Every finding on record at Ayden Healthcare of Waterville

Based on observation, resident and staff interview, record review and policy review, the facility failed to ensure residents were treated with dignity while receiving feeding assistance. This affected one (#112) of three residents reviewed for dignity. The facility census was 68.Findings include:Review of the medical record for Resident #112 revealed an admission date of 08/03/16 and a readmission date of 10/09/24, with diagnoses of Parkinsonism, paranoid schizophrenia, anxiety, dementia, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/30/26, revealed Resident #112 had impaired cognition and was dependent on staff for eating. Review of the care plan initiated 11/06/24 and revised on 04/20/26 revealed Resident #112 was at risk for decline in activities of daily living (ADL) function and/or ADL participation as evidenced by a need for total (assistance) with ADLs, transfers, ambulation, and toileting related to requiring staff assistance for ADLs. Further review revealed Resident #112 had contractures of the hands and wrists. Additionally, Resident #112 was at risk for altered nutrition. Interventions included staff to feed Resident #112 as needed.Observation on 05/14/26 at 7:53 A.M. revealed Resident #112 lying in bed with a breakfast tray on her overbed table. Both of Resident #112's arms were lying across her chest and both hands appeared to be contracted. Certified Nursing Assistant (CNA) #62 was standing next to Resident #112 and holding a cup for Resident #112 to drink from.Observation on 05/14/26 at 8:00 A.M. revealed CNA #62 was no longer in Resident #112's room and the resident's breakfast tray remained in the room and was full of food. Concurrent interview with Resident #112 revealed she was still hungry and did not know if someone was coming back to assist her to eat.Observation on 05/14/26 at 8:02 A.M. revealed CNA #62 was in the main dining room assisting with serving breakfast to residents. Observation on 05/14/26 at 8:10 A.M. revealed CNA #62 was standing next to Resident #112, instead of sitting with the resident, providing assistance with eating. Concurrent interview with CNA #62 confirmed he was standing while providing assistance to Resident #112. CNA #62 stated he would sit next to residents while providing assistance in the dining room but indicated there appeared to be nowhere to sit at bedside while assisting Resident #112.Interview on 05/14/26 at 1:15 P.M. with the Director of Nursing (DON) confirmed staff should not be standing while feeding residents.Review of the facility policy titled, Assistance with Meals revised July 2017, revealed residents who could not feed themselves would be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals.This deficiency represents non-compliance investigated under Complaint Number 2992378.

Based on observation, medical record review and staff interviews, the facility failed to provide timely repositioning for dependent residents. This affected two (#112 and #113) of three residents reviewed for repositioning. The facility census was 68.Findings include: 1. Review of the medical record for Resident #112 revealed an admission date of 08/03/16 and a readmission date of 10/09/24, with diagnoses of Parkinsonism, paranoid schizophrenia, anxiety, dementia, and need for assistance with personal care.Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/30/26, revealed Resident #112 had impaired cognition and was dependent on staff for eating, repositioning and toileting hygiene. Further review revealed Resident #112 was always incontinent of bladder and bowel.Review of the care plan initiated 11/06/24, and revised on 04/20/26, revealed Resident #112 was at risk for decline in activities of daily living (ADL) function and/or ADL participation as evidenced by need for total (assistance) with ADLs, transfers, ambulation, and toileting related to requiring staff assistance for ADLs. Continuous observations on 05/14/26 from 8:10 A.M. through 11:04 A.M. revealed Resident #112 was lying on her back in bed. No staff were observed to enter the resident's room to provide incontinence care.Interview on 05/14/26 at 10:17 A.M. with Certified Nursing Assistant (CNA) #62 verified the last time Resident #112 was checked for incontinence was at approximately 7:30 A.M. Observation on 05/14/26 at 11:04 A.M. revealed CNA #67 came from another hall to assist Resident #112 with getting up into her wheelchair. CNA #67 did provide incontinence care for Resident #112 at this time. Concurrent interview with CNA #67 confirmed incontinence care was not provided for Resident #112 and CNA #67 verified the resident's incontinence brief contained both urine and stool.2. Review of the medical record revealed Resident #113 was admitted to the facility on [DATE]. Diagnoses included dementia, major depressive disorder, anxiety, fall and cerebral vascular accident (stroke). Review of the quarterly MDS assessment dated [DATE] revealed Resident #113 had a Brief Interview for Mental Status Score (BIMS) of five, indicating severe cognitive deficit. Further review of the MDS revealed Resident #113 was dependent on others for toileting, personal hygiene and rolling left to right. Resident #113 was frequently incontinent for urine and always incontinent for bowel. Review of the revised care plan dated 02/27/26 revealed Resident #113 required total (staff) assistance with ADLs, ambulation and toileting. Further review revealed staff were to provide incontinence care as needed. Finally, the care plan revealed Resident #113 was receiving diuretic therapy, which could increase urinary output. Multiple observations on 05/14/26 from 8:10 A.M. through 2:04 P.M. revealed Resident #113 was in her recliner, in the same position.Interview on 05/14/26 at 10:17 A.M. with CNA #62 verified the last time Resident #113 was checked for incontinence was at approximately 7:30 A.M. CNA #62 stated Resident #113 was placed in her recliner before his arrival at 6:30 A.M. Observation on 05/14/26 at 11:34 A.M. revealed CNA #62 entered Resident #113's room and asked the resident if he could check to see if incontinence care was needed. CNA #62 pulled the front of Resident #113's pants forward and looked at and felt the front of the incontinence brief. CNA #62 stated Resident #113 was not soiled. Concurrent interview with CNA #62 revealed the incontinence brief worn by Resident #113 would change color from yellow to blue if the resident was incontinent of urine. CNA #62 confirmed the resident was not checked for bowel incontinence and verified this was the first incontinence check on Resident #113 since 7:30 A.M., approximately four hours between checking the resident for incontinence care needs.Review of the facility policy titled, Urinary Continence and Incontinence- Assessment and Management, dated September 2010, revealed for residents with severe cognitive impairment, a check and change strategy was to be implemented. The check and change strategy involved checking the resident's continence at regular intervals and using incontinence devices or garments. The primary goal of the check and change strategy was to maintain dignity and comfort and to protect the skin. This was an incidental finding discovered during the complaint investigation.

Based on observation, medical record review, staff interview and policy review the facility failed to provide timely incontinence care. This affected two (#112 and #113) of three residents reviewed for incontinence care. The facility census was 68.Findings include: 1.Review of the medical record for Resident #112 revealed an admission date of 08/03/16 and a readmission date of 10/09/24, with diagnoses of Parkinsonism, paranoid schizophrenia, anxiety, dementia, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/30/26, revealed Resident #112 had impaired cognition and was dependent on staff for eating, repositioning and toileting hygiene. Further review revealed Resident #112 was always incontinent of bladder and bowel. Review of the care plan initiated 11/06/24 and revised on 04/20/26 revealed Resident #112 was at risk for decline in activities of daily life (ADL) function and/or ADL participation as evidenced by need for total (assistance) with ADLs, transfers, ambulation, and toileting related to requiring staff assistance for ADLs. Interventions included Resident #112 should be turned and repositioned per facility policy.Interview on 05/14/26 at 10:17 A.M. with CNA #62 verified the last time Resident #112 was checked for incontinence was shortly after his arrival at 7:30 A.M. Observation on 05/14/26 at 11:04 A.M. revealed CNA #67 came from another hall to assist Resident #112 with getting up into her wheelchair. CNA #67 did provide incontinence care at this time. Resident #112's brief did contain both urine and stool, this was verified by CNA #67.2. Review of the medical record revealed Resident #113 was admitted to the facility on [DATE]. Diagnoses included dementia, major depressive disorder, anxiety, fall and cerebral vascular accident. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #113 revealed a Brief Interview for Mental Status Score (BIMS) of 5, indicating severe cognitive deficit. Further review of the MDS revealed Resident #113 was dependent on others for toileting, personal hygiene and rolling left to right. MDS further revealed Resident #113 was frequently incontinent for urine and always incontinent for bowel. Review of the revised care plan for Resident #113 dated 02/27/26 revealed Resident #113 was a total assist with activities of daily living (ADL's), ambulation and toileting. Further review of Resident #113's care plan revealed staff were to provide incontinence care as needed. Finally, the care plan revealed Resident #113 was receiving diuretic therapy which could increase urinary output. Interview on 05/14/26 at 10:17 A.M. with CNA #62 verified the last time Resident #113 was checked for incontinence was shortly after his arrival at 7:30 A.M. CNA #62 continued to state Resident #113 was placed in her recliner before his arrival at 6:30 A.M. Observation on 05/14/26 at 11:34 A.M. of CNA #62 going into the room of Resident #113. CNA asked Resident #113 if he would check to see if incontinence care was needed, resident agreed. CNA #62 pulled the front of Resident #113's pants forward, looked at and felt the front of the brief. CNA #62 stated Resident #113 was not wet.Interview on 05/14/26 at 11:34 A.M. with CNA #62 revealed the brief worn by Resident #113 will change colors from yellow to blue if resident was incontinent of urine. CNA #62 verified this was the first incontinence check on Resident #113 since 7:30 A.M. Review of the policy titled Urinary Continence and Incontinence- Assessment and Management dated 09/2010 revealed for residents with severe cognitive impairment, a check and change strategy is to be implemented. The check and change strategy involved checking the resident's continence at regular intervals and using incontinence devices or garments. The primary goal of the check and change strategy is to maintain dignity and comfort and to protect the skin. This deficiency represents noncompliance investigated under Complaint Number 2992378.

Based on observation, staff interview, and facility policy review, the facility failed to ensure foods were prepared and stored in a safe manner to prevent spoilage and contamination and failed to maintain the kitchen environment in a sanitary manner. This had the potential to affect all 72 residents who received food from the kitchen. The facility identified four (#1, #44, #50, and #74) residents who received no food by mouth and no food from the kitchen. The facility census was 76.Findings include:Observation on 03/16/26 at 8:10 A.M. of the kitchen found significant dust build up on the ceiling vent and on the ceiling surrounding the vent over the coffee area, juice dispenser, toaster and preparation area.Observation on 03/16/26 at 8:16 A.M. of the walk-in cooler found a box of multiple cartons of liquid eggs being stored on the floor.Interview on 03/16/26 at 8:18 A.M. with Dietary Supervisor (DS) #698 verified the box of eggs were being stored on the floor of the walk-in cooler. DS #698 reported deliveries were received on Tuesdays and Fridays and it was noted to be Monday. Observation on 03/16/26 at 8:20 A.M. of the dry storage room found two large bags of pasta opened, undated, and on the dry storage shelf. One bag of pasta was open to air. Coinciding interview with DS #698 verified the pasta was open and undated and the one bag was open to air. The open to air pasta was removed from use. Observation on 03/16/26 at 8:26 A.M. of the ceiling vents over the clean dish end of the dishwasher in the dish room and ceiling vents over the clean plate stack for meal service in the steam table and cooking area of the kitchen found significant dust build up. Additionally, the wall above the steam oven and the wall along the meal tray line near the clean plates for meal services had significant dust build up.Interview on 03/16/26 at 8:27 A.M. with DS #698 verified the significant dust build up on the vents, ceilings, and walls in the dish room and kitchen preparation and serving area. Observation on 03/16/26 at 8:29 A.M revealed DS #698 was cooking ground beef on the stove. DS #698 was observed not wearing a hair net. Coinciding interview with DS #698 verified she had not been wearing a hairnet and stated it must have fallen off. DS #698 replaced her hair net. Observation on 03/16/26 at 8:32 A.M. of the reach-in cooler found one cup of cottage cheese and six small cups of what appeared to be ranch salad dressing undated and unlabeled. Coinciding interview with DS #698 verified the cups were undated and they were disposed of. Observation on 03/16/26 8:35 A.M. of the reach-in freezer found an opened cup of ice cream on the shelf with the lid not covering the entirety of the ice cream. Coinciding interview with DS #698 verified the ice cream should not have been open in the freezer and the ice cream was discarded. Review of the facility policy titled, Employee Sanitary Food Practices, revised 03/07/21, revealed all employees would wear hair restraints including hair net and or a beard restraint. Review of the facility policy titled, Food Storage, revised 03/07/21, revealed dry storage foods should be dated and the label should be visible. Plastic containers with tight fitting covers must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk food. Refrigerated food should be covered, labeled, and dated. All foods will be stored off the floor. Frozen foods should be covered, labeled, and dated.

Based on observation, medical record review, staff interview, review of the facility water management plan, review of facility policies, and review of the Centers for Disease Control and Prevention (CDC) Legionella control guidance, the facility failed to ensure measures to prevent the growth of Legionella were implemented, failed to ensure urinary catheter drainage bags were maintained in a manner to prevent infection, failed to ensure appropriate personal protective equipment was worn during high-contact care interactions for residents on enhanced barrier precautions, and failed to ensure appropriate hand hygiene was maintained and performed during resident interactions involving potential exposure to bodily fluids. This deficient practice had the potential to affect all 76 residents residing in the facility. The census was 76. Findings include: 1. Review of the facility risk management plan for Legionella control revealed that control of Legionella would involve the on-going review and removal of long plumbing runs and/or dead ends. Further review revealed where it was not practical, the facility would follow its policy of regular flushing of the system. Furthermore, the control plan recommended storing water above 140 degrees Fahrenheit (F) to continuously kill the Legionella bacteria. Review of facility vacant room water flush logs revealed the last documented flush was on 03/12/24. No documentation of water temperature logs were provided. Interview on 03/19/26 at 11:28 A.M. with Director of Maintenance (DM) #686 revealed the facility was not recording water temperatures. Additionally, the DM #686 confirmed that, although the facility was flushing water in unused areas of the facility, they were not tracking or logging the flushes. Review of the Centers for Disease Control and Prevention (CDC) plan for legionella control titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 06/24/25, revealed there are seven steps to an effective water management program including establishing a water management program team, describing the building water systems using text and flow diagrams, identifying areas where Legionella could grow and spread, deciding where control measures should be applied and how to monitor them, establishing ways to intervene when control limits are not met, making sure the program was running as designed and was effective, and documenting and communicating all the activities. 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included morbid obesity, neuromuscular dysfunction of the bladder, and fracture of an unspecified part of the neck of the right femur. Review of Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 revealed the resident was cognitively intact. Resident #13 was dependent on staff for all activities of daily living (ADLs). Review of the care plan dated 03/11/26 for Resident #13 revealed the resident was at risk for alteration in elimination related to being occasionally incontinent of bowel and had an indwelling urinary (Foley) catheter. Goals include the resident would be free from complications related to appliance/catheter use. Interventions included catheter care every shift, change Foley catheter as needed, empty Foley catheter bag every shift and as needed, and Foley catheter to straight drain. Observation on 03/16/26 at 8:41 A.M. revealed Resident #13 had a urinary catheter bag that was laying on the floor and up against the bottom bedrail while the bed was in a low position. Interview on 03/16/26 at 8:41 A.M. with Certified Nurse Aide (CNA) #623 confirmed Resident #13's urinary catheter bag was on the floor. Furthermore, CNA #623 revealed when Resident #13's bed was in the lowest position the bag would rest on the floor and the staff could not figure out where to hang the bag to avoid contact with the floor. Review of facility policy titled, Catheter Care, Urinary, revised 09/2014, revealed infection control measures for residents with indwelling urinary catheters included catheter tubing and drainage bag are to be kept off the floor. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included unspecified head injury, type II diabetes, moderate protein calorie malnutrition, chronic obstructive pulmonary disease, chronic kidney disease stage 3, post-traumatic stress disorder, psychophysiologic insomnia, acquired absence of the right leg below the knee, absence of the left leg above the knee, and retention of urine. Review of a significant change MDS assessment for Resident #2 dated 02/06/26 revealed Resident #2 was cognitively intact and was assessed with an indwelling urinary catheter. Review of the revised care plan for Resident #2 dated 02/02/26 revealed no direction on the use of enhanced barrier precautions (EBP) when caring for the suprapubic catheter. Review of Resident #2's orders revealed on 02/27/26 an order was entered for a 16 French suprapubic catheter to be exchanged now and then every four weeks thereafter. Further review of the orders for Resident #2 revealed no order for EBP. Observation on 03/16/26 at approximately 9:00 A.M. revealed Resident #2 activated the call light due to having a wet brief caused by bladder spasms. Shortly after activating call light, Certified Nurse Aide (CNA) #656 entered the room. CNA #656 donned gloves but no gown and provided incontinence care including peri-care and changing the resident's incontinence brief. Interview on 03/16/26 at 9:13 A.M. with CNA #656 verified a gown was not worn while providing incontinence care to Resident #2. CNA #656 stated she was not aware that a gown was needed to be worn to provide incontinence care to a resident with an indwelling urinary catheter. CNA #565 stated she believed Resident #2 was in EBP for wounds and since she was not providing wound care a gown was not needed. Interview on 03/16/26 at 9:15 A.M. with Registered Nurse (RN) #694 revealed she believed Resident #2 was in EBP due to wounds on his buttocks, but she believed those wounds to be healed at that time. RN #694 stated personal protective equipment (PPE) did not need to be worn to provide care to Resident #2 unless wound care was being provided. Review of the EBP sign posted on the door to Resident #2's room revealed staff were to wear gloves and gown when providing high-contact resident care activities such as changing briefs and with device care or use of urinary catheter. Review of the facility policy titled, Enhanced Barrier Precautions, dated 08/2022, revealed when providing high-contact resident care activities to residents with indwelling medical devices (central line, urinary catheter, or feeding tube), gloves and gown are to be applied prior to the high contact care activity. 4. Observation on 03/17/26 at 10:50 A.M. revealed Resident #2 was in bed sleeping and the indwelling urinary catheter drainage bag was lying on the floor. There was no barrier between the drainage bag and the floor. Observation on 03/17/26 at 12:58 P.M. revealed Resident #2 was in bed sleeping and the indwelling urinary catheter drainage bag was lying on the floor. There was no barrier between drainage bag and the floor. Interview on 03/17/26 at 1:02 P.M. with CNA #651 verified Resident #2's indwelling urinary catheter drainage bag was on the floor with no barrier between bag and floor. CNA #651 donned gloves and hung the drainage bag on the side of the bed. Review of facility policy titled, Catheter Care, Urinary, revised 09/2014, revealed infection control measures for residents with indwelling urinary catheter's included catheter tubing and drainage bag are to be kept off the floor. 5. Observation on 03/17/26 between 7:05 A.M. and 7:40 A.M. revealed Licensed Practical Nurse (LPN) #692 obtained finger stick blood glucose levels for Resident #53 and Resident #76 and did not wear gloves and did not perform hand hygiene prior to nor after obtaining the finger stick blood glucose levels for Resident #53 and Resident #76. Interview on 03/17/26 at 7:40 A.M. with the Director of Nursing (DON) and LPN #692 confirmed LPN #692 did not wear gloves while obtaining finger stick blood glucose levels and did not perform hand hygiene between residents as noted in the above observation. Review of facility policy dated August 2019 and titled, Handwashing/Hand Hygiene, revealed facility staff would perform hand hygiene before and after direct contact with residents.

Based on observation, medical record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident was provided a call light that accommodated the resident's needs. This affected one (#7) of one residents reviewed for accommodation of needs. The facility census was 76.Findings include:Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included unspecified parkinsonism, acute respiratory failure with hypoxia, paranoid schizophrenia, major depressive disorder, suicidal ideations, dementia, and anxiety disorder. Review of the significant change Minimum Data Set (MDS) assessment for Resident #7 dated 01/06/26 revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating the resident had moderate cognitive impairment. Functional abilities for Resident #7 were assessed as dependence on others for eating, oral hygiene, toileting, showering/bathing, upper/lower body dressing and personal hygiene. Review of the revised care plan dated 12/09/25 revealed Resident #7 had self-care deficits and was at risk for alteration in mood and behavior related to schizophrenia and auditory hallucinations. Additionally, the care plan revealed Resident #7 was at risk for falls related to debilitation and weakness.Observation and interview on 03/17/26 at 8:40 A.M. of Resident #7 revealed she was lying awake in bed with call a light device attached to the top of the mattress near her shoulder. The call light device was a red pull cord string. Resident #7 was asked if she was able to pull the cord and Resident #7 shook her head, No. Resident #7 was asked to lift her right arm and the resident was unable to do so. Resident #7 was asked to open the fingers on her left hand and the resident was only able to open her first finger and thumb. Resident #7 was asked to try and pull the call light cord and the resident was able to bend her left arm back slightly but was unable to pull the string.Interview on 03/17/26 at 8:59 A.M. with Certified Nurse Aide (CNA) #651 revealed she had not seen Resident #7 activate her call light device. CNA #651 stated Resident #7 was unable to move her right arm, had limited movement to her left arm, and her left hand was contracted, but the resident was able to use her pointer finger and thumb. CNA #651 verified Resident #7 was unable to use the current call light device. CNA #651 stated the facility had soft touch call light devices that Resident #7 would be able to activate but they were not able to be used on Resident #7's hall due to the type of outlet needed. CNA #651 stated Resident #7 would not be able to activate her current call light device if help was needed. Review of the policy titled, Quality of Life - Accommodation of Needs, revised 08/2009, revealed a resident's individual needs and preferences, including adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure residents were bathed per their scheduled preference. This affected one (#46) of three residents reviewed for activities of daily living. The facility census was 76.Findings include:Review of the medical record for Resident #46 revealed he was admitted on [DATE] with diagnoses including chronic respiratory failure, alveolar hypoventilation, morbid obesity, neurogenic bladder, hypertension, dependence on ventilator, chronic obstructive pulmonary disease, asthma, type two diabetes mellitus, depression, and anxiety.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #46 revealed he was cognitively intact at the time of the assessment and did not exhibit any behaviors nor refusals of care. The resident was dependent for all activities of daily living and transfers, and was incontinent of bowel and had a urinary catheter in place.Interview on 03/16/26 at 10:45 A.M. with Resident #46 revealed he did not receive bathing care twice a week as scheduled.Review of shower sheets for Resident #46 revealed he did not receive bed baths on 01/04/26, 01/14/26, 01/18/26, for two weeks between 01/21/26 and 02/04/26, 02/08/26, 02/22/26, and not for two weeks between 03/01/26 and 03/15/26.Interview on 03/18/26 at approximately 3:00 P.M. with the Director of Nursing (DON) confirmed Resident #46 was scheduled for bathing on Wednesdays and Sundays and Resident #46 did not refuse bathing. Continued interview confirmed there was no documentation to support Resident #46 received his bed baths on 01/04/26, 01/14/26, 01/18/26, for two weeks between 01/21/26 and 02/04/26, 02/08/26, 02/22/26, or for two weeks between 03/01/26 and 03/15/26.Interview on 03/19/26 at 10:20 A.M. with the DON revealed the facility standard was for residents to be offered bathing scheduled two times per week.

Based on medical record review and staff interview, the facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects was completed. This affected two (#2 and #3) of five residents reviewed for unnecessary medications. The facility census was 76.Findings include:1. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included unspecified head injury, post-traumatic stress disorder (PTSD), and psychophysiologic insomnia. Review of a significant change Minimum Data Set (MDS) assessment for Resident #2 dated 02/06/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #2 was cognitively intact. Resident #2's behaviors were assessed to include physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds happening one to three days in the look back period. Review of the revised care plan dated 02/02/26 for Resident #2 revealed a history of trauma related PTSD related to military history. Interventions included to observe for increasing anxiety, decrease environmental stimulation, provide reassurance and comfort measures if applicable, and to refer to psychiatric services if applicable. Additional review of the care plan for Resident #2 revealed the resident was at risk for alteration in mood and behavior. There was no direction given in regard to monitoring for the side effects of the psychotropic medications ordered for Resident #2. Review of the physician orders for Resident #2 revealed an order entered on 01/28/26 for psychiatric evaluation and treatment as needed. Medication orders for Resident #2 included Ativan oral tablet 0.5 milligrams (mg) by mouth two times a day as needed for anxiety related to generalized anxiety disorder. Continued review of medication orders revealed an order for mirtazapine 7.5 mg by mouth at bedtime for sleep related to insomnia related depression. There were no physician orders initiated to monitor the side effects of psychotropic medications.2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE]. Diagnoses included aphasia, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, schizoaffective disorder, and personal history of traumatic brain injury.Review of the quarterly MDS for Resident #3 completed on 12/12/25 revealed a BIMS score of 15 indicating Resident #3 was cognitively intact. Continued review of MDS revealed Resident #3 felt down and depressed two to six days during the look back period and no behaviors were exhibited at the time of the assessment. Review of the revised care plan for Resident #3 dated 02/27/26 revealed a risk for behavior symptoms such as exit-seeking or throwing self on the floor when the resident was upset. Further review of the care plan for Resident #3 revealed a risk for changes in mood related to depression, diagnosis of bipolar disorder, and antidepressant and antipsychotic medications. Continued review of the care plan revealed no direction given in regard to monitoring for the side effects of the psychotropic medications. Review of the physician orders for Resident #3 revealed an order initiated on 12/19/25 for psychiatric services evaluation and treatment as needed. Medication orders initiated for Resident #3 included divalproex sodium oral tablet delayed release 125 mg by mouth twice a day related to schizoaffective disorder, bipolar type as well as mirtazapine tablet 7.5 mg by mouth at bedtime for weight loss related to major depressive disorder. Further review revealed no orders entered to monitor the side effects of psychotropic medications.Interview on 03/18/26 at 2:00 P.M. with the Director of Nursing (DON) revealed the order used by the facility to monitor the side effects of psychotropic medications was a house order and if the order was not seen in Resident #2 and Resident #3's active orders then the button was not clicked. The DON stated she would look elsewhere for documentation that monitoring of the side effects of psychotropics for Resident #2 and Resident #3 was completed. Interview on 03/19/26 at 7:58 A.M. with the DON revealed Residents #2 and Resident #3 did not have an active order to monitor for psychotropic medication side effects. The DON verified monitoring for psychotropic medication side effects for Resident #2 and Resident #3 was not completed. The DON further stated the order to monitor for psychotropic medication side effects was entered for Resident #3 that morning.

Based on medical record review, review of electronic mail (email) documents, staff interview, and review of facility policy, the facility failed to ensure a resident was provided a safe and appropriate discharge. This affected one (#84) of three residents reviewed for transfer and discharge. The facility census was 76.Findings include: Review of Resident #84's medical record revealed an admission date of 09/23/25 and a discharge date of 02/13/26. Diagnoses included epilepsy, traumatic brain injury, anxiety disorder, mood disorder, depression, tracheostomy status, and thyroiditis.Review of Resident #84's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #84 was rarely or never understood. A Staff Assessment for Mental Status was completed and Resident #84 was noted to have short and long term memory problems. Resident #84 required moderate assistance with toilet use, bathing, and dressing. Resident #84 displayed physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and rejection of care one to three days during the review period. Resident #84 displayed other behavioral symptoms and wandering behaviors four to six days of the review period. Review of Resident #84's care plan initiated on 09/23/25, and cancelled on 02/20/26, revealed supports and interventions for being at risk for decline in activities of daily living, at risk for falls, at risk for alteration in comfort, a discharge plan to return home to a safe environment of her choice, cognitive impairment, notation that the resident could become fearful and agitated in group activities, and was at risk for alteration in mood and behaviors. Resident #84's behaviors included crying, tearfulness, yelling help me, repeatedly asking for the same thing, and taking her clothes off and walk down the hallways. Interventions included to acknowledge mood in one-on-one interactions, administer medications as ordered, discuss feelings, encourage loved ones to visit, encourage to wear clothes in the hallway, utilize a weighted blanket to help with mood and comfort, and involve in making own schedule. Review of Resident #84's progress notes from 11/01/25 to her discharge on [DATE] found no instances of Resident #84's behaviors being a risk to herself or other residents. Resident #84's behaviors were directed only toward staff and included hitting, kicking, throwing items, and hitting the medication cart against the wall. Further review revealed no evidence of the facility submitting and referrals to other skilled nursing facilities for alternate placement.Review of a late entry progress note written by the Director of Nursing (DON) dated 02/12/26 at 8:30 P.M. revealed she was notified that Resident #84 was out of control, had hit a nurse, and the police were called. The Administrator and Resident #84's husband were notified. The police were with Resident #84 for approximately one hour to get her to calm down and Physician #200 was emailed who had been caring for Resident #84.Review of an email sent by the DON to Physician #200 on 02/12/26 at 11:37 P.M. revealed Resident #84 needed a psychiatric facility but also needed to be overseen by neurology and the area where the facility was located did not have any facilities which meet that criteria. Further review revealed Resident #84 had gotten physical with staff and the facility was not equipped for her (Resident #84) behaviors and the facility was not sure what to do at this point. The DON asked if there were any service near Physician #200's where the resident could go.Review of a late entry progress note written by the DON on 02/13/26 at 2:29 A.M. revealed she received a call from Physician #200 indicating she and her psychiatric team did not know of a psychiatric facility that had a neurologist on board. Further review revealed Physician #200 recommended Resident #84's husband take the resident to an ER that had a psychiatric center. The DON also asked for information from Resident #84's insurance to determine what hospitals would accept her. Further review of the progress note revealed the DON spoke to Resident #84's husband who was going to take the resident to the ER and he would do research on which hospital to take her to. Resident #84's husband indicated he would not be able to pick the resident up until 9:30 P.M.Review of an email sent by Physician #200 to the DON on 02/13/26 at 8:43 A.M. revealed discussion about adding antipsychotic medication to Resident #84's medication regimen, but first Physician #200 suggested a formal psychiatric evaluation and help with her medications would be the next best step. Further review revealed Physician #200 indicated her facility's inpatient psychiatric units did not have neurology onsite to provider care for Resident #84.Review of a progress note written by Social Services Director (SSD) #603 on 02/13/26 at 4:12 P.M. revealed a information packet was made for Resident #84's husband to take the resident to a hospital for acute psychiatric behaviors.Review of a late entry progress note written by the DON on 02/13/26 at 10:17 A.M. revealed Resident #84's husband was in the ER at a local hospital and he felt the hospital was not going to admit Resident #84. The DON asked the resident's husband to give them her telephone number to speak with them. It was documented Resident #84's husband stated a male in the ER stated this was not even the place for her (Resident #84). Resident #84's husband stated the resident would probably end up at another hospital if she could not come back to the facility.Review of a late entry progress note written by the DON on 02/13/26 at 12:00 A.M. revealed she spoke with the Administrator about Resident #84 being at the hospital, and the hospital not admitting the resident. Further review revealed the husband asked if he could bring the resident back that night. The Administrator called the DON back and stated Resident #84 could not come back to the facility because she was a harm to herself and others. The DON relayed this to Resident #84's husband and stated the ER physicians told him they would not call the DON.Review of an email sent by the DON to Physician #200 on 02/13/26 at 1:13 P.M. revealed she was told by the facility corporate staff that she needed to find a psychiatric facility to send Resident #84 to as soon as possible due to uncontrolled behaviors. Review of an email sent by Physician #200 to the DON on 02/13/26 at 1:23 P.M. revealed she had not heard from her psychiatric team and informed the DON to let her know if the facility found someplace local to transfer Resident #84.Review of a late entry progress note written by the DON on 02/14/26 at 1:45 A.M. revealed she was notified by Resident #84's husband that psychiatric services had finally come to the ER to evaluate the resident. Further review revealed he told the ER staff the facility was not accepting Resident #84 back due to being a harm to herself and others.Review of a late entry progress note written by the DON on 02/14/26 at 2:40 A.M. revealed Resident #84's husband notified the DON that the hospital was not admitting the resident and he had no medications and no place to take the resident. The DON approved for staff to provide Resident #84's husband with the resident's medication for the morning and late afternoon which would give the resident enough medications before being taken to another hospital. Review of a progress note written by Licensed Practical Nurse (LPN) #696 on 02/14/26 at 6:14 A.M. revealed Resident #84 went to the hospital with her husband and the hospital did not admit the resident. The resident was not allowed to return to the facility. The morning and noon dose of medications were given to Resident #84's husband per the DON's request as well as the resident's belongings. Resident #84's husband was upset that the resident could not return to the facility and was taking the resident home. Review of a late entry progress note dated 02/14/26 at 3:36 P.M. revealed the facility spoke with Resident #84's husband who indicated the resident was home, was very confused, but was safe. He stated he spoke with Physician #200 and she was calling in Resident #84's medications to be obtained, and if he was not able to afford them, then he needed to take Resident #84 to the ER.Review of discharge instructions dated 02/14/26 revealed Resident #84 was discharged home from the hospital with her husband as care giver. A home health referral was to be sent the following Monday (02/16/26) for physical, occupational, and speech therapy, as well as nursing needs. No durable medical equipment was needed for the resident. The resident's medications were called in by Resident #84's neurologist, however, the resident's medications were not common and the facility received approval from the Medical Director to send the resident's medications home with her. Medication instructions were given to Resident #84's husband and told the importance of the resident receiving her seizure medications and need to contact the neurologist and take the resident to the ER if any seizures were noted. The resident required 24 hour supervision, especially while in the kitchen, showering, and using stairs. Review of Resident #84's medical record revealed no documentation of the facility providing Resident #84 or her husband of a discharge notice prior to being discharged or rights to appeal the discharge.Interview on 03/18/26 at 8:05 A.M. with the DON verified Resident #84 had no behaviors directed toward other residents or herself. The DON reported all of Resident #84's behaviors were directed toward staff. Resident #84 had no episode to justify transfer to the ER for mental health evaluation and treatment via squad, so Resident #84's husband was spoken to about Resident #84's continued behaviors toward staff. Resident #84's husband agreed to pick Resident #84 up and take her to the hospital ER. The DON verified Resident #84 was not admitted to the hospital and was not permitted to return to the facility. The DON reported she contacted the facility corporate offices and was advised Resident #84 was not permitted to return to the facility because she was a risk to herself and others. The DON verified Resident #84's husband was upset Resident #84 was not able to return to the facility and reported she arranged for Resident #84 to get her medications for the next day. The DON reported Resident #84 received her scheduled medications before she left the facility around 9:30 A.M. and had not missed any doses. The DON stated Resident #84's husband took the resident and the husband told her the first night Resident #84 was confused but was sleeping and eating well. The plan was for Resident #84's brother to stay with the resident and the husband so Resident #84's husband could go back to work. Review of the facility policy titled, Transfer and Discharge, revised August 2024 revealed it was the policy of the facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility excepts when the resident or responsible party requests, when the resident or the responsible party was no actively paying, or when the health and safety of the individual or other residents were endangered.

Based on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure pressure ulcer prevention measures were in place as ordered. This affected one (#11) of one residents reviewed for pressure ulcers. The facility census was 76.Findings include:Review of the medical record for Resident #11 revealed an admission date of 03/28/21 with diagnoses of hemiplegia and hemiparesis, aphasia, and anxiety. Review of the annual Minimum Data Set (MDS) assessment, dated 01/16/26, revealed Resident #11 had impaired cognition and was dependent on staff for transfers and mobility. Further review revealed Resident #11 was at risk for skin breakdown and had no pressure ulcers at the time of the assessment.Review of the care plan initiated 01/05/22, and revised 03/19/26, revealed Resident #11 was at risk for impaired skin integrity related to activities of daily living (ADL) needs, incontinence, and frail/thin skin. Interventions included use of pressure reduction devices as needed. Further review revealed Resident #11 was at risk for decline in ADL function and/or ADL participation as evidenced by the need for total assistance with ADLs, mechanical lift (Hoyer) transfers, Broda chairs (a specialized positioning chair) and toileting related to requiring staff total care for ADLs. Review of the current physician order, dated 12/13/22, revealed Resident #11 had orders per wound care for bilateral protective boots as tolerated to be removed for hygiene and skin care.Observation on 03/17/26 at 7:38 A.M. revealed Resident #11 in her room in an adjustable reclining wheelchair. Further observation revealed two offloading boots on the dresser behind her television. Concurrent interview with Resident #11 revealed she would allow staff to put the offloading boots on her.Observation on 03/17/26 at 9:56 A.M. revealed Resident #11 in an adjustable reclining wheelchair in the interim dining room. Resident #11 had a blanket covering her body, legs, and feet. Resident #11's arms were outside the blanket. Concurrent interview with Resident #11 revealed she could not move her legs independently. Interview on 03/17/26 at 10:30 A.M. with Certified Nurse Aide (CNA) #682, who was assigned to Resident #11, stated the staff was about to provide personal care to Resident #11. CNA #682 stated the shift began at 6:30 A.M. and Resident #11 was transferred from the bed to the wheelchair on the previous shift. CNA #682 further stated he had not provided care to Resident #682 since the beginning of his shift on Resident #11's hall four hours earlier, and was in the process of finding a mechanical lift to assist in transferring Resident #682 from the chair to the bed to provide care. Continued observation and interview outside the door to Resident #11's room with CNA #682 confirmed Resident #11's offloading boots were in the room and not on Resident #11. CNA #682 stated the boots were intended to be used while Resident #11 was in bed. Continued observation on 03/17/26 revealed CNA #682 was assisted by CNA #635 as they wheeled Resident #11 from the interim dining room toward Resident #11's room. Concurrent observation revealed CNA #635 moved the blanket covering Resident #11's feet. Resident #11's legs were crossed at the ankle and one heel was resting on the footpad of the adjustable wheelchair. Concurrent interview with CNA #635 confirmed Resident #11's heel was resting on the footpad. Follow-up interview on 03/17/26 at approximately 2:00 P.M. with CNA #635 revealed she placed Resident #11's offloading boots on both feet after the earlier observation of her heel resting on the wheelchair footpad. Review of the weekly body audit dated 03/18/26 revealed Resident #11 had no skin breakdown.Review of the policy titled, Skin Management Program, dated 04/2023, revealed interventions will be implemented that are person-centered and measurable. Interventions may include but are not limited turning and repositioning and offloading heels.

Based on medical record review, staff interview, and policy review, the facility failed to ensure non-pharmacological interventions were attempted prior to receiving an as-needed pain medication. This affected one (#63) of one residents reviewed for pain. The facility census was 76.Findings include:Review of the medical record for Resident #63 revealed an admission date of 04/02/25 with diagnoses of dementia, rheumatoid arthritis, disc degeneration, and neuropathy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/24/25, revealed Resident #63 had intact cognition, received as-needed pain medications, and did not receive non-medication interventions for pain.Review of the care plan, initiated 04/03/25, revealed Resident #63 was at risk for alteration in comfort due to complaints of pain, generalized pain, and gastroesophageal reflux disease. Interventions included but were not limited to staff attempting non-pharmacological interventions if the resident allowed.Review of the physician order dated 11/21/25 revealed Resident #63 received oxycodone hydrochloride (HCl) oral tablet, five (5) milligrams (mg), one tablet by mouth every six hours as needed for pain. Review of Resident #63's February 2026 medication administration record (MAR) revealed Resident #63 received 59 doses of oxycodone HCl.Review of the March 2026 MAR revealed Resident #63 received 28 doses of oxycodone HCl between 03/01/26 and 03/17/26 at 4:00 P.M.Further review of Resident #63's medical record revealed no evidence of non-pharmacological interventions prior to administration of the as-needed doses of oxycodone HCl in February and March 2026.Interview on 03/19/26 at 8:24 A.M. with Licensed Practical Nurse (LPN) #630 confirmed non-pharmacological interventions should be attempted prior to administering as-needed pain medication. Further interview, and concurrent review of Resident #63's medical record, confirmed no evidence Resident #63 received non-pharmacological pain interventions prior to receiving as-needed doses of oxycodone HCl.Review of the policy titled, Pain Assessment and Management, revised 03/2020, revealed guidance for implementing pain management strategies included non-pharmacological interventions may be appropriate or alone in conjunction with medications.

Based on medical record review, staff interview, and review of facility guidelines, the facility failed to ensure resident-specific interventions were implemented to address a resident's history of trauma. This affected three (#63, #13 and #2) of three residents reviewed for trauma informed care and treatment. The facility census was 76. Findings include:1. Review of the medical record for Resident #63 revealed an admission date of 04/02/25 with diagnoses of dementia, bipolar disorder, and depression. Review of the Minimum Data Set (MDS) assessment, dated 12/24/25, revealed Resident #63 had intact cognition. Review of Resident #63's comprehensive care plan, initiated 04/02/25 and revised 04/15/25, revealed Resident #63 had trauma related to sexual abuse. Interventions included providing reassurance and comfort measures if applicable; provide visits to the resident to communicate the activity schedule and encourage the resident to participate in social interactions; and referral to psychiatric services and/or counseling services as warranted. Interview on 03/19/26 at 8:10 A.M. with the Director of Nursing (DON), Licensed Practical Nurse (LPN) #630, and Social Service Director #603 confirmed Resident #63's care plan did not include any trauma-specific triggers or interventions to address and/or avoid Resident #63's trauma-specific triggers. 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included morbid obesity, neuromuscular dysfunction of the bladder, and fracture of an unspecified part of the neck of the right femur. Review of the MDS assessment dated [DATE] for Resident #13 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #13 was cognitively intact. Resident #13 was dependent on staff for all activities of daily living (ADLs). Review of the care plan dated 03/11/26 revealed Resident #13 had a history of trauma related to being in a situation/environment and being a victim of a violent crime with goals that included Resident #13 will express triggered stresses, traumatic events, and how to cope with them. Interventions included displaying warmth, answering questions, offering unconditional acceptance, being available, and respecting the residents use of personal space. There were no identified trauma triggers noted in the care plan. Interview on 03/19/26 at 8:00 A.M. with the DON verified the care plan for Resident #13 contained no specific triggers for the residents past trauma. The DON also verified the interventions for the resident's trauma-informed care were not specific to the resident. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included unspecified head injury, post-traumatic stress disorder (PTSD), and psychophysiologic insomnia. Review of a significant change MDS assessment for Resident #2, dated 02/06/26, revealed Resident #2 was cognitively intact. The resident was assessed with behaviors including physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or disruptive sounds occurring one to three days on the look back period. Review of the revised care plan dated 02/02/26 for Resident #2 revealed a history of trauma-related PTSD from military history with interventions to establish and maintain a trusting relationship by listening to the resident. Further interventions included to observe for increasing anxiety, decrease environmental stimulation, provide reassurance and comfort measures if applicable and to refer to psychiatric services if applicable. Additional review of the care plan for Resident #2 revealed the resident was at risk for alteration in mood and behavior. The care plan for Resident #2 revealed no resident-specific PTSD triggers. Interview on 03/19/26 at 8:00 A.M. with the DON verified the care plan for Resident #2 contained no specific PTSD triggers. The DON stated the interventions for trauma-informed care for Resident #2 were not resident-specific due to lack of triggers. Review of the facility guidelines that were followed and provided by the facility titled, Trauma-Informed Care, Implementing a Trauma-Informed Approach Talking Points, revised in 2021, revealed the facility was to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization.

Based on medical record review and staff interview, the facility failed to ensure medications were administered per physician order. This affected one (#63) of five residents reviewed for medications. The facility census was 76.Findings include:Review of the medical record for Resident #63 revealed an admission date of 04/02/25 with diagnoses of dementia, hypertension, and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 12/24/25, revealed Resident #63 had intact cognition.Review of the physician order dated 08/29/25 revealed Resident #63 received midodrine hydrochloride (HCl) tablet 2.5 milligrams (mg) to give one table by mouth every eight hours for hypotension with instructions to give the medication for systolic blood pressure (SBP; the reading of pressure against the artery walls when the heart beats and is represented as the top number of a blood pressure reading) less than 100 millimeters of Mercury (mmHg). Review of Resident #63's February 2026 medication administration record (MAR) revealed Resident #63 received midodrine HCl on 02/09/26 at 10:00 P.M. for a blood pressure (BP) of 124/50 mmHg, on 02/16/26 at 2:00 P.M. for a BP of 117/58 mmHg, on 02/19/26 at 2:00 P.M. for a BP of 125/72 mmHg, on 02/20/26 at 10:00 P.M. for a BP of 163/59 mmHg, on 02/21/26 at 10:00 P.M. for a BP of 104/76 mmHg, on 02/22/26 at 10:00 P.M. for a BP of 108/62 mmHg, on 02/23/26 at 6:00 A.M. for a BP of 106/69 mmHg, on 02/25/26 at 2:00 P.M. for a BP of 106/54 mmHg, on 02/27/26 at 6:00 A.M. for a BP of 126/57 mmHg, and on 02/28/26 at 2:00 P.M. for a BP of 108/74 mmHg.Review of Resident #63's MArch 2026 MAR revealed Resident #63 received midodrine HCl on 03/06/26 at 10:00 P.M. for a BP of 143/51 mmHg.Interview on 03/19/26 at 9:13 A.M. with Unit Manager #683 confirmed Resident #63 received midodrine HCl outside the ordered parameters on 02/09/26, 02/16/26, 02/19/26, 02/20/26, 02/21/26, 02/22/26, 02/23/26, 02/25/26, 02/27/26, 02/28/26, and 03/06/26.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure medications were stored in a secure manner. This affected one (#9) of one residents reviewed for hemodialysis and related care. The facility census was 76.Findings include:Review of the medical record for Resident #9 revealed an admission date of 05/13/21 with diagnoses of dementia, heart disease, and end stage renal disease. Review of the Minimum Data Set (MDS) assessment, dated 12/23/25, revealed Resident #9 had intact cognition and received dialysis.Review of the current physician order, initiated 01/09/26, revealed Resident #9 received midodrine hydrochloride (HCl) oral tablet 10 milligrams (mg) with instructions to give 10 mg orally in the afternoon every Monday, Wednesday, and Friday, and send with the resident to dialysis.Review of the current physician order, initiated 01/20/26, revealed Resident #9 went to an offsite hemodialysis (HD) clinic three times weekly and as needed for HD.Interview on 03/17/26 at 10:23 A.M. with Registered Nurse (RN) #706 revealed Resident #9's HD communication binder was located in the bag in Resident #9's room. Observation and interview on 03/17/26 at 10:45 A.M. with Certified Nurse Aide (CNA) #644 and Resident #9, in Resident #9's room, revealed a tote bag on Resident #9's recliner, zipped, and closed. Further observation, with Resident #9's permission, revealed Resident #9's HD notebook inside the tote bag. Continued observation revealed medication was inside a pouch inside the notebook. CNA #644 confirmed medications were inside the notebook. Continued observation revealed CNA #644 carried the notebook to Licensed Practical Nurse (LPN) #692, who was at the medication cart on the secured unit. Interview on 03/17/26 at 10:48 A.M. with LPN #692, and concurrent observation of Resident #9's HD notebook, revealed a medication card for Resident #9 for midodrine HCl 10 mg containing seven tablets. LPN #692 placed the notebook in a locked drawer of the medication cart. Review of the policy titled, Storage of Medications, revised April 2019, revealed drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls.

Based on medical record review, resident representative interview, and staff interview, the facility failed to ensure diagnostic testing results were obtained and communicated in a timely manner. This affected one (#44) of one residents reviewed for diagnostic testing. The facility census was 76.Findings include:Review of the medical record for Resident #44 revealed he was admitted on [DATE] with diagnoses including respiratory failure, depression, anxiety, pneumonia, neurogenic bladder, acute infarction of the spinal cord, hypertension, and gastrointestinal hemorrhage. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #44 revealed he was cognitively impaired. Resident #44 experienced functional range of motion limitations on both sides to his upper and lower extremities and was dependent for all care and transfers.Interview on 03/16/26 at 2:23 P.M. with Resident #44's representative revealed diagnostic testing results completed in January 2026 had not been communicated to them.Review of the medical record for Resident #44 revealed a progress note dated 01/20/26 indicating a bone biopsy had been rescheduled for 02/03/26. A progress noted dated 02/03/26 revealed Resident #44 was out of the facility.Review of the medical record for Resident #44 revealed the absence of results from the bone biopsy scheduled on 02/03/26.Interview on 03/18/26 at 10:48 A.M. with the Director of Nursing (DON) confirmed the bone biopsy results had not been obtained by the facility nor communicated to the physician and resident representative.Interview on 03/19/26 at 10:00 A.M. with the Administrator revealed the facility did not have a policy for obtaining diagnostic testing results nor physician and family representative notification of said results.Interview on 03/19/26 at 10:20 A.M. with the DON revealed diagnostic testing results would typically be communicated to the physician within 24 hours.

Based on medical record review and staff interview, the facility failed to ensure a resident's medical record was complete to include communication with a dialysis provider. This affected one (#9) of one residents reviewed for hemodialysis. The facility census was 76.Findings include:Review of the medical record for Resident #9 revealed an admission date of 05/13/21 with diagnoses of dementia, heart disease, and end stage renal disease. Review of the Minimum Data Set (MDS) assessment, dated 12/23/25, revealed Resident #9 had intact cognition and received dialysis.Review of a document on the hemodialysis (HD) clinic's letterhead titled, Patient Curfew Letter, dated 10/01/25, revealed Resident #9 was receiving emergency HD treatments at the clinic in the area and the scheduling of the treatments required him/her to be traveling through the area during hours before and after curfew. Review of Resident #9's nursing progress notes dated 10/01/25 through 02/25/26 revealed communication between the facility and Resident #9's HD clinic was documented on 10/31/25, 11/13/25, 12/08/25, and 02/25/26.Review of the current physician order, dated 01/20/26, revealed Resident #9 went to an offsite HD clinic three times weekly and as needed for HD.Review of the care plan, initiated 04/09/24 and revised 03/19/26, revealed Resident #9 received dialysis Mondays, Wednesdays, and Fridays. Interventions included to check for new orders upon return from dialysis (initiated 04/09/24) and maintain communication with dialysis staff and physician (initiated 03/19/26). Interview on 03/17/26 at 10:23 A.M. with Registered Nurse (RN) #706 revealed staff obtained Resident #9's vital signs and checked the fistula (dialysis access site) and the dressing before and after each HD treatment. Interview on 03/18/26 at 10:45 A.M. with Licensed Practical Nurse (LPN) #659 stated Resident #9's HD clinic stayed in very good communication with the facility and called if there were any emergency needs. LPN #659 stated the HD clinic did not often send any paperwork back with Resident #9. Interview on 03/19/26 at 12:02 P.M. with the Director of Nursing (DON) revealed there was no expectation the facility would send information with Resident #9 to the HD clinic on dialysis days. Continued interview on 03/19/26 with the DON and Unit Manager #683 revealed the facility received electronic mail (email) and telephone calls from the HD clinic and stated there was ongoing communication with the HD clinic. Further interview confirmed the ongoing exchange of information with the HD clinic was not routinely documented in the resident's medical record.

Based on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure a resident who was dependent on staff for activities of daily living (ADL) received adequate assistance with personal hygiene. This affected one (#16) of three residents reviewed for ADL care. The facility census was 75. Findings include:Review of the medical record for Resident #16 revealed an admission date of 03/30/18. Diagnoses included chronic respiratory failure, tracheostomy status, ventilator dependent, quadriplegia, and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was severely cognitively impaired and was dependent on staff for all ADL care. Review of the care plan revised 08/2025 revealed Resident #16 was care planned for risk for decline in ADL function with an intervention of total dependent assistance for all ADL care. Review of the facility's shower schedule revealed Resident #16 was scheduled for showers on Tuesday and Friday by the night shift staff. Review of the shower sheet for Resident #16 revealed she received a shower on her regularly scheduled shower day on 09/23/25. Observation on 09/23/25 at 11:28 A.M. revealed Resident #16 was laying in bed, eyes closed, unarousable (comatose) with facial hair on her upper lip and chin that was approximately one to two inches in length resembling a man's goatee. Resident #16's upper lip revealed the hair was hanging beyond the top lip line where it begins to form the top full lip. The facial hair on Resident #16's chin revealed the hair was nearly touching the drain sponge underneath the tracheostomy drainage sponge, which was a four-by-four split gauze dressing that was placed around the tracheotomy opening. Observations on 09/24/25 at 7:29 A.M. and 11:39 A.M. revealed Resident #16 was clean, her hair appeared freshly washed, damp, and combed to the side with the facial hair unchanged from observation on 09/23/25. Interview on 09/24/25 at 11:39 A.M. with Certified Nursing Assistant (CNA) #369 verified she received in report from night shift that Resident #16 was showered. CNA #369 further stated the staff don't want to use the facilities razors on her face so they didn't shave her. Observation concurrent with interview on 09/24/25 at 11:40 A.M. with Licensed Practical Nurse (LPN) #381 verified the long facial hair on Resident #16 and stated the expectations of the CNAs during showering was to trim nails, wash hair, and shave facial hair. Further observation of the facility's razors revealed the razors were the traditional two blade razor. Review of the facility policy titled Activities of Daily Living (ADLs) revised 03/2018 revealed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADLs independently will receive the service necessary to maintain good nutrition, grooming, and personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Number 2607782.

Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to maintain a clean, sanitary, and homelike environment. This had the potential to affect all 72 residents residing in the facility. The census was 72. Findings Include: 1. Review of the medical record for Resident #64 revealed an admitted [DATE] and diagnoses of malignant neoplasm of lower third of esophagus, hypothyroidism, diabetes mellitus type two, protein-calorie malnutrition, chronic obstructive pulmonary disease, hepatitis C, morbid obesity, bacteremia, and hypertension. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] for Resident #64 revealed a brief interview for mental status (BIMS) score of 14, indicating Resident #64 was cognitively intact. Interview on 10/07/24 at 8:01 A.M. with Resident #64 revealed the toilet and the toilet riser in his restroom had not been cleaned and were covered with feces. Resident #64 also stated the linens on his bed were soiled and had not been changed. Observation on 10/07/24 at 8:04 A.M. revealed the toiled and toiled riser in his restroom were covered with feces. Observation on 10/07/24 at 8:05 A.M. revealed the linen on Resident #64's bed was soiled with an unknown brown substance. Interview on 10/07/24 at 9:05 A.M. with Housekeeping Assistant #118 verified the toilet and toilet riser in Resident #64's restroom were covered in feces and verified the linen on Resident #64's bed was soiled with an unknown brown substance. 2. Review of the medical record for Resident #59 revealed an admitted [DATE] with diagnoses of injury of unspecified body region, morbid obesity, hypothyroidism, hyperlipidemia, iron deficiency anemia, chronic pulmonary embolism, hypertension, syncope and collapse, and bipolar disorder. Review of the most recent MDS assessment dated [DATE] for Resident #59 revealed a BIMS score of 11, indicating Resident #59 was moderately cognitively intact. Observation on 10/07/24 at 9:05 A.M. revealed the floor in Resident #59's room was dirty. Interview on 10/07/25 at 9:05 A.M. with Resident #59 revealed her room was not kept clean. Interview on 10/07/24 at 9:08 A.M. with Licensed Practical Nurse (LPN) #136 verified the dirt on Resident #59's bedroom floor. 3. Observation on 10/07/24 at 9:18 A.M. revealed the carpet in the 300 Hall was stained and dirty with pieces of food ground into it. Interview on 10/07/24 at 9:19 A.M. with State tested Nurse Aide (STNA) #100 verified the appearance of the 300 Hall carpet and stated that was how the area normally looked and was maintained. Review of the facility policy titled, Quality of Life - Homelike Environment, dated 05/17, revealed residents are provided with a safe, clean, comfortable, and homelike environment.

Based on medical record review, staff interview, review of the facility investigation, review of the facility's Self-Reported Incidents, and review of the facility policy, the facility failed to ensure incidents of potential neglect related to elopement of cognitively impaired residents were reported to the state agency. This affected one resident (#3) of three residents reviewed for risk of elopement. The facility census was 72. Findings include: Review of Resident #3's medical record revealed an admitted [DATE]. Diagnoses included dementia, frontotemporal neurocognitive disorder, seizures, general anxiety disorder, major depressive disorder, osteoarthritis, cognitive communication deficit, and hallucinations. Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #3 was rarely or never understood. A Staff Interview for Mental Status was completed and indicated Resident #3 was severely cognitively impaired. Resident #3 was independent with mobility and required moderate assistance with transfer. Resident #3 was dependent on staff for toilet use and bathing. Resident #3 displayed physical behavioral symptoms directed toward others and wandering behaviors one to three days during the review period. Review of Resident #3's care plan revised 09/12/24 revealed supports and interventions for cognitive impairment, risk for alteration in mood, behaviors including wandering, self-care deficit, and risk for elopement and wandering. Interventions for elopement and wandering included completing an elopement risk assessment, involve Resident #3 in activities of her choice, monitor and report any changes in behavior, orientate to new surrounds, and redirection as needed. Review of the facility's investigation documentation from Resident #3's 08/28/24 incident of exiting the facility revealed prior to the incident, Resident #3 was noted to be closing the fire doors throughout the morning. She was redirected by staff and the doors were reopened after Resident #3 had shut them. It was noted the door alarm to the outside door was tested after the incident and was found to be in working order. It was noted Licensed Practical Nurse (LPN) #494 reported she had taken a smoke break between 7:20 A.M. and 7:30 A.M. at which time during her smoke break she noticed Resident #3 outside the facility walking in the grassed area toward the corn field. LPN #494 intervened and walked with Resident #3 back to the door at the end of the 200 hallway. State tested Nursing Assistant (STNA) #431 was interviewed and reported she arrived at work around 7:10 A.M. and parked in the back parking lot near the 200 hallway door. No alarm was noted to be sounding at the time. STNA #431 proceeded to clock in, the time recorded was 7:17 A.M., and entered the 200 hallway. STNA #431 reported the fire doors were closed, she opened them and responded to the alarm that was sounding. STNA #431 reported she looked outside and did not see any residents. She then proceeded to go up and down the unit to verify resident presence. As she was reviewing residents, Resident #3 and LPN #494 were found walking down the hallway and STNA #431 was updated on what took place. Interview with LPN #484 indicated she was at the nurses station and had visual of the 200 hallway during the occurrence. LPN #484 could not recall hearing the alarm sounding but had visualized Resident #3 closing the fire doors and the housekeeper on the unit redirecting Resident #3 away from the fire doors. LPN #484 reported she was aware LPN #494 had left the unit and had been watching the 200 hall in her absence. It was noted STNA #431 was not on the floor at the start of her 6:30 A.M. shift. No staff observed Resident #3 exit the facility. The Interdisciplinary team reviewed the care plan of Resident #3. Resident #3 was noted to be a new admission to the unit and was becoming acclimated to the facility. Review of the facility's Self-Reported Incidents (SRIs) revealed there was no SRI submitted for Resident #3's 08/28/24 potential neglect incident related to elopement. Interview on 09/17/24 at 9:39 A.M. with Licensed Practical Nurse (LPN) #484 verified Resident #3 was a resident on secured dementia hall of the facility. LPN #484 reported she became aware Resident #3 had gotten out of the facility when she let LPN #494 and Resident #3 back into the facility through the door at the end of the secured dementia wing hallway. Interview on 09/18/24 at 7:29 A.M. with LPN #494 verified Resident #3 resided on the secured dementia unit, had exited the building on 08/28/24 and she had located her near the [NAME] and brought her back into the facility. Interview on 09/18/24 at 7:40 A.M. with State tested Nursing Assistant (STNA) #431 verified Resident #3 had exited the building on 08/28/24. Interview on 09/18/24 at 8:08 A.M. with Corporate Director #516 asked why they would need to report and create a Self-Reported Incident (SRI) for Resident #3's situation. Verifying an SRI had not been completed. Review of the facility policy titled, Freedom from Abuse, Neglect and Exploitation, revised October 2022 revealed the facility would ensure residents were free from neglect by having structures and processes to provide needed care and services to all residents. Alleged violations were to be reported immediately to the Administrator, state agency, adult protective services, and to all other required agencies. In response to allegations of abuse and neglect the facility must have evidence all alleged violations were thoroughly investigated and report the results of the investigation to the administrator and other officials including the state agency within five working days of the incident.

Based on observations, medical record review, staff interview and review of facility policy, the facility failed to provide supervision to prevent resident elopement for residents identified as at risk for elopement. This affected one resident (#3) of three residents reviewed for being at risk for wandering and elopement. The facility census was 72. Findings include: Review of Resident #3's medical record revealed an admitted [DATE]. Diagnoses included dementia, frontotemporal neurocognitive disorder, seizures, general anxiety disorder, major depressive disorder, osteoarthritis, cognitive communication deficit, and hallucinations. Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #3 was rarely or never understood. A Staff Interview for Mental Status was completed and indicated Resident #3 was severely cognitively impaired. Resident #3 was independent with mobility and required moderate assistance with transfer. Resident #3 was dependent on staff for toilet use and bathing. Resident #3 displayed physical behavioral symptoms directed toward others and wandering behaviors one to three days during the review period. Review of Resident #3's care plan revised 09/12/24 revealed supports and interventions for cognitive impairment, risk for alteration in mood, behaviors including wandering, self-care deficit, and risk for elopement and wandering. Interventions for elopement and wandering included completing an elopement risk assessment, involve Resident #3 in activities of her choice, monitor and report any changes in behavior, orientate to new surrounds, and redirection as needed. Review of Resident #3's elopement risk assessment completed 08/27/24 revealed Resident #3 was at risk for elopement. Resident #3 had a history of elopement, was confused, and wandered. Review of the facility's investigation documentation from Resident #3's 08/28/24 incident of exiting the facility revealed prior to the incident Resident #3 was noted to be closing the fire doors throughout the morning. She was redirected by staff and the doors were reopened after Resident #3 had shut them. It was noted the door alarm to the outside door was tested after the incident and was found to be in working order. It was noted Licensed Practical Nurse (LPN) #494 reported she had taken a smoke break between 7:20 A.M. and 7:30 A.M. at which time during her smoke break she noticed Resident #3 outside the facility walking in the grassed area toward the corn field. LPN #494 intervened and walked with Resident #3 back to the door at the end of the 200 hallway. State tested Nursing Assistant (STNA) #431 was interviewed and reported she arrived at work around 7:10 A.M. and parked in the back parking lot near the 200 hallway door. No alarm was noted to be sounding at the time. STNA #431 proceeded to clock in, the time recorded was 7:17 A.M., and entered the 200 hallway. STNA #431 reported the fire doors were closed, she opened them and responded to the alarm that was sounding. STNA #431 reported she looked outside and did not see any residents. She then proceeded to go up and down the unit verify resident presence. As she was reviewing residents, Resident #3 and LPN #494 were found walking down the hallway and STNA #431 was updated on what took place. Interview with LPN #484 indicated she was at the nurses station and had visual of the 200 hallway during the occurrence. LPN #484 could not recall hearing the alarm sounding but had visualized Resident #3 closing the fire doors and the housekeeper on the unit redirecting Resident #3 away from the fire doors. LPN #484 reported she was aware LPN #494 had left the unit and had been watching the 200 hall in her absence. It was noted STNA #431 was not on the floor at the start of her 6:30 A.M. shift. No staff observed Resident #3 exit the facility. The Interdisciplinary team reviewed the care plan of Resident #3. Resident #3 was noted to be a new admission to the unit and was becoming acclimated to the facility. An interview was attempted on 09/17/24 at 9:37 A.M. with Resident #3. Resident #3 was not able to be interviewed. Resident #3 was observed walking back and forth in the hallway and stopped to look out the glass exit door on a couple occasions. Interview on 09/17/24 at 9:39 A.M. with Licensed Practical Nurse (LPN) #484 revealed she was standing at the nurses' station on 08/28/24 when Resident #3 got out of the building. LPN #484 reported Resident #3 had been pacing the hallway on the secured unit and closing the dining room doors and fire doors when she last saw her. LPN #484 was not sure when Resident #3 actually got out the door. LPN #484 reported she did not hear the door alarm sounding, and did not visualize Resident #3 leaving the facility. The fire doors were closed and there had been a laundry cart at the end of the hallway blocking her view. LPN #484 reported she became aware Resident #3 had gotten out of the facility when she let LPN #494 and Resident #3 back into the facility through the door at the end of the 200 hallway. Interview on 09/18/24 at 7:29 A.M. with LPN #494 revealed she was the nurse working the secured 200 hall on 08/28/24 when Resident #3 got out of the building. LPN #494 had covered the 200 hall and five residents on the 300 hall that day. LPN #494 reported Resident #3 was closing the fire doors on the 200 hallway, was pacing, and appeared anxious. LPN #494 reported she was assisting a high needs resident on the 300 hall and when she was done, she went out for a smoke break before she began medication administration on the 200 hallway. LPN #494 reported it was around 7:30 A.M. when she went out to smoke. The door alarm was not sounding when she went out. LPN #494 reported she had just sat down at the picnic table in the staff smoking area when she looked up and saw Resident #3 standing in the grass by the corn field. She immediately went to Resident #3 and she was able to be redirected back to the building. LPN #484 opened the door, and they entered back into the facility. Resident #3 was assessed, and no injury was found. LPN #494 stated she was not aware of the exact time Resident #3 exited the building, but it had only been a matter of minutes from when she went on break and saw Resident #3 standing near the corn field. Observation on 09/18/24 at 7:34 A.M. of the staff smoking area, the outside of the exit door on the 200 hallway and the grass area where Resident #3 was found and redirected into the facility found it was approximately 120 feet Resident #3 had walked before being noticed. Interview on 09/18/24 at 7:40 A.M. with State tested Nursing Assistant (STNA) #431 revealed she had been running late on 08/28/24 and it was about 7:15 A.M. when she got onto the floor. STNA #431 reported when she entered the secured unit, 200 hallway, the fire doors were shut and she could lightly hear the sound of the door alarm. She opened the fire doors, and the door alarm was sounding much louder. STNA #431 reported she walked down the hallway and looked out the door but had not seen anything or anyone. She reported she turned off the alarm and proceeded to check the resident rooms to see if anyone was missing. STNA #431 stated she was halfway down the hall doing room checks when LPN #494 and Resident #3 met her in the hallway. STNA #431 reported Resident #3 had only been in the facility a day, had been observed looking out the window on the door previously but had not tried to get out of the facility prior to this incident. Resident #3 was able to be redirected. Interview on 09/18/24 at 9:45 A.M. with Housekeeper #443 verified she was on the 200 hallway delivering personal items on 08/28/24 when Resident #3 got out of the facility. Housekeeper #443 reported she was in a resident room putting items away and heard a beeping noise. Housekeeper #443 stated she was new and had heard a similar sound from the doors entering onto the unit from the main facility when the doors were not closed tightly. She had assumed the beeping was from those front doors. Housekeeper #443 reported she delivered personal items to a second resident and when she came out she saw LPN #494 outside the facility at the door with Resident #3. Housekeeper #443 reported she did not have the code for the door so she got LPN #484 who let Resident #3 and LPN #494 back into the facility. Housekeeper #443 was not able to recall when exactly the incident occurred, but stated it was some time before 8:00 A.M. because the residents had not had breakfast yet. Review of the facility policy titled, Wandering and Elopement, revised March 2019 revealed the facility would identify residents at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of the facility protocol titled, Secured Unit Protocol, dated October 2023 revealed the facility would strive to provide person centered care to all residents. Cognitively impaired residents were provided care in a safe and structured environment. This deficiency represents non-compliance investigated under Complaint Number OH00157852.

Based on medical record review, review of hospital records, review of a facility Self-Reported Incident (SRI), review of the facility abuse investigation, review of the coroner's report, staff interviews, review of the facility policy titled Freedom from Abuse Neglect, and Exploitation, review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, and review of facility policy titled Resident to Resident Altercations, the facility failed to ensure Resident #100 and Resident #101, were free from abuse. This resulted in Immediate Jeopardy and serious life-threating injuries and/or death for Resident #101 when after witnessing a verbal altercation between Resident #100 and Resident #101, during which time Resident #101 had exhibited physical aggression, State tested Nursing Assistant (STNA) #230 was unable to obtain assistance from additional staff and left the two residents unsupervised in their room while she went to notify the nurses of the situation. Upon returning to the room after obtaining assistance, staff discovered Resident #100 and Resident #101 involved in a physical altercation in which Resident #100 had been struck in the head and Resident #101 had been repeatedly struck in the head and face. Resident #101 was bleeding from lacerations above the eye and to the mouth and was transported via emergency services to a local hospital where he was identified to have a subdural hematoma, subarachnoid hemorrhage, and an epidural hematoma. Consequently, Resident #101 expired nine hours and 20 minutes after the incident from the blunt force trauma injuries sustained in the altercation. This affected two (#100 and #101) of four (#6, #12, #100, and #101) residents reviewed for physical abuse. The facility census was 69. On [DATE] at 5:19 P.M., the facility Administrator, Director of Nursing (DON), and the [NAME] President of Clinical Operations #500 were notified Immediate Jeopardy began on [DATE] at 6:05 P.M., when STNA #230 witnessed a verbal altercation and per her statement, a lunging motion with a fist by Resident #101 toward Resident #100, which was occurring in their shared room. STNA #230 intervened and attempted to call for assistance by activating the call light with no other staff responding. STNA #230 left the residents unsupervised in the room, sitting on their beds after the arguing stopped, and went to the nurses' station to notify the nurse of the situation. STNA #230 returned to the room after notifying Licensed Practical Nurse (LPN) #297 and found Resident #100 holding Resident #101 in a headlock and yelling for help. Resident #101 was bleeding from a laceration to his eyebrow and his mouth. Resident #101 told staff he bopped Resident #100 on the head. Resident #100 told staff he hit Resident #101 about 20 times while demonstrating an upper cut motion. Resident #101 was transferred to a local emergency room for evaluation and treatment. Resident #101 had sustained head injuries of a subdural hematoma, subarachnoid hemorrhage, and an epidural hematoma. Resident #101 expired on [DATE] at 3:25 A.M. The coroner's report listed the manner of death as a homicide from blunt force trauma with subdural hematoma. The Immediate Jeopardy was removed on [DATE] when the facility educated all staff on the facility abuse policy and initiated the use of walkie talkies for staff communication on the dementia unit. The deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until it was corrected on [DATE] when the facility implemented the following corrective actions: On [DATE] at 6:15 P.M., LPN #243 notified the DON of the altercation. An investigation was initiated, and the SRI was reported to the State Survey Agency. On [DATE] at 6:15 P.M., the DON directed the nurses to stay on the dementia unit to document and not at the nurse's station. On [DATE] at approximately 6:20 P.M., the police responded to the facility with the emergency medical services (EMS) and were notified of the incident. On [DATE] at approximately 6:20 P.M., LPN #243 notified the families and physicians for Resident #100 and Resident #101 regarding the incident. On [DATE], the DON started daily audits to identify any roommate conflicts. These occurred daily on the dementia unit for seven days, then three times a week for the rest of the facility through [DATE]. On [DATE] at 10:00 P.M., LPN #296 completed skin sweeps for all the residents residing on the dementia unit to identify any injuries, with no injuries reported. On [DATE], the Administrator, the DON, [NAME] President of Clinical Operations #500, and Medical Director #315 met via the telephone and developed a plan of correction. On [DATE], Corporate Director of Clinical Education #520 provided education to all facility staff on the facility abuse and neglect, communication and behaviors, and behavior interventions via an online education program. The DON conducted post education competencies for all facility staff from [DATE] through [DATE]. On [DATE], the facility purchased walkie talkies for use by all staff on the dementia unit with the use implemented at 4:00 P.M. LPN #243 educated staff on the dementia unit on the use of the walkie talkies. On [DATE], Maintenance Supervisor #289 changed the lock on the door that accessed the dementia unit from the nursing station from a keypad to a push button for quicker access to the unit. On [DATE], the facility placed a new desk on the dementia unit for nursing staff to utilize when charting to enable the staff to remain on the unit at all times. Interviews on [DATE] and [DATE] with LPN #239, LPN #243, LPN #297, LPN #305, Respiratory Therapist (RT) #302, STNA #230, and Registered Nurse (RN) #287 verified they were educated on the facility's abuse policy and the protection of residents during resident-to-resident altercations. On [DATE], the medical records for Resident #6 and Resident #12 were reviewed for abuse. No concerns were identified. Findings include: Review of the SRI, dated [DATE], revealed the facility reported an allegation of physical abuse involving Resident #100 and Resident #101. The allegation concluded that Resident #100 and Resident #101 had a verbal altercation followed by a physical altercation. Resident #101 went over to Resident #100 and hit him on the head. Resident #100 put Resident #101 in a headlock and hit him in the face and head. Resident #101 was bleeding from the mouth and eyebrow. Both residents were sent to the local emergency room for evaluation and treatment. The responsible parties and the physician were notified of the incident on [DATE]. Local Law Enforcement was notified of the allegation on [DATE]. As a result of the investigation the facility unsubstantiated the allegation of abuse. Review of the medical record for Resident #101 revealed an admitted [DATE] with diagnoses of atrial fibrillation, dementia, diabetes mellitus, high blood pressure, and heart failure. Review of Resident #101's quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had moderately impaired cognition and behaviors of rejection of care. Review of Resident #101 nurses' notes dated [DATE] at 7:21 P.M. revealed the resident was involved in an altercation with his roommate with the family and doctor notified. Review of hospital emergency department to admission discharge record dated [DATE] revealed Resident #101 was initially evaluated at a freestanding emergency room (ER) following an assault. At the initial evaluation the resident was found to have a large subdural hematoma, subarachnoid hemorrhage, and possibly an epidural hematoma with a mild midline shift by computerized tomography (CT) scan. A Glascow coma scale (GCS) (a way to measure consciousness after brain injury) was initially 14 (able to answer and respond appropriately) upon arrival to the freestanding ER. Then his mentation began declining with the resident requiring intubation (placement of breathing tube) prior to transfer to a second hospital for a higher level of care. Upon arrival to the hospital the GCS was three without sedation. The patient was on the blood thinner Eliquis and was given Kcentra (medication used to reverse blood thinning effects). A repeat CT scan of the head was obtained with results of significant progressive enlargement of the right subdural hematoma with the maximum thickness increased to three centimeters (cm) from 2.3 cm. There was compression to the right lateral ventricle and a dilated left ventricle with herniation. The neurosurgeon was consulted and discussed with family members the poor prognosis even with surgery. The family decided to change the code status to do not resuscitate comfort care. The patient was admitted to the neurological intensive care unit where he was passionately extubated (breathing tube removed). Resident #101 expired on [DATE] at 3:25 A.M. Review of the coroner's report dated [DATE] revealed Resident #101's cause of death was from blunt head trauma with subdural hematoma that occurred in an altercation. The manner of death was identified as a homicide. Review of the medical record for Resident #100 revealed an admitted [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), anxiety, and dementia with agitation. Review of Resident #100's admission MDS assessment, dated [DATE], revealed moderately impaired cognition and rejection of care. Review of Resident #100's physician orders from [DATE] revealed hospice care, Ativan 1 milligram (mg) every six hours for anxiety and every four hours as needed for anxiety, and Buspar 30 mg three times daily for anxiety. Review of Resident #100's care plan, dated [DATE], revealed the resident was care planned for verbal aggression toward staff, and resisting medication and personal care. Interventions included allowing resident choices, analyze circumstances and triggers to care, and deescalate behaviors. Review of nurses' notes dated [DATE] at 7:18 P.M. revealed the resident was involved in an altercation with the roommate. The family and doctor were notified. Review of the facility investigation revealed a staff statement from STNA #230 which noted on [DATE] around 6:00 P.M. she witnessed Resident #101 lunge over to Resident #100 with a fist but did not hit Resident #100. She yelled for Resident #101 to stop. He then turned towards her and cussed at her stating You want some to? STNA #230 assisted the resident to his bed, and he was still cussing and yelling. STNA #230 asked Resident #101 to go with her to the nurse to report the incident and he refused. STNA #230 asked Resident #100 to go with her to report the incident to the nurse and he also refused. Resident #100 was on his bed and calm the whole time. STNA #230 yelled for a nurse and then ran to the nurses' station where she alerted LPN #297 of the situation, and that Resident #101 was yelling and threatening her. STNA #230 ran back to the room and found Resident #101 on Resident #100's bed in a headlock and Resident #101 was bleeding. Resident #100 was yelling Help during this time. STNA #230 stated the residents were alone for approximately 30 seconds. The nurses arrived and directed STNA #230 to get LPN #297. STNA #230 stated 911 was called and police arrived. Both residents were sent out for evaluation. STNA #230 stated Resident #100 had red knuckles. Review of an addendum statement dated [DATE] from STNA #230 revealed there was an argument between Resident #100 and Resident #101 about urine on the floor. STNA #230 felt comfortable with leaving the residents as they were not arguing, and both were safely sitting on their beds. STNA #230 stated she felt comfortable leaving them alone because these two residents didn't have any prior aggressive behaviors toward anyone, just verbal bickering and fighting. Review of the facility investigation revealed a staff statement dated [DATE] from LPN #239 which indicated she was at the nurses' station and STNA #230 advised Resident #100 and Resident #101 were arguing and might need to be separated. LPN #239, along with LPN #297, got up immediately and went to the residents' room. When the nurses got to the room both residents were in their beds already separated. Blood was observed on the curtain. Resident #101 stated he went over to Resident #100 and bopped him on the head. Resident #100 told the nurses he hit Resident #101 20 times and demonstrated using an upper cut motion. LPN #239 was not able to control Resident #101's bleeding, so LPN #297 took over and LPN #239 went to get help from LPN #243. Review of the facility investigation revealed a staff statement dated [DATE] from LPN #297 that documented LPN #297 and LPN #239 were at the nurses' station when STNA #230 reported Resident #100 and Resident #101 were arguing, had an altercation, and were bleeding. Both nurses went to the residents' room and found Resident #100 and Resident #101 both on their own beds. Resident #101 was bleeding from his mouth and eye and there was blood on the curtain. Resident #101 told the nurse he went over to Resident #100 and bopped him on the head once. Resident #100 told LPN #297 he hit Resident #101 20 times. Resident #100 had blood on his hand. LPN #297 called 911 for Resident #101. LPN #297 stated the police and emergency medical services both responded and spoke to both residents. LPN #297 stated Resident #101 was communicating prior to leaving the facility and appeared to be cognitively alright. LPN #297 stated the entire incident lasted approximately five minutes. Review of the facility investigation revealed a staff statement dated [DATE] from LPN #243 which noted she was alerted to an altercation between Resident #100 and Resident #101 that went from verbal to physical. Resident #101 had injuries that needed medical attention. LPN #243 instructed staff to separate the residents and call 911 for transportation. Police and emergency medical services arrived, and Resident #101 was transported by stretcher. Resident #101 was alert and talking when he was transported. Review of a staff statement dated [DATE] from LPN #243 revealed she notified that an altercation had occurred and Resident #101's mouth was bleeding. She then notified the DON of the situation who directed LPN #243 to notify the doctor and families and send the residents out for evaluation. Interview on [DATE] at 8:00 A.M., the DON stated she was notified of an altercation between Resident #100 and Resident #101 on [DATE] at approximately 6:15 P.M. She was informed Resident #101 was bleeding and staff could not get it to stop. The DON stated she directed the staff to send the resident out for evaluation. Resident #101 was sent to a local ER for evaluation and treatment. The DON stated the facility learned of the death of Resident #101 on [DATE] when Resident #101's son came to the facility to pick up the residents' personal belongings. Interview on [DATE] at 10:20 A.M., the Administrator stated neither of the residents had been involved in any previous altercations. Interview on [DATE] at 10:41 A.M., STNA #230 stated she was picking up dinner trays at approximately 6:00 P.M. on [DATE] when she heard a little commotion from the residents' room and went to see what was happening. STNA #230 found Resident #100 and #101 involved in a verbal argument about urinating on the floor. STNA #230 stated she was able to get the residents calmed down and both residents were sitting on their beds. STNA #230 stated she tried to get them as far away from each other in the room as possible. She did this by having Resident #101 sit on the side of the bed furthest away from the roommate and closest to the doorway. STNA #230 stated she tried to get each of the residents to go with her to alert the nurse about the argument but both residents refused. STNA #230 she stated she ran to the nurses' station and was away from the room about 10 seconds before returning. When STNA #230 returned to the room she found Resident #100 had Resident #101 in a headlock and Resident #101 was bleeding. STNA #230 stated she was able to get the residents separated and went to get the nurses. The nurses were already on the way to the room and STNA #230 told the nurses she found Resident #100 had Resident #101 in a headlock. STNA #230 stated the residents each told what happened and both residents told the same version of the incident. Resident #101 stated he went to Resident #100 and bopped him on the head. Resident #100 stated he hit him back about 20 times while holding him in a headlock. Resident #100 was demonstrating an uppercut hitting motion. Interview on [DATE] at 3:08 P.M., LPN #239 stated LPN #297 and LPN #239 were at the nurses' station documenting with their back toward the secured dementia unit. The nurses were notified of the arguing between the residents and went to the residents' room. When she arrived, she observed both residents were sitting in their beds and there was blood on the privacy curtain. LPN #239 stated the entire time Resident #101 was alert and telling the staff and the police officer the details of the incident. Resident #101 stated I bopped him on the head and then stated Resident #100 hit him on the head. During a follow up interview on [DATE] at 5:16 P.M., STNA #230 stated she yelled for assistance during the incident, and no one responded so she went to the nurse's desk. Interview on [DATE] at 9:28 A.M., LPN #297 stated she does not recall hearing anyone yell for help; however, she was training another nurse and other residents were at the half door near the nurses' station. It is possible she did not hear anyone. LPN #297 stated both nurses were sitting at the desk with backs toward the unit documenting. LPN #297 stated it was close to 6:05 P.M. when STNA #230 told the nurses about the residents having an argument. On the way to the room, STNA #230 met the nurse in the hall and was informed of the additional altercation between Resident #100 and Resident #101 with Resident #101 bleeding. LPN #297 stated she tended to Resident #101 first due to the bleeding, but she was unable to control the bleeding from his mouth. She called 911 for assistance for the uncontrolled bleeding. LPN #297 stated both residents were sent out to a local ER for evaluation and treatment. Follow up interview on [DATE] at 12:39 P.M., STNA #230 stated while picking up dinner trays she witnessed Resident #101 standing between the beds in his room cussing and yelling at Resident #100. STNA #230 stated she yelled at Resident #101 to stop. He then walked over to her with his fist raised, grabbed her by both wrists, shook her, and stated You want some of this too? STNA #230 stated she had Resident #101 sit down on his bed and he complied. She offered to take Resident #101 to the nurses' station to report the incident and he refused to leave. STNA #230 offered to Resident #100 to leave the room and he refused also. STNA #230 went to the nurses' station to report the verbal altercation and that he had grabbed and shook her. When she went back to the room, she heard Resident #100 yell Help me. She observed Resident #100 sitting on his bed with Resident #101 bent over being held in a headlock position by Resident #100. Resident #101 was bleeding. STNA #230 stated she did not witness any hits between the residents. STNA #230 stated she activated the call light after the verbal altercation but did not yell for help with the verbal altercation. STNA #230 stated she did not actually run to the nurses' station; it was just a figure of speech. Review of facility policy titled Freedom from Abuse Neglect, and Exploitation, revised ,d+[DATE], revealed it is the policy of this company that all residents have the right to be free from abuse, neglect, and exploitation. The facility must provide a safe resident environment and protect residents from abuse. Under the area of Protection lists the facility must have written procedures that ensures all residents are protected from physical and psychosocial harm during and after the investigation including increased supervision of the alleged victim and residents. Review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised ,d+[DATE], revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. If a resident is accused or suspected, the facility will protect the resident and will ensure other residents are protected as determined by the circumstances, which may include but are not limited to increased supervision of the alleged perpetrator and/or other residents, room or staffing changes, and immediate transfer or discharge, if indicated. Review of the facility policy titled Resident to Resident Altercations, revised [DATE], revealed if two residents are involved in an altercation the staff must separate the residents and institute measures to calm the situation.

Based on medical record review, review of emergency department medical records, review of hospital medical records, staff interviews, physician interview, physician assistant (PA) interview, review of the facility policy titled Food and Nutrition Services, and review of the facility policy titled Resident Hydration and Prevention of Dehydration, the facility failed to ensure adequate hydration was provided to a resident, failed to provide an assessment of a resident refusing food and fluids, and failed to notify the physician and Dietetic Technician, Registered (DTR)/Registered Dietitian (RD) of a resident's refusal of food and fluids for three days. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death for Resident #6 who had refused foods and fluids on 08/07/23, 08/08/23, 08/09/23 and 08/10/23 with no assessment of the resident being completed and no notification to the facility DTR #320/RD or the resident's physician for additional interventions. Consequently, Resident #6 suffered an acute change in condition, was sent by emergency squad to the emergency department and then to a secondary hospital and was admitted to the hospital's critical care unit with diagnoses of acute kidney failure, dehydration and acute respiratory failure which required intubation. This affected one (#6) of four (#6, #23, #59, and #62) residents reviewed for nutrition and hydration needs. The facility census was 69. On 08/21/23 at 1:12 P.M., the Administrator, [NAME] President of Clinical Operations #500 and the Director of Nursing (DON) were notified Immediate Jeopardy began on 08/10/23 when Resident #6, who had a recent history of acute kidney failure and had been having meal intakes of less than 25%, was transferred to the hospital with lethargy after refusing food and fluids since 08/07/23. Staff failed to ensure adequate fluids were provided to the resident, failed to provide an assessment of the resident's hydration status when ongoing refusals of meals and fluids occurred, and failed to notify Medical Director #315 and DTR #320 of the resident's refusal to eat and drink to allow for assessments of the resident and the potential implementation of additional interventions to prevent dehydration. Resident #6 was emergently transferred to the emergency department on 08/10/23 where laboratory (lab) tests revealed acute kidney injury and dehydration. Resident #6 was intubated, transferred to a secondary hospital, and admitted to a critical care unit with diagnoses of acute respiratory failure, acute renal failure, and dehydration. The Immediate Jeopardy was removed on 08/18/23 when the facility implemented the following corrective actions: On 08/18/23, the Corporate Director of Clinical Education #520 changed the settings in the electronic medical records so a clinical alert would come up when a resident had a meal intake less than 25 percent. These alerts will be followed up on daily and discussed on business days in the facility morning meetings. If a trend is noted, the physician and DTR #320/RD will be notified for a follow-up assessment. On 08/18/23, the DON or designee, began daily audits of the electronic record clinical alerts to ensure they were followed up on. The audits are to be done daily for one week, then three times a week for four weeks to ensure follow up with the physician. The results of the audits will be reviewed by the facility Quality Assurance Performance Improvement (QAPI) team. On 08/18/23, the DON and Medical Records Clerk #282 educated all nurses on the clinical alerts, reporting decreased meal intakes to the physician and to assess residents who are not taking adequate food and fluids. On 08/18/23, the Administrator, the DON, [NAME] President of Clinical Operations #500, and Medical Director #315 met via the telephone and developed a plan of correction.??? On 08/21/23, the medical records for Resident #23, Resident #59, and Resident #62 were reviewed for nutrition and hydration. No concerns were noted. Although the Immediate Jeopardy was removed on 08/18/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #6 revealed an admitted [DATE]. Admitting diagnoses for Resident #6 included cerebral infarct, vascular dementia, hypertension, acute kidney failure, insomnia, anxiety disorder, and hyperlipidemia. Resident #6 was discharged on [DATE] to the hospital. Review of the admission assessment dated [DATE] revealed Resident #6 was on a regular diet with thin liquids, had no difficulty swallowing, and had a pink coloration to the tongue, cheeks, and lips. Review of the admission physician orders dated 07/12/23, revealed the resident was ordered a regular diet. Review of the history and physical completed by Physician #321, dated 07/14/23, revealed Resident #6 was admitted to the facility from the hospital on 07/12/23 with a history of vascular dementia. Resident #6 had a creatinine of 1.16 milligram/deciliter (mg/dl) which was down from 1.72 mg/dl upon admission (normal 0.7 - 1.2 mg/dl). Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/19/23, revealed Resident #6 had moderate cognitive impairment and had disorganized thinking. The resident required supervision after setup for eating. Review of the care plan initiated on 07/20/23, revealed Resident #6 was noted with potential for altered nutrition and hydration status related to unplanned weight loss related to inadequate oral intakes as evidenced by less than seventy-five percent intake of some meals. Interventions included the administration of medication as ordered, assistance with meals as needed, honor food preferences as able, obtain weights as ordered, offer meal substitutions as needed, provide diet as ordered and provide snacks per facility policy. Review of the nutritional assessment completed by DTR #320 on 07/20/23 revealed the resident was on a regular diet with thin liquids. The average meal intake was fifty to seventy-five percent. The resident's weight upon admission was 138.4 pounds and on 07/19/23 the resident had a weight of 134.4 pounds but was still within his body mass index (BMI). Daily nutritional needs were 1520 to 1840 kilocalories and 1530 to 1840 milliliters (ml) of fluid. Resident #6 was assessed with a potential for malnutrition. Review of the physician orders dated 07/21/23 revealed an order for a comprehensive metabolic panel (CMP) and complete blood count (CBC) weekly on Fridays. Review of the laboratory testing results for the CMP collected on 07/21/23 revealed a normal creatinine level of 1.1 mg/dl and an elevated blood urea nitrogen (BUN) level of 25 mg/dl (normal 8-23 mg/dl). The physician was notified, and no additional orders were received. Review of the laboratory testing results for the CMP collected on 07/28/23 revealed a creatinine level of 1.25 mg/dl and an elevated BUN level of 28 mg/dl. The sodium level was 138 milliequivalant/liter (meq/l) (normal 133-146) and the chloride level was 106 meq/l (normal 95-117). The physician was notified, and no new orders were received. Review of the laboratory testing results for the CMP collected on 08/04/23 revealed an elevated creatinine level of 2.05 mg/dl, an elevated BUN of 59 mg/dl, and elevated sodium level of 152 meq/l, and an elevated chloride level of 114 meq/l. The physician was notified with no new orders written. Review of the meal intakes revealed on 07/30/23, 07/31/23, and 08/01/23, Resident #6 consumed 0-25% of all meals. On 08/02/23, Resident #6 refused breakfast and lunch and consumed only 0-25% of the dinner meal. On 08/03/23, Resident #6 consumed 0-25% of all meals. On 08/05/23, Resident #6 consumed 0-25% of two meals and refused the third meal. On 08/06/23, Resident #6 only consumed 0-25% of all three meals. On 08/07/23, Resident #6 consumed 0-25% of the breakfast meal and refused lunch and dinner. On 08/08/23, 08/09/23, and 08/10/23, the meal intakes document Resident #6 refused all meals. Review of the snack acceptance logs for 08/07/23 through 08/10/23 revealed Resident #6 accepted a snack twice a day; however, the log does not indicate what was offered or how much was consumed. Review of the nursing progress notes from 07/30/23 through 08/10/23 revealed no documentation of Resident #6's meal intakes of less than 25%. The nursing progress notes of 08/07/23 through 08/10/23 did not have any documentation of an assessment of Resident #6 when he had refused all meals. The medical record had no evidence the DTR #320, or the physician were notified of the resident's refusal of meals. Review of the monthly progress note dated 08/08/23 and timed 7:28 P.M., completed by Physician Assistant (PA) #326, revealed Resident #6 did not appear to be in any distress and there were no concerns from nursing staff other than increased incidents of falls. Review of the nursing progress note dated 08/10/23 at 8:58 P.M., revealed Resident #6 was sent to the hospital. The nursing progress note dated 08/11/23 at 8:55 A.M. documented Per charge nurse from shift who sent resident out he went for labored breathing and irregular pulse going from 33 to over 100 and lethargy. Review of the emergency department record for Resident #6, dated 08/10/23, revealed the resident was seen for altered mental status. Lab work revealed the resident had a critically high BUN of 97 mg/dl, an elevated creatinine level of 2.6 mg/dl, a critically high sodium level of 165 meq/l, and a critically high chloride level of 131 meq/l. A chest x-ray revealed no cardiopulmonary disease. Diagnoses in the emergency department were acute respiratory failure, acute renal failure, and dehydration. The emergency department transferred Resident #6 to a secondary hospital for critical care. Review of the emergency department record from the second hospital, dated 08/11/23 at 3:37 A.M. revealed Resident #6 was minimally responsive to verbal and painful stimuli with pinpoint pupils. The resident was hypoxemic and was intubated for airway protection. The resident's labs revealed acute kidney injury. He was given two boluses of normal saline intravenous (IV) for a total of 1500 ml, then started on normal saline IV 150 ml per hour. The computerized tomography (CT) scan of the head and chest were negative for an acute problem. The resident's weight was 115 pounds 15.4 ounces. The resident was transferred to the hospital for intensive care unit level care. Resident #6 remains hospitalized . Interview on 08/17/23 at 4:25 A.M. with State tested Nursing Assistant (STNA) #252 verified Resident #6 had not eaten lunch or dinner on 08/07/23 and did not consume any meals or drinks on 08/08/23 or 08/10/23. STNA #252 stated Resident #6 was offered finger foods and drinks but refused the alternatives. STNA #252 stated at each meal Resident #6 did not eat the nurse was notified. Interview with STNA #238 on 08/17/23 at 3:30 P.M. verified Resident #6 did not consume any food or drinks on 08/09/23. STNA #238 stated the nurse was notified of the resident's meal refusal and refusal of alternative food and drink choices. Interview on 08/17/23 at 4:32 P.M. with Licensed Practical Nurse (LPN) #239 verified working on 08/07/23 through 08/10/23 from 7:00 A.M. and 7:00 P.M. LPN #239 verified she was notified of Resident #6 refusing to eat or drink. LPN #239 stated alternatives were offered, and the resident consumed very little. LPN #239 stated Resident #6 spent time sleeping. LPN #239 verified she did not notify the physician or dietary of Resident #6 not eating or drinking. Interview on 08/17/23 at 3:46 P.M., DTR #320 revealed no knowledge of Resident #6's refusal to eat and drink and denied knowledge of abnormal lab results. DTR #320 stated there had been no communication from nursing regarding Resident #6's meal refusals. DTR #320 verified with awareness of the situation there could have been an assessment and possible interventions put into place to encourage Resident #6 to eat and drink. Interview on 08/21/23 at 8:29 A.M. with PA #326 revealed no knowledge of Resident #6's refusal to eat for three days. PA #326 stated the nurses shared Resident #6 had a decreased appetite and the PA related the decreased appetite to the psychiatric medication changes. Interview 08/21/23 at 8:57 A.M. with Physician #315 revealed no knowledge of Resident #6 not eating or drinking and further stated fluids were to be encouraged due to the resident's abnormal kidney function. Physician #315 stated had he been notified of Resident #6 not eating and drinking there would have been other interventions that could have been implemented to prevent hospitalization . Physician #315 verified the cumulative of not eating and drinking adequately for three and half days caught up with Resident #6 and hospitalization was required. Interview with the DON on 08/21/23 at 11:15 A.M. verified the physician had recommended for staff to encourage fluids for Resident #6 and further verified no order existed related to the recommendation. Review of the facility policy titled Food and Nutrition Services, revised October 2017, revealed the multidisciplinary staff, including nursing staff, the attending physician, and the dietician will assess each resident's nutrition needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake. Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate and document as indicated, food and fluid intake of resident with, or at risk for, significant nutritional problems. Variations of unusual eating or intake patterns will be recorded in the resident medical record and brought to the attention of the nurse. The nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietician. Review of the facility policy titled Resident Hydration and Prevention of Dehydration, dated October 2017, revealed nurses will assess for signs of dehydration during daily care. If the potential inadequate intake or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan and the physician will be notified. Orders may be written for extra fluids to be encouraged in between meals and or with medication passes. The dietician, nursing staff and the physician will assess all factors that may be contributing to inadequate fluid intake with orders for medications that may exacerbate dehydration reviewed and held, if appropriate, and laboratory tests ordered to assess actual hydration. Additionally, the physician may initiate intravenous hydration and hospitalization if necessary. This deficiency demonstrates non-compliance related to the allegations in Master Complaint OH00145553.

Based on medical record review, observation, staff interview, review of facility prevention of pressure ulcers/injuries policy, and review of National Pressure Injury Advisory Panel (NPIAP), the facility failed to ensure physician ordered pressure reduction interventions were implemented. This resulted in actual harm to Resident (#11) when the resident developed an avoidable deep tissue injury to her left lateral foot. The resident had a history of [REDACTED]. This affected one (#11) of four residents reviewed for skin breakdown. The census was 70. Findings include: Review of the medical record revealed Resident #11 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of the minimum data set (MDS) assessment dated [DATE] revealed the resident had severe impaired cognition. The resident was dependent on staff for the completion of activities of daily living including transferring and repositioning. The resident was always incontinent of bowel and bladder. The resident was admitted with a pressure ulcer and was at risk for pressure ulcer development. Pressure relieving intervention was listed as in use to the bed along with a wound treatment. Review of physician orders [REDACTED]. Review of a skin breakdown assessment dated on 07/26/20 revealed the resident was at high risk. Review of a care plan, with revision date of 08/06/20, for the potential for alteration in skin integrity related to extensive to dependent assistance for bed mobility, bowel incontinence, and [DIAGNOSES REDACTED]. Review of wound care specialist progress notes dated 08/06/20 revealed the resident was evaluated for a right hip wound of unknown etiology measuring 0.5 centimeters (cm) by (x) 0.5 cm x 0.5 cm, left lateral foot and right heel wounds which were recorded as resolved at the time of the evaluation. The wound specialist prescribed orders for the right heel and left lateral foot to have a foam dressing for protection applied every three days. Review of wound care specialist evaluation note dated 09/10/20 revealed an area to the right hip 0.2 cm x 0.2 cm x 0.2 cm with 100% pale pink tissue, etiology unknown and improving. Additional documentation recorded bilateral feet with areas resolved and an order to off load both feet with boots. Observation on 09/24/20 at 5:32 A.M. revealed the resident was in bed with the air mattress on and set at 180 pounds. The head of the bed was elevated, tube feed was infusing, and the bed was in the low position. There were no bilateral protective boots observed on the resident. The residents feet were laying directly on the mattress. Per the medical record the most current documented weight was on 09/01/20 and the resident weighed 148.6 pounds. On 09/24/20 at 8:47 A.M. observation with wound care specialist Certified Nurse Practitioner (CNP) #1 and Licensed Practical Nurse (LPN) #104, unit manager, revealed an existing dressing to the right hip was dated 09/23/20. CNP #1 removed the hip dressing and indicated the wound was healed. During the observation the resident did not have on bilateral off-loading boots. CNP #1 stated Resident #11 had a history of [REDACTED]. At the time of observation CNP #1 discovered the right outer aspect of the right foot with a red blanchable area of tissue. CNP #1 further stated the residents left lateral foot had a history of [REDACTED]. At the time of the observation a deep tissue injury, black in color, was discovered measuring approximately 1.0 cm x 0.5 cm x 0 cm. CNP #1 applied foam dressings to the areas. Interview with LPN #104, unit manager, at the time of the observation confirmed the off-loading boots could not be located in the resident's room and the boots were not on as ordered. LPN #104 also verified the air mattress was set for someone who weighed 180 pounds. LPN#104 stated the residents most current weight was around 160 pounds and the difference of 20 pounds would not make a difference in pressure relieving properties. Further review of the medical record noted on 09/24/20 skin grids documented a newly acquired pressure suspected deep tissue injury to the left lateral foot measuring 1.0 cm x 0.5 cm x 0 cm with purple tissue. Additionally, a skin grid noted stage 1 pressure ulcer measuring 1.0 cm x 1.0 cm with a discovery date of 09/10/20. On 09/24/20 at 12:55 P.M., a request was made of the Administrator and Director of Nursing (DON) to provide manufacturer instructions for the air mattress use. The facility was unable to provide any documentation regarding the appropriate use and monitoring of the air mattress Review of the facility prevention of pressure ulcers/injuries policy revised October 2018 noted interventions selected as appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Report and document potential changes in skin. Review the interventions and strategies for effectiveness on an ongoing basis. According to NPIAP the definition of a deep tissue injury is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. This deficiency substantiates Complaint Numbers OH 511 and OH 373.

Based on observation, medical record review, staff interview, and pressure redistribution mattress manufacturer's instructions for use, it was determined the facility failed to implement aggressive interventions and treatments to prevent or minimize skin breakdown for one (#1) of five residents reviewed for pressure sore development. This resulted in actual harm for Resident #1 who developed an in-house acquired pressure sore which progressed to a Stage IV, exposing underlying tissue and bone. The facility identified four residents with in-house acquired pressure sores. Findings include: Review of Resident #1's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) assessment, dated 04/09/12, identified the resident with severely impaired cognition and unable to make needs known. The resident required the total dependence of two staff for the completion of activities of daily living (ADL). No skin breakdown was noted. On 04/09/12, the resident's skin breakdown risk was assessed to be at high risk. A nursing plan of care was initiated on 04/03/12 to address the resident's risk for alteration in skin integrity related to impaired mobility. Interventions included: float heels as able; observe skin condition with ADL care daily and report abnormalities; provide preventive skin care routinely and as needed (prn); encourage to reposition as needed; use assistive devices as needed; pressure reducing mattress to bed and cushion to chair. On 04/09/12, physician progress notes [REDACTED]. On 04/16/12 at 2:16 P.M., nurses' notes revealed new orders were received for a treatment to the resident's sacrum. At 2:47 P.M., the sacrum wound measurements were noted to be 4.0 centimeters (cm) long by 7.0 cm wide with an unstageable depth. There was no undermining or tunneling of the tissue and the wound had a brown thick area to the middle. A plan of care to address pressure area at the sacrum was developed on 04/16/12. No new interventions to the plan of care was noted, other than administer treatment per physician orders. According to the record, on 04/16/12, a treatment was ordered by the physician to be administered on Monday, Wednesday, Friday, and PRN. The order revealed the sacrum wound was to be cleansed, dried, and to apply two [MEDICATION NAME] agents (santyl and mesalt) then cover with a collagen based dressing. On 04/19/12, the dietitian ordered [MEDICATION NAME] and [MEDICATION NAME] laboratory blood levels to be drawn on 04/20/12 and a nutritional supplement (Juven), one packet twice a day. Review of the laboratory levels dated 04/20/12 revealed the resident's [MEDICATION NAME] level was low at 2.9 g/dL (normal 3.4-4.8 grams per deciliter (g/dL)) and [MEDICATION NAME] low at 12.7 mg/dL (normal 18-40 milligrams per deciliter). On 04/26/12 at 9:33 A.M., wound measurements to the sacrum were 3.0 cm x 7.0 cm with an unstageable depth and a brown thinning area in the middle. No additional interventions to provide pressure relief was documented. On 05/02/12 at 1:20 P.M., the sacral wound measured 7.0 cm by 7.0 cm and was unstageable. The same dressing treatment was changed to be given twice a day. No additional interventions were recorded in the medical record. On 05/04/12, the physician ordered an indwelling urinary catheter to be inserted to assist with wound healing and to obtain [MEDICATION NAME] and [MEDICATION NAME] laboratory levels on 05/07/12. Review of the laboratory levels noted the [MEDICATION NAME] level to be low at 3.0 g/dL and [MEDICATION NAME] to be low at 9.9 mg/dL. On 05/16/12 at 9:39 A.M., the sacrum wound measurements were 7.0 cm by 7.0 cm with an unstageable depth. The wound has a moderate amount of drainage from the bottom and was documented to be serous and foul smelling. The physician ordered an antibiotic medication for seven days to address the wound. No additional interventions to relieve pressure to the area were noted. On 05/18/12, Hospice services were ordered for the resident with the [DIAGNOSES REDACTED]. No additional interventions or treatment changes were documented as obtained. On 05/23/12 at 6:57 A.M., the sacrum wound measured 5.0 cm by 9.0 cm by 2.0 cm with undermining at 3.4 cm at 12 o'clock, 4.0 cm at 3 o'clock and 2.3 cm at 9 o'clock. Twenty-five percent of the wound bed was beefy pink granulation tissue and the rest of the wound was lifting with foul smelling, dark slough material with moderate drainage. No change to the treatment was noted and no additional pressure relieving measures were implemented. On 06/01/12 at 5:42 P.M., a new order was obtained by Hospice to decrease the tube feeding to 50 ml per hour due to poor tolerance. On 06/06/12 at 10:11 A.M., sacral wound measurements revealed the wound to measure 10.0 cm x 11.0 cm x 3.0 cm with undermining and tunneling noted at 12 o'clock of 3.4 cm, at 3 o'clock of 8.5 cm and 9 o'clock of 12.8 cm. The wound was foul smelling, dark slough material draining. The nurse documented the wound continues to deteriorate with large amounts of drainage. No additional interventions were noted. On 06/13/12 at 11:58 P.M., Resident #1's sacral wound measured 10.0 cm x 13.0 cm x 3.0 cm with undermining and tunneling noted at 12 o'clock of 3.6 cm, 3 o'clock of 9.0 cm and 9 o'clock of 12.8 cm. The wound continued with deterioration. No additional interventions or treatment revision was documented. On 06/14/12 at 3:18 A.M., nurses' notes revealed an additional open area to the right hip measuring 2.5 cm x 4.0 cm with 6.0 inch reddened tissue surrounding the area. Observation on 06/18/12 at 2:05 P.M. noted Resident #1 in bed on a standard pressure relief mattress and positioned to the left. Interview with Hospice Registered Nurse (HRN) #1 at the time of the observation revealed the resident was currently receiving treatment for [REDACTED]. HRN #1 was unaware the resident was on a standard mattress. Review of the pressure redistribution mattress (eMax) manufacturer's instructions for use revealed the resident was on the eMax classic mattress. The manufacturer's instructions indicated this mattress is designed for individuals with up to Stage II pressure ulcers. The mattress is not designed for residents with Stage IV pressure ulcers. Interview on 06/18/12 at 5:05 P.M. with the wound nurse, Licensed Practical Nurse (LPN) #3, verified Resident #1 has remained on the eMax mattress. The resident is positioned with her feet and head elevated. When this takes place the air mattress provided by the facility has a low spot in the sacral region and causes a potential for increased breakdown. LPN #3 also verified the wound treatment has remained the same from the time of discovery on 04/16/12 until current, 06/18/12. No explanation was provided. LPN #3 also verified no changes to the skin/pressure area plan of care were initiated. Observation on 06/19/12 at 8:00 A.M. noted Resident #1 to remain on the eMax classic mattress. Observation with LPN #3 during a dressing change noted the sacral wound to measure 9.0 cm x 14.0 cm x 2.7 cm with undermining at 12 o'clock of 4.0 cm, at 3 o'clock of 8.1 cm, at 5 o'clock the tunneling was observed to be unobtainable due to increased depth, and at 9 o'clock of 2.9 cm. The wound was observed to have moderate dark brown slough and large amount of purulent drainage with a strong foul odor. A second area was observed on the right trochanter measuring 3.0 cm by 3.0 cm and unstageable with dark black tissue. LPN #3 then cleansed the wound, applied the santyl to the soughing tissue, mesalt to the wound bed, packed the tunneling with mesalt and covered with a dry sterile dressing. Interview on 06/19/12 at 11:20 A.M. with the physician revealed no knowledge of Resident #1 remaining on the eMax classic mattress. The physician stated the resident should have been placed on an air mattress when the area to the sacrum was discovered. Further interview revealed the treatment to the sacrum should have been changed when the wound did not show improvement. "This deficiency substantiates Complaint Number OH 984."