towards others. Resident #20 had impaired range of motion to bilateral lower extremities and was dependent upon staff to complete activities of daily living. Resident #20 was incontinent of bowel and bladder. Resident #20 had prognosis of life expectancy of less than six months. Resident #20 weight was 90 pounds with no weight loss of five percent in last month or 10 percent or more in six months. Resident #20 had no chewing or swallowing concerns and was not receiving a mechanically altered diet. Review of the plan of care revised 04/25/24 revealed Resident #20 had potential for alteration in nutrition/hydration status related to multiple chronic health issues, advanced age, supplement in place, variable oral intake with the need for fortified foods, a significant weight loss at 30 days, body mass index of less than 23 percent for her age. On 01/29/25 had a significant weight loss in 30 days, on 02/07/24 weight loss trend was more stable, on 02/19/24 significant weight gain following weight loss and on 04/24/24 started hospice care. The goal stated Resident #20 would remain comfortable as evidenced by no signs and symptoms of hunger or thirst through next review. The interventions included to administer medications as ordered, assess and report signs of edema to physician, assess resident for signs and symptoms of aspiration, assist resident with meals as needed, coordinate/collaborate care with hospice services, encourage family to bring in favorite foods from home, honor food preferences as able, monitor for signs and symptoms of dehydration, monitor labs as ordered, obtain food preferences, obtain weights as ordered, offer meal substitutions as needed, provide diet as ordered, provide snacks per facility policy and supplements as ordered. Review of the nutritional assessment dated [DATE] revealed Resident #20 received fortified foods, regular diet, with double portions and house supplement three times daily. Resident #20 was dependent upon staff to eat her meals, and had no oral status concerns. An observation on 05/15/24 at 12:10 P.M. of Resident #20 eating her lunch meal. Resident #20 daughter was in the facility assisting her mother to eat. Resident #20 meal ticket stated she received a mechanical soft diet, fortified foods (mashed potatoes), double portions of protein and thin liquids. Resident #20 food noted on her lunch tray consisted of mechanical soft hamburger meat-double portion of meat, mashed potatoes-fortified, and mixed vegetables. An interview on 05/15/25 at 2:01 P.M. with Dietary Manager #400 revealed Resident #20 received mechanical soft diet, double portions of protein and thin liquids. Dietary Manager #400 stated she received the order on a communication form provided by the nurses. Review of the communication form dated 03/22/25, unable to determine nurse signature, revealed Resident #20 had a diet change to mechanical soft meats. Review of the nursing progress notes revealed the notes were silent related to diet order change dated 03/22/25. An interview on 05/15/25 at 12:06 P.M. with Registered Nurse (RN) MDS Coordinator #930 revealed she completed all MDS for the facility. RN MDS Coordinator #930 stated she reviewed the 24 hour report and orders every day to compile information and complete the MDS and care plans. RN MDS Coordinator #930 confirmed Resident #20 diet order was not mechanically altered per the MDS dated [DATE]. An interview on 05/15/25 at 2:08 P.M. with Licensed Practical Nurse (LPN) #720 revealed she was not sure what Resident #20 diet order was and she would check the order. On 05/15/25 at 2:13 P.M. LPN #720 confirmed she changed the diet order in the electronic medical record to mechanical soft diet, double portions of protein and fortified mashed potatoes. LPN #720 did not state where or who she received the order from. An interview on 05/15/25 at 2:30 P.M. with the Director of Nursing (DON) revealed she would look in to the diet order and where it came from. The DON confirmed there was not any documentation related to diet order change on 03/22/25. The facility did not provide a policy related to dietary orders.

Based on observations, interview and record review the facility failed to ensure Resident #20 family concerns of being overmedicated were timely and appropriately assessed. This effected one of one residents reviewed for opioid medication side effects. The facility census was 78. Findings include: Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, hypertension, protein calorie malnutrition, bipolar disorder, dementia, anxiety and hyperlipidemia. Review of the physician orders dated 05/25 revealed Resident #20 was ordered the following medications: Tylenol eight hour extended release 650 milligrams (mg) by mouth every eight hours as needed for pain, tramadol hydrochloride 50 mg by mouth two times daily for pain, and attempt non pharmacological interventions as resident allows such as reposition for comfort, massage, diversion/guided imagery, music and relaxation techniques. Review of the Medication Administration Record (MAR) dated 04/25 and 05/25 revealed Resident #20 received tramadol 50 mg by mouth two times daily. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was cognitively impaired with inattention, disorganized thinking, had hallucinations and delusions and physical, verbal and other behavioral symptoms towards others. Resident #20 had impaired range of motion and was dependent on staff to complete activities of daily living. Resident #20 had no pain identified and a prognosis of less than six months life expectancy. Resident #20 received opioid medication and was on hospice services. Review of the pain assessment completed 05/14/25 revealed Resident #20 had no pain. Review of the plan of care imitated 04/09/25 revealed Resident #20 had potential for alteration in comfort related to generalized pain as evidenced by advanced age and frailty. The goal stated Resident #20 would display or express signs of comfort through review date. The interventions included the following: attempt non pharmacological interventions if resident allows, coordinate and collaborate care with hospice provider, monitor for increased levels of pain and notify the physician and pain assessment per facility policy. Observations of on 05/13/25 at 9:44 A.M. and on 05/15/25 at 1:17 P.M. revealed Resident #20 was sleeping and hard to arouse to verbal stimuli. Interview on 05/13/25 at 9:44 A.M. with Resident #20's daughter revealed the resident was sleeping a lot. The daughter comes in every day to feed her mother lunch. At times she would not wake up and eat and lost weight. The daughter stated the nurses were giving Resident #20 pain medicine two times a day and she can not handle that. The daughter stated she had asked the facility to only give her the night time dose to help her sleep and the other dose if she complained or appeared to be in pain. The daughter stated she was not sure the facility had done that yet. Interview on 05/16/25 at 10:28 A.M. with Licensed Practical Nurse (LPN) #620 confirmed Resident #20 continued to receive her pain medication tramadol two times a day. LPN #620 stated the daughter had not told her that personally but the nurse was told by another nurse. Interview on 05/16/25 at 10:33 A.M. with the Director of Nursing (DON) stated she had seen a nursing note about too much pain medication and sleeping but had not spoke to Resident #20's daughter. DON stated if Resident #20 was oversedated and or the daughter had concerns we could certainly change the dosage. The facility did not have a policy related to opioid medication/over sedation.

Based on interview and medical record review the facility failed to ensure blood pressure medications were held per the physician parameters. This effected one (Resident #69) of one reviewed for significant medication errors. The facility census was 78. Findings include: Review of the medical record for Resident #69 revealed an admitted [DATE] with diagnoses including unspecified fracture of left lower extremity, generalized anxiety disorder, major depressive disorder, congestive heart failure, atrial fibrillation, diabetes mellitus type two, and hypertension. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #69 was cognitively intact with no mood symptoms or behaviors. Resident #69 had impaired range of motion to bilateral lower extremities. Resident #69 required substantial-maximum assistance from staff to complete activities of daily living. Resident #69 was incontinent of bowel and bladder. Resident #69 did not have any pain, falls or skin impairment. Review of the monthly medication review by the pharmacy revealed a recommendation on 03/04/25, that was signed by physician on 03/08/25: please consider adding parameters to Midodrine hydrochloride 10 mg by mouth three times daily of hold if systolic blood pressure greater than 120 mmHg. Review of the physician orders dated 05/25 revealed Resident #69 was ordered the following medications and treatments: blood glucose before meals and at bedtime, notify physician if blood sugar less than 60 or above 400, oxycodone hydrochloride five milligrams (mg) by mouth every six hours for pain, dated 4/7/25 Metoprolol tartrate 50 mg by mouth two times daily for hypertension-hold if systolic blood pressure less than 120 milliliters of mercury (mmHg) or pulse less than 60 beats per minute (bpm) added on , Sertraline hydrochloride 100 mg by mouth once daily for depression, buspirone hydrochloride 10 mg by mouth three times daily for anxiety and Midodrine hydrochloride 10 mg by mouth three times daily for hypotension-hold if systolic blood pressure greater than 120 mmHg. Review of the Medication Administration Record (MAR) dated 05/25 revealed the medication Metoprolol tartrate 50 mg by mouth two times daily with parameters to hold if systolic blood pressure than 120 mmHg or pulse less than 60 beats per minutes was not held on the following dates when systolic blood pressure was less than 120 mmHg: 05/01/25 evening dose, 05/02/25 morning dose, 5/3/25 morning dose, 5/7/25 morning dose, evening dose, 5/8/25 morning dose, 5/89/25 morning and evening dose, 5/10/25 morning and evening dose, 5/11/25 evening dose. The medication Midodrine hydrochloride 10 mg by mouth three times daily with parameters to hold when systolic blood pressure was greater than 120 mmHg was not held on the following dates when systolic blood pressure was greater than 120 mmHg: 5/1/25 morning and afternoon dose, 5/3/25 night dose, 5/6/25 night dose, and 5/12/25 night dose. Review of the nursing progress notes dated 05/13/25 at 5:28 P.M. the nurse noted a conversation with the Nurse Practitioner (NP) concerning the resident received scheduled Midodrine 10 mg by mouth three times daily related to hypotension and Lopressor 50 mg by mouth two times daily related to hypertension and atrial fibrillation. New orders received to continue the Lopressor as scheduled and change the perimeters to hold the medication if pulse was less than 60 beats per minute. A order to taper the Midodrine off at this time at a slow pace due to risk of arrhythmia if medication was stopped to suddenly. The resident was updated on the orders given. Review of the plan care initiated on 05/13/25 revealed Resident #69 had hypotension and atrial fibrillation. The goal stated Resident #69 would be free of signs and symptoms of hypotension through review date. The interventions included: give medications as ordered, monitor for side effects and effectiveness, monitor/document/report to the physician as needed any signs and symptoms of hypotension (dizziness, fainting, syncope, blurred vision, lack of concentration, nausea, fatigue, and or cold clammy pale skin), and obtain and monitor lab/diagnostic work as ordered, report the results to physician and follow up as indicated. Interview on 05/13/25 at 3:45 P.M. with Licensed Practical Nurse (LPN) #620 confirmed Resident #69 had orders for both Metoprolol tartrate and Midodrine. LPN #620 stated you should hold one or the other based on the residents blood pressure reading. Interview on 05/14/25 at 10:00 A.M. with the Director of Nursing (DON) and facility Nurse Practitioner (NP) confirmed Resident #69 received both Metoprolol tartrate 50 mg by mouth two times daily and hold if systolic blood pressure was less than 120 mmHg or pulse was less than 60 beats per minute for hypertension and received Midodrine hydrochloride 10 mg by mouth three times daily and hold if systolic blood pressure was greater than 120 mmHg for hypotension. The NP stated one or the other of the medications would be held based on blood pressure. The DON confirmed Resident #20 received medications Metoprolol tartrate and Midodrine hydrochloride when parameters to hold were met.

Based on record reviews and staff interviews, the facility failed to ensure laboratory testing was performed as ordered by the physician. This affected one resident (#39) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 78. Findings include: Record review for Resident #39 revealed the resident was admitted to the facility on [DATE] and had diagnoses include pressure ulcer of the right heel, morbid obesity, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/20/25, revealed the resident was assessed to have intact cognition. Review of the active physicians order, dated 12/10/24, revealed the resident was to have a Complete Blood Count (CBC) with differential, and Basic Metabolic Panel (BMP), and a Hemoglobin(Hgb) A1C level drawn and resulted every three months in January, April, July, and October. Review of the laboratory results for Resident #39 from 10/11/24 through 05/14/25 revealed no CBC, BMP, or HgbA1C levels were obtained from 01/2025 through 05/2025. Interview with Licensed Practical Nurse (LPN) #300 on 05/15/25 at 10:50 A.M. confirmed the order for a CBC, BMP, and HgbA1C for Resident #39 had not been obtained as ordered in 01/2025 or 04/2025.

Based on observation and interview the facility failed to ensure indwelling foley catheter drainage bags were off the floor. This effected two residents (Resident #76 and #233) of three residents reviewed for indwelling foley catheters. The facility census was 78. Findings include: 1. Review of the medical record for Resident #76 revealed an admitted [DATE] with diagnoses including dysarthria, neuromuscular dysfunction of bladder, transient ischemic attack (TIA), cirrhosis of liver, benign prostate hypertrophy (BPH), insomnia, viral Hepatitis B, hypertension and major depression. Review of the physician orders dated 05/25 revealed Resident #76 was ordered the following medications and treatments: 16 French indwelling foley catheter with 10 milliliter (ml) balloon to catheter bag drainage system related to neurogenic bladder, change indwelling foley catheter monthly and as needed, monitor urinary output related to foley catheter every shift, irrigate bladder three times per week with normal saline and enhanced barrier precautions due to foley catheter. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #76 was cognitively intact with little interest or pleasure in doing things, feeling down, depressed and or hopeless, had trouble with sleeping, and feeling tired, feeling bad about self and trouble concentrating 12-14 days of look back period. Resident #76 had no impaired range of motion. Resident #76 required substantial to maximum assistance with toileting and personal hygiene, partial to moderate assistance with transfers and was dependent on the staff for showers and bathing. Resident #76 had an indwelling catheter for urinary output, and was occasionally incontinent of bowel. Resident #76 had no falls or skin impairment. Observations on 05/12/25 at 10:20 A.M., 05/12/25 at 3:46 P.M. and 05/15/25 at 2:38 P.M. revealed Resident #76 seated in the chair in his room with the indwelling foley catheter bag lying on the floor with no dignity bag cover. Interview on 05/12/25 at 3:49 P.M. with Licensed Practical Nurse (LPN) #620 confirmed Resident #76 indwelling foley catheter bag was lying on the floor with no dignity bag. LPN #620 stated Resident #76 likes to drag the bag around on the floor wherever he goes. Review of the plan of care initiated 02/24/25 and revised on 05/14/25 revealed Resident #76 was not compliant with showers/bathing, not letting indwelling foley catheter bag hang, not keeping the cover on his indwelling foley catheter bag and taking medications. The goat stated Resident #76 would verbalize understanding of education. The interventions included: document educational attempts with resident and family related to non compliance, educate resident and family on adverse effects of non compliance, and notify the physician of non compliance. 2. Review of the medical record for Resident #233 revealed an admitted [DATE] with diagnoses including complete amputation of right leg between the right hip and knee, complications of amputation stump, pressure ulcer of sacral area stage four, diabetes mellitus type two, hypotension, and sebhorrheic dermatitis. Review of the physician orders dated 05/25 revealed Resident #233 was ordered to have foley catheter care every shift only. The physician orders did not include size of foley catheter or when to change it. Review of the Medicare five day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #233 had cognitive impairment with inattention, disorganized thinking, delusions, and other behavioral symptoms directed towards others. Resident #233 had no impaired range of motion to bilateral upper extremities or bilateral lower extremities and used a wheelchair for mobility. Resident #233 was dependent on the staff to complete activities of daily living. Resident #233 had indwelling foley catheter for urination and was incontinent of bowels. Resident #233 diagnoses included coronary artery disease, diabetes mellitus, complete traumatic amputation at level between right hip and knee, stage four pressure ulcer to sacral region. Resident #233 had frequent mild pain with as needed pain medications. Resident #233 had recent weight loss while not on a prescribed weight loss regimen. Resident #23 had one stage two pressure ulcer on admission, one stage four pressure ulcer on admission, and one unstageable/deep tissue injury upon admission. Review of the plan of care initiated on 05/08/25 revealed Resident #233 had indwelling foley catheter related to stage four pressure ulcer to sacrum. The goal stated Resident #233 would be free from catheter related trauma through review date. The interventions included position catheter bag and tubing below the level of the bladder and away from the entrance room door, monitor and document intake and output per facility policy, monitor for signs and symptoms of discomfort on urination and frequency, and monitor, document and report to physician any signs and symptoms of urinary tract infection. (pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse and temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status and change in behavior. Observations on 05/12/25 at 3:29 P.M. and 05/15/25 at 8:09 A.M. revealed Resident #233 had indwelling foley catheter. The foley catheter drainage bag was not covered and lying on the floor. Interview on 05/15/25 at 8:10 A.M. with Certified Nursing Assistant (CNA) #101 confirmed Resident #233 foley catheter bag was not covered and lying on the floor. Review of the facility policy titled Infection Control revised on 08/24 did not address infection prevention related to foley catheters. Review of the facility policy titled Catheter Care revised on 04/28/25 did not address infection prevention related to foley catheters.

Based on staff interview and record review the facility failed to give residents the correct form when they were cut from therapy services and stayed in the facility. This affected two (Resident #12 and #35) of three residents reviewed for beneficiary notices. The facility census was 74. Findings include: 1. Record review of Resident #12 revealed an admitted [DATE] and she was cut from therapy services on 07/03/23 and stayed in the facility and her pay source was Medicare part A. The resident had pertinent diagnoses including: stroke, hypertension and diabetes. Review of beneficiary notice date 06/29/23 revealed Resident #12 was being cut from therapy services on 07/03/23 and she did not receive CMS form 10055 that gives them the option to appeal, pay for it themselves, or agree to cut services. Interview with the Administrator on 08/09/23 at 2:00 P.M. verified there was no CMS form 10055 for Resident #12 given. 2. Record review of Resident #35 revealed an admitted [DATE] and he was cut from therapy services on 05/04/23 and stayed in the facility and his pay source was Medicare part A. The resident had pertinent diagnoses including: hemiplegia, hypertension, anxiety, depression and hyperlipidemia. Review of beneficiary notice date 05/02/23 revealed Resident #35 was being cut from therapy services on 05/04/23 and he did not receive CMS form 10055 that gives them the option to appeal, pay for it themselves, or agree to cut services. Interview with the Administrator on 08/09/23 at 2:00 P.M. verified there was no CMS form 10055 for Resident #35 given.

Based on interviews, record reviews, review of facility Self Reported Incident (SRI), review of facility investigation, and review of facility policy, the facility failed to prevent staff to resident abuse. This affected one resident (#14) out of the three residents reviewed for abuse during the annual survey. The facility census was 74. Findings include: Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified convulsions, osteomyelitis, unspecified dementia, Alzheimer's disease, bipolar disorder, and altered mental status. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/24/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision with one person physical assistance for eating. Review of the facility SRI form, dated 07/03/23, revealed on 06/08/23 at approximately 4:00 A.M. Resident #14 was yelling due to having pain in her finger. Licensed Practical Nurse (LPN) #555 entered the room and stated Stop yelling, you are going to wake up the other residents. LPN #555 then exited the room and closed the door. A facility State tested Nursing Assistant (STNA), who was caring for the resident, entered the residents room and sat with her. The facility reported the incident to the residents daughter, the physician, and the Abuse Coordinator. The agency LPN #555 was from was notified of the incident and LPN #555 was removed from working at the facility. The facility Social Worker assessed the psychosocial well-being of the resident. The resident had continued on with their normal daily function that evening and currently. Review of the facility Report of Concern form, dated 06/28/23 and initiated by STNA #222, revealed documentation Resident #14 reported LPN #555 and STNA #333 closed the residents door and yelled at her to quit crying. Resident #14 stated she told them not to, but they did anyway's. Review of the facility Witness Statement Form, dated 06/29/23, revealed Resident #48 stated at 4:00 A.M. I got up to use the restroom. I heard the nurse yelling at the old lady. She told her to shut up and quit crying. She stated you are going to wake up everybody. The nurse then shut her door. After the nurse shut her door, I went over to try to get her to calm down. When I left her room I left the door open. Review of the facility Witness Statement Form, dated 06/29/23, revealed STNA #333 reported Resident #14 was crying all night saying her finger hurt. I asked the nurse (LPN #555) for something for pain for Resident #14 and was told she did not need anything, she was just in a mood. I went back and sat with Resident #14 for 30 minutes then went back to LPN #555. LPN #555 said again Resident #14 was fine and she was not going to put up with it. LPN #555 then shut the door to Resident #14's room and told her to quit crying. Review of the hand-written statement from STNA #222, dated 07/03/23, revealed STNA #222 was in Resident #14's room the morning after the incident in question. STNA #222 went into Resident #14's room to check on her at shift change and the resident was in her bed crying and reaching for her to hug her, saying she was glad to see her. Resident #14 went on to say the night before LPN #555 came into her room because she was crying out loud saying her hands were hurting and LPN #555 told her to stop crying alligator tears or she was going to shut the door. Resident #14 stated this happened a couple times then LPN #555 shut her door. Resident #14 stated she was claustrophobic and did not want her door shut but LPN #555 and STNA #333 kept shutting her door anyway's. Interview with Resident #14's daughter on 08/07/23 at 9:44 A.M. revealed Resident #14 was crying and verbalizing complaints of pain during the night shift. The agency nurse who was working that night told resident #14 to stop crying or she was going to shut the door to the room. When Resident #14 continued to cry due to pain, the agency nurse shut the door. Telephone interview with STNA #333 on 08/07/23 at 2:03 P.M. revealed STNA #333 was in a room two doors down from Resident #14 and heard her start screaming. STNA #333 responded and Resident #14 stated her finger was hurting. STNA #333 stated she asked LPN #555 for pain medication for the resident and LPN #555 stated Resident #14 did not need it. STNA #333 stated she went and sat with Resident #14 for almost an hour and calmed her down some, but she was still hurting. STNA #333 stated LPN #555 then came to the room and shut Resident #14's door and said something along the line of When you stop acting like a toddler I will open the door up. STNA #333 stated she wanted to open the door, but was told not to. STNA #333 stated Resident #14 screamed for almost two hours. STNA #333 stated she opened up the door around 4:00 A.M. to 4:30 A.M. when she was passing ice. STNA #333 stated she did not report the incident during that night to management and LPN #555 continued to work the remainder of the night shift. STNA #333 stated she felt the incident which occurred was abuse. Telephone interview with STNA #222 on 08/08/23 at 10:17 A.M. revealed STNA #222 was doing her morning walk through and saw the door to Resident #14's room was closed, which was abnormal. STNA #222 stated Resident #14 was lying in bed crying and reaching for her and told her they closed the door on her and were not listening to her about her pain. STNA #222 stated staff knew the resident did not like her door closed. STNA #222 stated there was a sign put on the residents door by her daughter to keep the door open because the resident was claustrophobic but it was taken down. STNA #222 stated Resident #14 told her LPN #555 told her to dry up her alligator/crocodile tears or I will close your door. STNA #222 stated she filled out a concern form with the resident and gave it to LPN #999. STNA #222 stated she felt the residents report of the incident constituted abuse. Interview with LPN #999 on 08/08/23 at 10:45 A.M. revealed STNA #222 reported the incident on 06/28/23 involving Resident #14 and LPN #555 by providing her a concern form after morning meeting. LPN #999 stated she interviewed Resident #14 who would not disclose much information during the interview and just kept saying she wanted her daughter. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/02/22, revealed abuse was defined by the facility as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Staff should immediately all incidents/allegations of abuse immediately to the Administrator or designee. If a staff member is accused or suspected the facility should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation.

Based on interviews, record reviews, review of facility Self Reported Incident (SRI), review of facility investigation, and review of facility policy, the facility failed to ensure timely reporting of an allegation of abuse. This affected one resident (#14) out of the three residents reviewed for abuse during the annual survey. The facility census was 74. Findings include: Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified convulsions, osteomyelitis, unspecified dementia, Alzheimer's disease, bipolar disorder, and altered mental status. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/24/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision with one person physical assistance for eating. Review of the facility SRI form, dated 07/03/23, revealed on 06/08/23 at approximately 4:00 A.M. Resident #14 was yelling due to having pain in her finger. Licensed Practical Nurse (LPN) #555 entered the room and stated Stop yelling, you are going to wake up the other residents. LPN #555 then exited the room and closed the door. A facility State tested Nursing Assistant (STNA), who was caring for the resident, entered the residents room and sat with her. Review of the facility Report of Concern form, dated 06/28/23 and initiated by STNA #222, revealed documentation Resident #14 reported LPN #555 and STNA #333 closed the residents door and yelled at her to quit crying. Resident #14 stated she told them not to, but they did anyway's. Review of the facility Witness Statement Form, dated 06/29/23, revealed STNA #333 reported Resident #14 was crying all night saying her finger hurt. I asked the nurse (LPN #555) for something for pain for Resident #14 and was told she did not need anything, she was just in a mood. I went back and sat with Resident #14 for 30 minutes then went back to LPN #555. LPN #555 said again Resident #14 was fine and she was not going to put up with it. LPN #555 then shut the door to Resident #14's room and told her to quit crying. Review of the hand-written statement from STNA #222, dated 07/03/23, revealed STNA #222 was in Resident #14's room the morning after the incident in question. STNA #222 went into Resident #14's room to check on her at shift change and the resident was in her bed crying and reaching for her to hug her, saying she was glad to see her. Resident #14 went on to say the night before LPN #555 came into her room because she was crying out loud saying her hands were hurting and LPN #555 told her to stop crying alligator tears or she was going to shut the door. Resident #14 stated this happened a couple times then LPN #555 shut her door. Resident #14 stated she was claustrophobic and did not want her door shut but LPN #555 and STNA #333 kept shutting her door anyway's. Interview with Resident #14's daughter on 08/07/23 at 9:44 A.M. revealed Resident #14 was crying and verbalizing complaints of pain during the night shift. The agency nurse who was working that night told resident #14 to stop crying or she was going to shut the door to the room. When Resident #14 continued to cry due to pain, the agency nurse shut the door. Telephone interview with STNA #333 on 08/07/23 at 2:03 P.M. revealed STNA #333 was in a room two doors down from Resident #14 and heard her start screaming. STNA #333 responded and Resident #14 stated her finger was hurting. STNA #333 stated she asked LPN #555 for pain medication for the resident and LPN #555 stated Resident #14 did not need it. STNA #333 stated she went and sat with Resident #14 for almost an hour and calmed her down some, but she was still hurting. STNA #333 stated LPN #555 then came to the room and shut Resident #14's door and said something along the line of When you stop acting like a toddler I will open the door up. STNA #333 stated she wanted to open the door, but was told not to. STNA #333 stated Resident #14 screamed for almost two hours. STNA #333 stated she opened up the door around 4:00 A.M. to 4:30 A.M. when she was passing ice. STNA #333 stated she did not report the incident during that night to management and LPN #555 continued to work the remainder of the night shift. STNA #333 stated she felt the incident which occurred was abuse. Telephone interview with Corporate Regional Clinical Director #900 on 08/07/23 at 3:13 P.M. revealed she had come to the facility on [DATE] or a visit and was informed of the incident which had occurred on 06/28/23 for the first time. Corporate Regional Clinical Director #900 stated she filed an SRI with the state agency and filed a report with the local Sheriffs office on 07/03/23 after being informed of the incident. Telephone interview with STNA #222 on 08/08/23 at 10:17 A.M. revealed STNA #222 was doing her morning walk through and saw the door to Resident #14's room was closed, which was abnormal. STNA #222 stated Resident #14 was lying in bed crying and reaching for her and told her they closed the door on her and were not listening to her about her pain. STNA #222 stated staff knew the resident did not like her door closed. STNA #222 stated there was a sign put on the residents door by her daughter to keep the door open because the resident was claustrophobic but it was taken down. STNA #222 stated Resident #14 told her LPN #555 told her to dry up her alligator/crocodile tears or I will close your door. STNA #222 stated she filled out a concern form with the resident and gave it to LPN #999. STNA #222 stated she felt the residents report of the incident constituted abuse. Interview with LPN #999 on 08/08/23 at 10:45 A.M. revealed STNA #222 reported the incident on 06/28/23 involving Resident #14 and LPN #555 by providing her a concern form after morning meeting. LPN #999 verified the police were not notified of the incident, nor was an SRI filed, until 07/02/23 when Corporate Regional Clinical Director #900 was notified of the incident as the Administrator and Director of Nursing (DON) had been out of the facility. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/02/22, revealed if any form of abuse was alleged, the Administrator of his/her designee will notify the Ohio Department of Health (ODH) immediately, but no longer than two hours after the allegation was made. For suspected crimes which did not involve serious bodily injury, law enforcement must be notified within 24 hours.

Based on interviews, record reviews, review of facility Self Reported Incident (SRI), review of facility investigation, and review of facility policy, the facility failed to ensure a timely and thorough investigation was completed following an allegation of abuse. This affected one resident (#14) out of the three residents reviewed for abuse during the annual survey. The facility census was 74. Findings include: Record review for Resident #14 revealed this resident was admitted to the facility on [DATE] and had diagnoses including unspecified convulsions, osteomyelitis, unspecified dementia, Alzheimer's disease, bipolar disorder, and altered mental status. Review of the significant change Minimum Data Set (MDS) assessment, dated 07/24/23, revealed this resident was rarely/never understood. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and to require supervision with one person physical assistance for eating. Review of the facility SRI form, dated 07/03/23, revealed on 06/08/23 at approximately 4:00 A.M. Resident #14 was yelling due to having pain in her finger. Licensed Practical Nurse (LPN) #555 entered the room and stated Stop yelling, you are going to wake up the other residents. LPN #555 then exited the room and closed the door. A facility State tested Nursing Assistant (STNA), who was caring for the resident, entered the residents room and sat with her. Review of the daily staffing sheet for 06/27/23 revealed there were two nurses and two STNA's scheduled to work on the [NAME] Wing of the facility from 7:00 P.M. on 06/27/23 through 7:00 A.M. on 06/28/23. Review of the facility investigation revealed a Report of Concern form was completed by STNA #222 on 06/28/23 regarding the incident involving Resident #14 and LPN #555 which was provided to LPN #999. A witness statement form detailing the incident was completed for Resident #48 on 06/29/23. A witness statement form was completed for STNA #333 on 06/29/23. Documentation of four resident interviews were completed on 07/03/23. A hand written statement from STNA #222, dated 07/03/23, was included in the investigation packet. No additional interviews with staff working night shift when the allegation of abuse occurred were present in the investigation packet. No statement from Resident #14 or assessment of the resident were included in the investigation packet. Telephone interview with Corporate Regional Clinical Director #900 on 08/07/23 at 3:13 P.M. revealed she had come to the facility on [DATE] or a visit and was informed of the incident which had occurred on 06/28/23 for the first time. Corporate Regional Clinical Director #900 stated she filed a SRI with the state agency and filed a report with the local Sheriffs office on 07/03/23 after being informed of the incident. Corporate Regional Clinical Director #900 further stated LPN #555 was unable to be interviewed regarding the allegation of abuse as the only telephone number the agency she worked for was not her correct phone number and attempts to reach her were unsuccessful. Interview with LPN #999 on 08/08/23 at 10:45 A.M. revealed STNA #222 reported the incident on 06/28/23 involving Resident #14 and LPN #555 by providing her a concern form after morning meeting. LPN #999 verified the police were not notified of the incident, nor was an SRI filed, until 07/03/23 when Corporate Regional Clinical Director #900 was notified of the incident as the Administrator and Director of Nursing (DON) had been out of the facility. LPN #999 verified the investigation of the incident did not include the other staff members working on [NAME] Wing during the night of the incident and interviews with four residents residing on the same hallway as Resident #14 at the time of the incident had not been conducted until 07/03/23. LPN #999 verified LPN #555 had not been interviewed as the employee had already completed her shift at the facility and left prior to her being notified of the incident and was not reachable by phone. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/02/22, revealed the person investigating the incident should generally take the following actions: Interview with resident, the accused, and all witnesses. Witnesses generally include anyone who witnessed or heard the incident, came in close contact with the resident the day of the incident, and employees who worked closely with the accused employee and/or alleged victim the day of the incident. If the allegation involves abuse/neglect, interview other residents, as appropriate, to determine if they may have been affected by the accused staff member or resident. The results of the investigation will be reported to the Administrator, and a final report will be submitted to the Ohio Department of Health (ODH) no longer than five working days after discovery of the incident.

Based on medical record review, staff interview, and review of facility policy for administering medication, the facility failed to ensure residents were free from significant medication errors when physician orders for a blood pressure medication were not followed and the medication was not administered to a resident. This affected one (Resident #281) of three residents reviewed for hospitalization . The facility census was 84. Actual harm occurred when Resident #281 was admitted to the facility from the hospital on 07/30/21 with orders for a blood pressure medication that was not administered resulting in elevated blood pressure and requiring the resident's treatment at the hospital. Findings include: Review of the medical record of Resident #281 revealed the resident admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the physician's orders revealed an order dated 07/31/21 at 12:21 A.M. to administer [MEDICATION(S)] (antihypertensive) 10 milligrams (mg) by mouth every 6 hours. Review of the medication administration record (MAR) revealed the resident did not receive [MEDICATION(S)] 10 mg as ordered on 07/31/21 at 6:00 A.M., 12:00 P.M., and 6:00 P.M. Review of a nursing progress note dated 07/31/21 at 6:56 P.M. revealed the resident complained of chest pain and shortness of breath and requested to go to the hospital. Resident #281's blood pressure was 209/53. Review of emergency department (ED) Note dated 07/31/21 revealed the resident stated he had not received his medications at the nursing home and the nurse practitioner spoke with nursing home staff, who stated they will work on getting all meds ordered at least by Monday. Review of the ED Report dated 07/31/21 revealed the resident was seen for generalized weakness, chronic pain, debility, acute urinary tract infection, and hypertension. Resident #281 received one dose of [MEDICATION(S)] 10 mg during ED visit on 07/31/21 at 11:48 P.M. Additional instructions included to get all medications filled ASAP. Interview on 08/11/21 at 5:00 P.M. with Registered Nurse (RN) #320 stated [MEDICATION(S)] 10 mg is not available in the e-box. RN #320 stated, if a medication is not available upon admission, she calls the pharmacy and asks for a drop ship and notifies the physician and responsible party of the medication being unavailable. RN #320 further stated these actions would be documented in the resident's medical record. Interview on 08/12/21 at 10:38 A.M., RN/Assistant Director Of Nursing (ADON) #325 stated Resident #281 admitted to the facility from the hospital on 07/30/21 at approximately 10:00 P.M. RN/ADON #325 stated pharmacy deliveries usually arrive daily between 1:00 and 2:00 P.M. and between 9:00 P.M. and 10:00 P.M. RN/ADON #325 stated Resident #281 arrived after the evening pharmacy delivery and the expectation would have been to have the meds sent STAT, which would have the meds delivered within 4 hours. RN/ADON #325 further verified Resident #281's MAR and progress notes lacked evidence of the [MEDICATION(S)] being administered on 07/31/21 at 6:00 A.M., 12:00 P.M. and 6:00 P.M. Review of the facility policy titled, Administration and Documentation of Medications, undated, revealed every resident should receive medications as prescribed by a licensed physician safely, properly, and in a timely manner, and all medications shall be accurately and completely documented.

Based on record review, staff interview and facility policy review, the facility failed to ensure Resident #580 did not develop an avoidable unstageable pressure ulcer (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough by eschar). Harm occurred when Resident #580 developed an unstageable pressure ulcer on the left foot requiring wound care, referral to wound clinic and pain. This affected one (Resident #580) of two residents reviewed for pressure ulcers. Findings include: Record review revealed Resident #580 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #580 was discharged to the hospital on [DATE] and did not return. A review of the Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #580 was moderately cognitively impaired, had no behaviors, was a two person extensive assist with bed mobility, transfers, and toileting and a two person assist with bathing. Resident #580 was assessed as frequently incontinent of bowel and bladder. No skin issues were noted. A physician order [REDACTED]. A plan of care dated 09/06/17 did not include interventions to monitor skin integrity. On 09/12/17, Resident #580 returned from an orthopedic appointment with a physician order [REDACTED]. Review of Nurses Notes dated 10/02/17 at 7:52 P.M., revealed the nurse was called into Resident #580's room by the resident's daughter concerning skin impairment on the resident's left foot posterior to the resident's ankle. The nurse evaluated the resident's skin and discovered a scabbed area with approximated edges measuring approximately 8 centimeter (cm) x 2 cm with no measurable depth. The resident's daughter stated I think its from her brace rubbing her skin. Review of a physician's telephone order dated 10/03/17 revealed an order to cleanse the posterior ankle with soap and water, rinse, pat dry and apply Allevyn (a [MEDICATION NAME] dressing with a breathable top film for fluid removal and a foam layer for absorption) topically to the left posterior ankle every three days and as needed if loose or soiled. The orders also included a referral to a wound clinic to be completed that day. Review of Nurses Note dated 10/03/17 at 4:07 P.M., revealed Resident #508 had a new unstageable pressure ulcer to posterior left (ankle) leg. The area was assessed by the Registered Nurse (RN) unit manager and director of nursing (DON). The area measured approximately 8 cm x 2.5 cm with black dry eschar (dead tissue) with mild redness to peri-wound. No drainage, [MEDICAL CONDITION] or foul odor. The resident indicated the area was painful when touched. Review of a 30 day MDS assessment dated [DATE] revealed an unstageable pressure ulcer measuring 0.8 cm x 2.5 cm x 0.0 cm with eschar (dead tissue). Review of a telephone order dated 10/12/17 revealed to paint the left achilles wound with [MEDICATION NAME], let dry before applying the leg brace twice a day, notify the wound center if the wound opened or started draining. On 03/22/18 at 1:15 P.M., an interview with Physical Therapist (PT) #114 revealed Resident #580 was not tall and the knee immobilizer that was put on at the hospital was too large and had a metal stay that went from about the achilles tendon to the gluteal fold. The initial order was for non-weight bearing with the knee immobilizer to be worn at all times when up and out of bed. The order did not specify it to be released. On 09/12/17 therapy received updated orders to allow for pain free range of motion and flexion. PT #114 said, regarding the skin brace not fitting appropriately, there was not a coordination of care between nursing and when it was brought to the attention of physical therapy staff they called for an alternate knee immobilizer. The smaller knee immobilizer was applied on 10/03/17 and therapy staff insured it did not cause additional irritation to the skin. A review of the bath record from 09/05/17 to 10/02/17 revealed bathing occurred on 09/15/17 at 8:17 A.M., 09/20/17 at 12:03 P.M., and on 010/02/17 at 2:59 P.M. The Nurses Notes dated 10/03/17 at 10:17 A.M. as a late entry for 09/30/17 revealed a family member provided a bed bath. A review of the facility procedure for skin assessments dated 2013 revealed skin assessment was completed on admission. For residents identified at risk for skin breakdown and without a pressure ulcer, a weekly skin evaluation would be completed by the licensed nurse. On 03/22/18 at 2:33 P.M., an interview with the Interim DON revealed the facility policy was for nursing to complete skin assessment and to record the assessment on the back of the treatment record. All shower sheets were reviewed by the unit managers, shredded and not available for review. This deficiency substantiates Complaint number OH 129.