Every finding on record at Belmont Manor

Based on observation, interview, and policy review the facility failed to ensure food that was expired and noted with mold. This affected all 52 residents in the facility. The facility census was 52.Findings include:Observations on 02/23/26 between 8:40 A.M. and 8:57 A.M. during the initial tour of the facility kitchen revealed an open cardboard box of on the bottom shelf in the pantry area with large Idaho potatoes. Several potatoes appeared to have a dusty fuzzy brownish blue film on them and some of the potatoes were cut in half with the dusty fuzzy brownish blue film on the open side of the potato. Further observation revealed a gallon of chocolate milk about one quarter full with an expiration date of 02/22/26 in the walk-in refrigerator. Interview on 02/23/26 at 8:58 A.M. with the dietary manager (DM) #202 revealed confirmation that the potatoes had some type of brownish blue fuzzy layer on them and removed the potatoes and placed them in the trash. DM #202 further confirmed the chocolate milk had an expiration date of 02/22/26 and removed the milk from the refrigerator and discarded it.Review of the facility's Food Receiving and Storage policy (undated) revealed refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

Based on record review, and interview, the facility failed to ensure residents or resident representatives knew in advance what charges a facility may impose against a resident's personal funds. This affected four residents (#8, #5, #22, #35 ) of five residents reviewed for personal funds. The facility census was 52. Findings include:1.Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, insomnia, diabetes, and transient ischemic attack.Review of Resident #8's quarterly banking statement revealed a charge in the amount of $7.05 titled bank service charge dated 01/31/26.2. Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, major depressive disorder, and paraplegia. Review of Resident #5's banking statement revealed a charge in the amount of $5.47 titled bank service charge dated 01/31/26. 3. Review of Resident #22's record revealed the resident was admitted on [DATE] with diagnoses including dementia, anxiety, Alzheimer's, and major depressive disorder.Review of Resident #22's banking statement revealed a charge in the amount of $1.23 titled bank service charge dated 01/31/26.Review of the Personal Funds Disposition Form revealed a statement reading the resident and/or resident representative authorize the facility to manage their personal funds while they [the resident] reside within the facility. This means the facility has the right to make deposits in my [the residents] personal account for me [the resident], and to make expenditures in my behalf for personal expenses that I may incur while staying in said facility. The form was dated 03/17/25 and witnessed by a contracted employee of the facility Certified Occupational Therapy Assistant (COTA) #255.4. Review of Resident #35's record revealed the resident was admitted on [DATE] with diagnoses including restlessness and agitation, wandering, diabetes, anxiety, Alzheimer's, and disorientation. Review of Resident #35's banking statement revealed a charge in the amount of $0.12 titled bank service charge dated 01/31/26. Interview with business office personnel #501 on 02/26/26 at 9:25 A.M. confirmed there is a banking service fee charged to each resident. This charge comes from the bank itself, not the facility, so she does not know much about it, it is a different fee for each resident and can vary because it depends on how much money is in the resident's account that month [the fee is a monthly charge]. Business office personnel #501 confirmed they were unaware if residents have been notified about the banking service fee. PNC bank handles the residents' trusts and funds. Business office personnel #501 confirmed COTA #255 who witnessed authorization forms for Resident #50 and Resident #22 is a contracted facility staff member.Review of the facility admissions packet, admission agreement cheat sheet notes, and facility rules, regulations, policies and procedure guides revealed no evidence of residents or their representatives being aware of the service fee charged monthly by PNC bank for residents to have their funds managed by the facility. Review of the personal funds disposition form statement revealed the form must be witnessed by a non staff member, examples or another family member, or another resident.

Based on observation, interview, policy review, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) to reduce the transmission of multidrug-resistant organisms in high contact resident care activities. This affected one resident (#20) of three residents reviewed for pressure ulcers. The facility census was 52.Findings include:Review of the medical record for Resident #20 revealed an admission date for 02/13/26. Diagnoses included type 2 diabetes mellitus, urinary tract infection, muscle weakness, overactive bladder, allergic rhinitis, hyperlipidemia, hypertension, atherosclerotic heart disease, need for assistance for personal care, difficulty in walking, lack of coordination, constipation, history of falling, pressure ulcer of sacral region, unstageable.Review of the medical record for Resident #20 revealed a Minimum Data Set (MDS) version 3.0, dated 02/20/26. The Brief Interview for Mental Status (BIMS)scored a 15 on a 0-10 scale. A score of 15 indicated intact cognitive function. The MDS further indicated the resident used a walker. There was no evidence of wheelchair use. She required set up and clean-up assistance with eating, was dependent with oral care, needed substantial to maximal assistance with toileting, dependent with showering and footwear, and needed substantial assistance with all other activities of daily living (ADL).Review of the medical record for Resident #20 revealed a initial care plan with a focus of care for the potential for pressure ulcer development. Goals of care included not developing any pressure ulcers. Interventions included consulting dietary, using enablers for turning and positioning, and a low air loss mattress which should be adjusted based on resident comfort. The resident should have a weekly skin evaluation.On 02/25/26 at 9:15 A.M., an observation of Resident #20's wound care revealed the resident had a stage III pressure ulcer (PU) to her sacrum. Wound care was provided by Registered Nurse (RN) #110. No infection control issues were noted during wound care.On 02/25/26 at 9:15 A.M., an observation of Room C1, Resident #20's room, failed to reveal any signage for Enhanced Barrier Precautions (EBP). This was confirmed by RN #110 at the time of the observation.On 02/25/26 at 9:25 A.M., an interview with RN #110 revealed the facility only used EBP when wounds were present for over a month or more. EBP was also used for residents who had foley catheters or intravenous lines. The facility did not use EBP when a pressure ulcer was new.Review of the facility Enhanced Barrier Precautions (EBP) policy dated 03/27/24, revealed an EBP sign will be placed on the resident's door and PPE will be inside of the resident's room near the door. EBPs are indicated for residents with any of the following regardless of where they reside in the facility: wounds and/or indwelling medical devices. Wounds include chronic wounds such as pressure ulcers. For residents for whom EBP are indicated, EBP is employed when performing the following high- contact resident care activities: wound care.

Based on medical record review, hospital record review, staff interviews, review of literature from the American Heart Association, and policy review, the facility failed to timely assess and monitor the cardiopulmonary status, including weights. This affected one resident (#25) of two residents reviewed for hospitalizations. The facility census was 52.Findings include: Record review revealed Resident #25 was admitted to the facility on [DATE] with a primary diagnosis of congestive heart failure. Resident #25's other diagnoses included respiratory failure, heart disease, anemia (low blood count), chronic kidney disease, diabetes, high blood pressure, and continuous oxygen use. Review of the nursing assessment completed on 01/05/26 upon admission to the facility revealed Resident #25 was alert and oriented to person, place, and time, lung sounds were clear, vital signs were stable, oxygen at two liters per minute, and 3+pitting edema (significant swelling on a 0-4 scale with 0 being none and 4 being the most severe) to bilateral arms and lower legs.The resident refused to be weighed on this date (01/05/26). Review of resident's hospital paperwork prior to her admission to the facility revealed the resident weighed 172 pounds on 01/02/26.Review of the physician orders for Resident #25 revealed an order dated 01/05/26 for facility staff to obtain weights daily for three days, then weekly for four weeks, then monthly.Review of Resident #25 care plan dated 01/05/26 revealed interventions for congestive heart failure to include weight monitoring as ordered by physician and as needed, observe and report signs and symptoms of congestive heart failure including but not limited to shortness of breath upon exertion, weight gain unrelated to intake, and orthopnea (difficulty breathing when lying flat).Review of the initial comprehensive minimum data set (MDS) assessment completed on 01/13/26 revealed Resident #25 had a brief interview for mental status score of 7/15 indicating severe cognitive impairment. Further review of the MDS assessment revealed Resident #25 was dependent on staff for personal care including dressing, bathing, and transferring out of bed. Resident #25 also required use of a wheelchair navigated by staff for mobility. The resident was incontinent of urine.Review of the medical record revealed an initial facility history and physical note completed on 01/08/26 authored by nurse practitioner (NP) #500 stating Resident #25 was found to have wheezes (an abnormal lung sound caused by narrowed or obstructed airways) and rales (abnormal lung sounds caused by mucus, fluid, or collapsed airways) noted during examination with continued severe swelling to lower legs. NP #500 prescribed Lasix 20 milligrams (mg) twice a day to start 01/09/26 (a diuretic medication used to treat fluid retention caused by conditions including congestive heart failure, and kidney disorders, and recommendations include daily monitoring of weights).Review of Resident #25's medication administration record (MAR) revealed the resident received Lasix as ordered by NP #500. However, there was no evidence that the resident was monitored or assessed for effectiveness of the medication.Another progress note dated 01/06/26 revealed Resident #25 refused to be weighed at this time and requested to be weighed after the X Ray of her right leg was done on this date. There was no weight recorded for 01/06/26 and no evidence the resident refused on this date. Further review of the medical record revealed on 01/07/26 Resident #25 weighed 177.6 pounds. There were no other weights recorded for Resident #25 after the weight obtained on 01/07/26. There was no evidence the resident had refused to be weighed. Further review of Resident #25's medical record revealed the NP #500 gave new orders on 01/08/26 for labs to be obtained on 01/09/26 for a basic metabolic panel (BMP) and complete blood count (CBC) which were obtained. The lab results revealed an elevated kidney function with a blood urea nitrogen (BUN) level of 69 mg/dL (normal BUN kidney function is identified as 6-24 mg/dL) and creatinine level of 1.12 (normal creatinine level is 0.6 to 1 3 mg/dL) and a hemoglobin (Hg) level of 9.0 (normal hemoglobin level is 12-15.5 g/dL)) and white blood cell count (WBC) of 17.2 (normal WBC ranges from 4-11). Further record revealed NP #500 was notified of lab results on 01/09/26 and responded that Resident #25 had chronic kidney disease stage 3. There were no new treatment orders.On 01/09/26 NP #500 gave an additional order to repeat labs for BMP and CBC on Monday 01/12/26. The labs were obtained on 01/12/26 and revealed continued elevation of the kidney function. The resident's BUN was 62 and creatinine was 1.09. The resident's WBC level had improved to 12.2. The resident's hemoglobin level had worsened and was now 8.0. The NP #500 was notified on 01/12/26 of the labs results and orders were given to have Resident #25 drink more water. Review of the medical record for Resident #25 revealed a pulse oximeter reading (device used to determine the saturation of oxygen molecules attached to the red blood cells with normal levels being 92-100%) was being checked twice a day with each shift from 01/05/26 through 01/13/26 with readings between 95-99% on 2-3 liters per minute via nasal canula.Review of the medical record for Resident #25 revealed skilled nursing assessments completed twice (each shift) a day starting on 01/05/26 through 01/13/26. Further review of each nursing assessment revealed documentation of cardiopulmonary assessment including observation of edema, lung sounds, breathing status, existence of oxygen and nebulizer use. All assessments completed for Resident #25 revealed no abnormal lung sounds, that Resident #25 was short of breath with exertion, had 3+ pitting edema to bilateral lower extremities and oxygen use at 3 liters/min via nasal canula and received nebulizer (breathing) treatments[LW1.1].Continued review of Resident #25 medical record revealed on 01/12/26 at 10:51 A.M. a complete nursing assessment revealed no change in lung sounds; however the resident had a change and now was short of breath while lying flat so the head of the resident's bed was elevated. Review of Resident #25 nursing progress note dated 01/12/26 at 12:26 P.M. revealed Resident #25 was short of breath while lying flat and a new intervention was added to keep the head of bed elevated at all times. Further review of Resident #25 medical record revealed no documentation of a medical provider/physician being notified of the resident's new onset of orthopnea.There was no evidence Resident #25's medical provider was notified of the resident's change in respiratory status and new onset of becoming short of breath while lying down (orthopnea).Further review of Resident #25 progress notes revealed a note dated 01/13/26 at 4:40 P.M. stating Resident #25 was found to have blisters on the skin of lower legs that were not present during her AM shower that day. The resident was noted with shortness of breath. The note further revealed vital signs being obtained as blood pressure of 145/70, heart rate of 89 beats per min, respiratory rate of 24, and pulse oximeter [NAME] of 98% on 3 liters of oxygen, and continued 3+ edema to bilateral upper and lower extremities. The progress note further revealed notification to the NP #500 of the resident's condition with new orders to send Resident #25 to the emergency room.Review of Resident #25 hospital records revealed a hospitalization from 01/13/26 to 01/23/26, totaling a ten-day hospital stay. Resident #25 was admitted to the hospital with a primary diagnosis of acute exacerbation of congestive heart failure with hypoxia (lack of oxygen). Other hospital admission diagnoses included pneumonia, obstructive uropathy (blockage in urinary system to prevent flow of urine) and hydronephrosis (water on the kidney).Observation and interview on 02/23/26 at 9:25 A.M. revealed Resident #25 resting in bed with head of bed elevated and wearing continuous oxygen at 2.5 liters via nasal canula. Resident #25 was observed to have a non-productive cough. Resident #25 reported she was hospitalized last month but could not provide details of events of hospitalization. Resident #25 further stated she thinks she was in the hospital for pneumonia and is uncertain if she was still on antibiotics. Interview on 02/25/26 at 11:10 A.M. with registered nurse (RN) #110 revealed the facility does not have any congestive Heart failure protocols for monitoring weights or symptoms. RN #110 reported that the nurses only obtain daily weights on residents if the provider/physician would order daily weights, otherwise the facility follows its weight protocol for all admissions of daily weights for three days, then weekly weights for four weeks, then monthly weights. RN #110 confirmed that the nurses can ask or recommend to the providers/physicians to obtain daily weights. RN #110 further reported that the nursing staff would monitor for signs and symptoms of congestive heart failure including increased shortness of breath, abnormal lung sounds, decreased oxygen levels, and increased swelling of arms and legs and notify the physician or provider of any changes to the residents status. RN #110 also confirmed from her nursing knowledge that residents with heart failure should be weighed daily and if the resident would gain 3-5 pounds in 24 hours it should be reported to the provider/physician. Interview on 02/25/26 at 12:20 P.M. with the Director of Nursing (DON) revealed that the facility does not report refusal or inability to obtain weights of residents to the providers/physicians unless it is persistent and affecting care of the residents. The DON further confirmed there was only one weight recorded for Resident #25 prior to hospitalization and no documentation of provider/physician notification of weights not being obtained. There was no documentation of recommendations by nursing staff for monitoring of daily weights. The DON agreed that the weights for Resident #25 should have been monitored more closely due to diagnosis of heart failure. According to the American Heart Association (AHA) website (www.heart.org/en/health-topics/heart-failure/living-with-heart-failure-and-managing-advanced-hf/physical-changes-to-report-for-heart-failure) symptoms to monitor for congestive heart failure include: Rapid weight gain. The AHA further instructs individuals with heart failure to Ask your health care professional about the amount of weight gain you should report to them. It's important to weigh yourself every day, in the morning before breakfast and after urinating. Weigh yourself with the same type of clothes on, without shoes, on the same scale and in the same location. The AHA further indicates symptoms of heart failure can include increased swelling of legs and need for more pillows at night to prevent shortness of breath.Review of the facility policy titled Notification of Resident Change, with a review date 01/26 revealed a physician will immediately be notified regarding a change in the resident's condition related to a significant change in the resident's physical, mental, or psychosocial status, or a need to alter treatment significantly.

Based on observation, record review, policy review and interview, the facility failed to ensure sanitary kitchen practices. This had the potential to affect all the individuals in the facility except for Resident #9 who did not receive nutrition from the kitchen. The facility census was 51. Findings include: 1. Observation of the kitchen [DATE] at 8:26 A.M. of Dietary #572 revealed she was washing dishes. Interview at the time of the observation revealed Dietary #572 thought the facility had a high temperature dishwasher. There were dishes that have been run through the dishwasher on the draining board. Dietary #576 did not know if they had a high or low temperature dishwasher. The surveyor noticed the facility had a low temperature chemical dishwasher. Dietary #572 was asked if she could test the sanitation in the dishwasher. Dietary #572 said she does not usually test the dishwasher, and stated Dietary #588 does the testing. Dietary #572 found a container of chlorine strips on the top of the dishwasher. She removed a strip opened the dishwasher and swished a strip around in the water. She checked the strip against the grid on the container and it measured 100 parts per million. Observation of the container of strips revealed they had expired in [DATE]. The instructions included to dip strip in water and remove. Dishwasher #572 had agitated the strip in the water. Observation of a storage cabinet revealed an additional container of chlorine strip that expired in [DATE] and a container that had expired in 2021. The facility had no strips that had not expired. Observation of the dishwasher temperature during the wash and rinse cycle revealed the gauge had a clouded covering making it difficult to read the gauge. Dishwasher #572 said she was guessing the temperature gauge was reading 120 degrees Fahrenheit. Review of the [DATE] dishwasher temperature log revealed on [DATE] there was no water temperature or sanitation level documented for breakfast. There was no lunch dishwasher water temperature or sanitation level recorded for [DATE]. Review of the undated Dishwashing policy included dishwasher temperature will be 120 Fahrenheit or greater. The policy did not address chemicals or sanitation level. Review of the Dishwasher Parts Per Million (PPM) and Temperature Log included the range of PPM was to be 50 PPM minimum and 200 maximum. Dishwasher #572 verified during the observations and interview, the dishwasher temperature and sanitation level had not been obtained that morning before starting breakfast dishes. She verified she did not know if they had a high or low temperature dishwasher. Further verified the chlorine strips had expired and she was unsure of the testing technique. Dietary #572 verified the water temperature gauge was clouded and difficult to read. 2. Observation [DATE] at 8:42 A.M. revealed the deep fryer oil was covered with debris. There were white/yellow flakes of food covering the oil. When the build up of debris floating on the oil was separated the oil appeared black. Interview at the time of the observation with Dietary #588 included the debris on the oil was tater tots. Dietary #588 said the oil turns black when they cook onion rings in the oil. Dietary #588 included maintenance cleans the oil every Friday. Review of the deep fryer cleaning log revealed the last time the oil was filtered was on [DATE]. The last time the deep fryer oil was changed was [DATE], over a month since the oil had been changed. Review of the Deep Fryer Cleaning log for 2024 revealed oil was changed twice in January and not filtered. The oil was changed twice in February and not filtered. In March the oil was filtered twice and changed once. In April the oil was filtered twice and changed once. In May the oil was changed twice and filtered once. In June the oil was changed once and filtered once. The oil was changed on [DATE] and not changed again until [DATE] going a month between change. Review of a [DATE] Procedure for Cleaning Deep Fryer included -Deep fryer is to be emptied and cleaned every other week, according to policy, with fresh fryer oil added after this cleaning. -Deep fryer oil is strained of debris weekly and fresh oil added as needed. Deep fryer should be kept clean by wiping it down as needed. Interview on [DATE] at 10:24 A.M. with Maintenance #556 revealed the oil was to be changed every other week and filtered on opposite weeks. He thought they only used the fryer on Friday but the deep fryer should be addressed weekly. Maintenance #556 said he gets to it when he can. When he is on vacation no one does anything. The deep fryer oil waits for him. Maintenance #556 verified the oil was not changed or filtered weekly. 3. Observation of the walk-in refrigerator [DATE] at 8:51 A.M. with Dietary #588 revealed macaroni salad made on [DATE] was to be discarded on [DATE] was still stored in the refrigerator. Review of the facilities Leftover Food policy dated [DATE] included foods may be stored up to seven days for reserving and then discarded. Dietary #588 verified at the time of the observation the macaroni was not discarded on [DATE] per policy. 4. Observation of the ice maker in the hall outside the kitchen [DATE] at 9:01 A.M. revealed the scoop was on top of a clear three drawer bin. The top of the plastic bin was soiled with brown. The top drawer had two silver metal scoops in it. There were visible hairs at the bottom of the drawer. The second and third drawers were empty, but had debris on the bottom. Interview with Dietary #588 at the time of the observation revealed the scoop holder broke. The one she ordered was not the correct size and she ordered another. She verified the ice scoop was on the soiled top of the bin. was not contained to keep it clean.

Based on observation, interview and policy review, the facility failed to ensure resident dignity was maintained during use of indwelling urinary catheters for three residents (#6, #12, and #22) and when dining for five residents (#3, #19, #21, #44 and #46). This affected eight residents (#3, #6, #12, #19, #21, #22, #44, and #46). The census was 51. Findings include: 1. Review of Resident #12's medical record revealed a 10/16/19 admission with diagnoses including Parkinson disease, end stage renal disease, Tourette's disorder, schizoaffective disorder, rheumatoid arthritis, neuromuscular dysfunction of bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and moderate intellectual disability. Review of the 06/26/24 quarterly Minimum Data Set Assessment (MDS) included the resident was moderately impaired for daily decision making, had an indwelling catheter and upper and lower extremity impairment on both sides. Observation on 08/05/24 at 1:12 P.M. revealed the resident had a urinary drainage bag hanging on the side of the bed facing the door. [NAME] urine was visible in the bag and tubing. Interview on 08/06/24 at 10:28 A.M. with Registered Nurses #522 and #528 verified Resident #12's urinary drainage bag was not in a protective cover and was visible to other residents and visitors. 2. Review of Resident #22's medical record revealed a 03/09/24 admission with diagnoses including encounter for fitting and adjustment of urinary device, pressure ulcer of right lower back, encounter for palliative care, retention of urine, cerebral infarction, dementia, osteomyelitis of vertebra, need for assistance with personal care, and anxiety. Review of a Significant Change MDS dated [DATE] for initiation of hospice care included the resident was severely impaired for daily decision making, dependent for personal hygiene, dependent on rolling in bed, had bilateral lower leg functional impairment, and had a Stage IV pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location). Observation on 08/05/24 at 11:20 A.M. revealed the resident had an indwelling catheter bag hanging on the side of the bed facing the door. The clear amber urine was visible in the tubing and bag. It was not covered for privacy and to maintain dignity, visible to anyone when they walked through the door to the room. Interview on 08/06/24 at 10:41 A.M. with Registered Nurses #522 and #528 verified Resident #22's urinary catheter tubing and bag was not covered and was visible to other residents and visitors. 3. Review of Resident #6's medical record revealed an admission on 05/11/23 with diagnoses including flaccid neuropathic bladder, retention of urine, history of urinary tract infections, and urinary incontinence. Review of the 07/21/24 Quarterly MDS revealed the resident was moderately impaired for daily decision making, functional impairment in both lower extremities, used a walker and a wheelchair, dependent for rolling left to right, and lying to sitting, has an indwelling catheter, at risk for pressure ulcer and has one vascular ulcer and had highly impaired hearing with the use of a hearing aide. Observation on 08/05/24 at 11:49 A.M. revealed the resident was in a low bed, with a mat to left side of bed on the floor. A television on and utilized a custom wheelchair. She had an indwelling urinary catheter with the bag hanging on the side of the bed. The catheter bag not covered, there was white sediment in the tubing and bag. Interview on 08/06/24 at 10:28 A.M. with Registered Nurses #522 and #528 verified Resident #6's catheter and tubing was not in a protective covering and did not provide dignity to the resident as it was visible to others. 28704 4. On 08/05/24 at 11:27 A.M., State tested Nurse Aide (STNA) #105 and STNA #108 were observed applying cloth clothing protectors to Resident #3, #19, #21, #44 and #46 without asking if the residents' wanted to wear one. On 08/07/24 between 7:22 A.M. and 8:50 A.M., observations of the secured unit morning meal revealed State tested Nurse Aide (STNA) #244 was putting clothing protectors on residents including Resident #21, #40 and #44. The cloth clothing protectors extended from the neck to the resident's lap and attached around the neck with velcro. STNA #244 did not ask the residents if they preferred to wear a clothing protector or not. At 8:10 A.M., the breakfast tray cart arrived and STNA #108 and #244 began distributing the meal trays to residents. The breakfast meal was served on orange cafeteria-style serving tray and the dishes remained on the serving trays during the course of the meal. STNA #108 and STNA #244 were observed during the meal intermittently having personal conversations between each other about what they were going to be doing later including shopping and selling personal property. The residents were not involved in the above conversations. During the course of the meal, STNA #244 was also observed standing while assisting and/or feeding Resident #21 and #44 during the meal. On 08/07/24 at 8:50 A.M., interview with STNA #244 verified the above. On 08/12/24 at 2:45 P.M., interview with the Director of Nursing verified residents were to be offered the choice to wear a clothing protector. Review of the policy: Quality of Life-Dignity (revised January 2024) included demeaning practices and standards of care that compromise dignity were prohibited. Staff shall promote dignity including to assist residents as needed by helping the resident to keep urinary catheter bags covered.

Based on medical record review and interview, the facility failed to ensure comprehensive care plans were revised. This affected four residents (#15, #21, #44 and #46) of 18 residents sampled. The census was 51. Findings include: 1. Medical record review revealed Resident #46 was admitted on [DATE] with diagnoses including non-Alzheimer's type dementia, anxiety, breast cancer and arthritis. Review of the care plan: No Nutritional Triggers at present dated 03/05/24 revealed interventions included to honor preferences, provide diet as ordered, record intakes every meal and weight per policy. The physician was to be notified of a significant weight change. The care plan had not been revised to reflect the resident's weight loss. Review of the Weight Change Note dated 07/30/24 revealed Dietitian #532 notified Resident #46's physician of a 13 pound (#) (12.1%) weight loss in a month; 18.2# (16.2%) weight loss in three months and a 16.6# (15%) weight loss in five months. Current weight was 94# with a BMI of 18.4 indicating borderline underweight. Resident meal intakes was fair, weight loss noted, receiving 60 ml nutritional supplements twice a day (since 07/09/24) and new order to start mighty shakes three times a day. Review of the note revealed no evidence the dietitian was notified of the restraint use or psychotropic medications. There was no evidence the Nutritional Triggers care plan had been revised regarding Resident #46's weight loss or implementation of supplements. On 08/12/24 at 11:09 A.M., interview with the Director of Nursing (DON) verified Resident #46's nutrition care plan was not revised. 2. Medical record review revealed Resident #21 was admitted on [DATE] with diagnoses including cataracts, glaucoma or macular degeneration, non-traumatic brain dysfunction, Alzheimer's disease, hypertension, pneumonia, thyroid disorder, arthritis, hip fracture and psychotic disorder. Review of the annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #21 was rarely/never understood, unclear speech, severely impaired for daily decision-making, had moderate difficulty hearing with no hearing aid and adequate vision with corrective lenses. Activities daily preferences discussed with family and assessed not to be important to have books, newspapers and magazines or keep up with news. Very important to listen to music she likes, be around animals, doing things with groups of people, fresh air when weather is good and to do your favorite activities. The resident was receiving hospice services and had less than six months life expectancy. On 08/06/24 at 2:23 P.M., observation revealed staff turned television (TV) on for Resident #21 to watch the Olympics. The resident was not wearing any glasses. Review of the Resident Participation Sheet for Daily Programs and Independent Activities dated June, July, August 2024 revealed Resident #21 participated in activities including exercise/groups, religious, manicures, mail, music, pets, visitors, arts/crafts, games, party, current events, reads/writes, walks/wheels, listens/watches TV, and visits others. Review of the care plan: Preferred social programs and activities dated 11/02/2020 revealed Resident #21's preferred activities included socials, parties picnics, holiday gatherings, musical programs, large games such as Yahtzee-bowling, volleyball-noodle exercise-tossing & batting games, group discussions, relaxing/napping, having snacks in between her meals, outdoor programs with supervision and assistance as needed and weather permitting, reminiscing groups, pet visits-especially dogs, children visits, and bird watching from her window or patio during her stay here at this facility. One activity goal included independent activities of choice such as: bird watching out her window or on the patio, likes to people watch, Television viewing-on occasion, independent prayer-Methodist by faith, napping/relaxing, having snacks in between her meals-chocolate-cheese balls, beauty shop visits-as needed or interested, manicures, reading her mail that she gets often, and listening to the radio and television in the common areas during her stay here at this facility. Review of the interventions revealed no revisions had been made since 11/02/24. On 08/12/24 at 3:35 P.M., interview with the DON verified Resident #21's activity care plan had not been revised since 2020 including being admitted to hospice services and her glasses have been missing for an unknown amount of time since at least May 2024. 3. Medical record review revealed Resident #44 was admitted on [DATE] with diagnoses including diabetes mellitus, muscular dystrophy, dementia, vitamin D deficiency and hypothyroidism. Review of the Weights revealed Resident #44 weighed 151# on 11/30/23 and the resident's weight was 129.2# on 07/25/24 indicating a weight loss of 14.4%. Review of the quarterly Nutritional Sheet dated dated 04/23/24 revealed Resident #44 had a decreased appetite. Mighty shakes are provided three times a day at meals and accepted well. The resident had a 12#/8.2% weight loss within two months since 02/20/24. Review of the Quarterly Nutrition Note dated 07/16/24 revealed Resident #44 had a 16.2#/11% weight loss within six months. Review of the electronic Physician Orders dated August 2024 revealed a nutritional supplement 60 milliliters twice a day was started on 07/02/24. Review of the Task List dated March 2024 revealed mighty shakes three times a day was administered starting 03/26/24. Review of Resident #44's care plan: Leaves greater than 25% of meals dated 10/27/23 revealed no evidence it had been revised to reflect the resident's significant weight loss or interventions implemented. On 08/14/24 at 10:13 A.M., interview with the DON verified the nutrition care plan was not revised to reflect the resident's significant weight loss or interventions implemented. 26706 4. Review of Resident #15's medical record revealed an admission on 10/26/23 with diagnoses including age related debility, herpes viral infection, need for assistance with personal care, mixed incontinence, muscle weakness, Alzheimer's disease, congenital hiatal hernia, disorder of the kidney an ureters, history of urinary tract infections, dementia, repeated falls, anorexia, hyperlipidemia, hypothyroidism, depression, difficulty walking, and gastroesophageal reflux disease. Admission orders included Macrobid Oral Capsule 100 milligrams (mg) daily for personal history of urinary tract infections. A 11/04/23 Bladder and Bowel Incontinence plan of care related to activity intolerance, Alzheimer's, dementia, chronic history of urinary tract infection, impaired mobility, inability to communicate needs, and loss of peritoneal tone. On Macrobid therapy for chronic urinary tract infections. Pharmacist review in November 2023 included a recommendation to change Macrodantin to Trimethroprim due to poor renal function. Trimethroprim Oral Tablet 100 mg was ordered 11/17/23 and the Macrobid was discontinued. The 11/04/23 Bowel and Bladder plan of care identified Macrobid as the current antibiotic used for chronic urinary tract infections. Review of the 07/31/24 Quarterly Minimum Data Set Assessment included the resident was severely impaired for daily decision making, received antidepressants and antibiotics, always incontinent of urine and was frequently incontinent of stool. Interview on 08/14/24 at 11:37 A.M. with the Director of Nursing verified the care plan still has Macrobid as the long term antibiotic when it was changed in November 2023 to Trimethroprim.

Based on observation, test tray, and interview, the facility failed to ensure food was pureed to the correct consistency. This affected four residents (#14, #17, #22 and #23) who receive a pureed diet. The facility census was 51. Findings include: Observation of the pureed process took place on 08/07/24 at 4:31 P.M. with Dietary #570. Dietary #570 pureed barbeque chicken, rice pilaf and mixed vegetables following the recipe and under sanitary conditions. After pureeing each food type she placed them in plastic containers, covered each with foil and placed them on the steam table to serve for the supper meal. Dietary #570 did not taste the chicken, rice or vegetables for texture after they were pureed. On 08/07/24 at 4:45 P.M. the surveyor completed a test tray. The chicken was tasted for consistency. It was fibrous and not pureed to a creamy consistency. The rice was smooth and the correct consistency. When the vegetables were tasted, there was visible bits of green and orange vegetables. It was visible the vegetables were not fully blended. To taste, the vegetables were in pieces, lumpy, not a smooth consistency. Dietary #570 verified at the time of the tasting the chicken and vegetables were not pureed to a smooth consistency. Review of the facility Pureed Diet policy (reviewed 06/18/17) included those with swallowing difficulties require modified texture to reduce the risk of aspiration or choking. The use of a pureed diet may reduce this risk and improve a resident's ability to consume adequate nutrition. Pureed food should be smooth and lump free, and served at a pudding or mashed potato consistency. Pureed soups and other liquids may be served thin if the resident does not require thickened liquids.

Based on observation, medical record review, missing item log review, policy review and interview, the facility failed to ensure visual appliances i.e. eyeglasses were readily available for resident use. This affected one resident (#21) of two resident reviewed for communication-sensory. The census was 51. Findings include: Medical record review revealed Resident #21 was admitted on [DATE] with diagnoses including cataracts, glaucoma or macular degeneration, non-traumatic brain dysfunction and Alzheimer's disease. Review of the care plan: Communication Problem dated 10/26/20 revealed Resident #21 vision was adequate as she will name things across the room, has glasses that she chooses not to wear at all times but staff was to encourage her to wear her glasses. Review of the Eye Care evaluation dated 01/17/24 revealed resident with severe cataracts, hyperopia and presbyopia (refractive errors that cause blurry close-up vision) in both eyes. Resident declined new prescription glasses and spectacle prescription for right and left eye was provided. Review of the annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #21 was severely impaired for daily decision-making and had adequate vision with corrective lenses. Review of the Missing Item Log dated 2024 revealed no evidence Resident #21's glasses were broken or missing. Resident #21 was observed not wearing eyeglasses on 08/05/24 at 9:09 A.M. and 3:56 P.M., on 08/06/24 at 1:53 P.M., on 08/06/24 at 2:23 P.M., on 08/06/24 at 2:43 P.M., on 08/07/24 at 7:00 A.M., and on 08/08/24 at 8:48 A.M On 08/08/24 at 8:48 A.M., observed Resident #21 up in wheelchair and she was not wearing glasses. Interview with Activities Director #594 at the time of the observation stated Resident #21 had a pair of glasses; but they broke during a fall and had not had a pair since. Activity Director #594 verified the resident activities included watching television and reading. Observation with Activity Director #594 of Resident #21's room revealed no evidence of a pair of prescription glasses. Activity Director #594 verified the resident liked to read but she did not know if she could read without her glasses. Picture books and novels were observed readily available in the resident's room and there was no evidence of a prescription pair of eyeglasses. Activity Director #594 found a pair of unlabeled, non-prescription reader glasses at the nursing station and placed them on the resident. On 08/08/24 at 8:50 A.M., interview with State tested Nurse Aide #112 stated she was unaware of any prescription glasses for Resident #21. On 08/08/24 at 9:55 A.M. and 10:05 A.M., interview with the Director of Nursing (DON) states the resident was seen by the eye doctor in January 2024 and did not need a new prescription pair of glasses but was not aware that the resident's glasses were missing or she would have called for a replacement. The DON stated the resident's glasses must have been lost between 05/22/24 and 08/08/24 because she had them at the time of the comprehensive assessment. The DON verified the vision assessment did indicate prescription glasses were needed for Resident #21. Review of the policy: Ancillary Services (dated January 2024) revealed facility will offer ancillary services including ophthalmology and residents/family can decline an utilize personal choices for these services. Dental will make visits schedules annually or by treatment plan as written. Ophthalmology will make visit schedules annually or by treatment plan as written. If resident presents with any emergency type needs, the emergency services department for ancillary services, as listed above will be contacted to make appointment for visit.

Based on observation, medical record review, policy review and interview, the facility failed to ensure accommodations of resident needs was met when call lights were not readily accessible to residents. This affected one resident (#26) of two residents reviewed for communication-sensory. The facility identified two residents being blind (#3, #26). In addition, based on observation, medical record review, policy review and interview, the facility failed to provide residents with appropriate table heights on the secured unit during meals. This affected one resident(#21) of 14 residents on the secured unit. The census was 51. Findings include: 1. Medical record review revealed Resident #26 was admitted on [DATE] with diagnoses including diabetes mellitus, unspecified macular degeneration and need for assistance with personal care. Review of the care plan: Highly Impaired Visual Function related to Macular Degeneration revised 04/22/24 revealed interventions including to arrange room and things in order to promote independence. Review of the care plan: Communication Problem dated 04/01/24 revealed Resident #26's call light was to be within reach to ensure/provide a safe environment. On 08/05/24 at 8:46 A.M., observation during initial tour revealed Resident #26 was in her room sitting in a wheelchair. The wheelchair was positioned near the door leading to the hallway. Resident #26 stated she had macular degeneration, was unable to see anything and asked the surveyor if she could find her call light and give it to her. The call light was observed looped over the bedside table positioned across the room next to the window. At the time of the observation, the surveyor stepped into the hallway and State tested Nurse Aide #114 was informed of the resident's request. STNA #114 verified Resident #26's call light was not within reach and she used her call light to alert staff that she needed help. Review of the policy: Quality of Life - Dignity (revised January 2024) revealed staff was to keep the resident informed and oriented to their environment. 2. Medical record review revealed Resident #21 was admitted on [DATE] with diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, and history of pneumonia. On 08/05/24 at 12:01 P.M., observation revealed State tested Nurse Aide (STNA) #105 and #108 distributed the lunch meals to residents on the secured unit. After distribution, STNA #108 sat at one of the dining room tables to assist Resident #21 and Resident #46 who were both seated in specialty tilt wheelchairs. The table height reached Resident #21's chin and this remained throughout the meal. STNA #108 was cueing Resident #21 to eat as the wheelchair was positioned low to the ground which positioned her at chin height with the table. STNA #105 and STNA #108 did not intervene or reposition either resident during the meal observation. On 08/07/24 at 8:07 A.M., Resident #21's breakfast was delivered and placed on the dining room table. The resident remained in a low wheelchair at the table, the food was covered and not within the resident's reach as she was positioned along the side of the table and not in front of the table with her legs under the table. STNA #112 and STNA #244 were observed in the dining room assisting residents but did not intervene or reposition Resident #21 to the front of the table with her legs under the table during the meal. On 08/07/24 at 8:50 A.M., interview with STNA #244 verified Resident #21 was not positioned at the table properly and stated if Resident #21 was positioned in front of the table, she grabs everything off the table and will spill or throw it. On 08/07/24 at 10:47 A.M., interview with the Director of Nursing verified residents should be upright, properly positioned and at an appropriate table height during meals. Review of the policy: Quality of Life - Dignity revised January 2024 revealed each resident shall be cared for in a manner that promotes and enhances quality of life. dignity, respect and individuality.

Based on observation, medical record review, policy review and interview, the facility failed to ensure resident information remained private. This affected one resident (#6) during a random observation. The census was 51. Findings include: Medical record review revealed Resident #6 was admitted on [DATE] with diagnoses including diabetes mellitus and depression. On 08/05/24 at 12:15 P.M., observation of the main nurses station revealed two medication carts behind the desk. One of the two medication carts computer screen was open revealing the electronic medical record for Resident #6. The screen included a picture of the resident, the resident's date of birth, physician name and medications. There was no staff observed at the nurses station. On 08/05/24 at 12:18 P.M., interview with Registered Nurse #528 verified the electronic medical record was visible and open exposing personal resident health information. This deficiency represents non-compliance investigated under Complaint Number OH00155816.

Based on observation, medical record review, policy review and interview, the facility failed to ensure residents were free from restraints. This affected two residents (#21 and #46) of three residents reviewed for restraints. The facility did not identify any residents having restraints. The census was 51. Findings include: 1. Medical record review revealed Resident #21 was admitted on [DATE] with diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, pneumonia, thyroid disorder, arthritis, hip fracture, psychotic disorder, and unsteadiness on feet. Review of the annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #21 was severely impaired for daily decision-making, and did not use restraints, chair alarms or a chair to prevent rising. Review of the Full Year Therapy Screen dated 2024 revealed on 02/27/24, 05/16/24 and 08/08/24 Resident #21 was dependent for wheelchair mobility and walking was not attempted due to medical condition/safety. Review of the electronic Physician Orders dated August 2024 revealed no orders for restraints or a chair alarm for Resident #21. Review of Resident #21's care plan: Impaired Self positioning and mobility revised 12/05/23 revealed the resident was unsteady on her feet, would not be able to get out of the recliner or tilt-in-space independently but had freedom of movement. The goal dated through 11/14/24 was for her not to experience any restriction of movement in her tilt-in-space wheelchair. Interventions included to ensure good body alignment, anticipate and meet needs, evaluate device use per protocol, observe resident response to/and effectiveness of positioning device with use, postural supports as ordered, and refer to therapy as needed. Observations on 08/05/24 at 9:09 A.M. and 11:50 A.M., on 08/06/24 at 2:23 P.M., on 08/07/24 at 7:00 A.M. and on 08/08/24 at 10:00 A.M., Resident #21 was seated in a reclined specialty wheelchair with the seat dropped with no leg rests. The resident's legs and feet were observed dangling in the air approximately 16 inches off the floor without any support. The resident was observed at times fidgeting, attempting to push against the wheelchair/furniture and in an attempt to sit upward and then would recline back against the backrest. An activated chair alarm was also observed attached to the back of the wheelchair on 08/05/24 and 08/06/24. Observation on 08/06/24 at 1:53 P.M. revealed Resident #21 was observed in a reclined, tilted specialty wheelchair with the back of the seat dropped and her knees bent toward her chest with no leg rests or support. On 08/06/24 at 1:55 P.M., interview with State tested Nurse Aide (STNA) #100 revealed Resident #21's wheelchair seat was lowered in the back to recline the resident to keep her legs elevated and feet off the floor. STNA #100 stated the resident was a high fall risk and when the wheelchair was in an upright position, the resident tries to self-propel and stand-up causing her to fall. STNA #100 verified the resident was unable to get out of the specialty chair when it was tilted. STNA #100 also verified chair alarms are used to alert staff of when residents at risk for falls are attempting to get up. The resident could not remove the sensor alarm and when the resident would raise up it would emit a sound. On 08/08/24 at 10:38 A.M., interview with the Director of Nursing (DON) verified the wheelchair seat should not be dropped to lower the resident to the point in which she cannot get up out of the chair or self propel as this would be considered a restraint. 2. Medical record review revealed Resident #46 was admitted on [DATE] from the community with diagnoses including non-Alzheimer's dementia, anxiety, major depressive disorder and diabetes mellitus type 2. Review of the Nursing Admission Evaluation dated 02/27/24 revealed Resident #46 required supervision with bed mobility, transfers, mobility and hygiene; had no balance concerns and was oriented to person and place. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #46 was severely impaired for daily decision-making, did not have functional limitations in range of motion, required partial/moderate assistance to perform sit to stand and walk 10 feet. Walking 50 feet with two turns and the ability to walk 150 feet was not attempted due to medical condition or safety concerns. Review of the Comprehensive Nursing Note 1.1 dated 07/18/24 indicated Resident #46 releases seatbelt frequently when in wheelchair but not observed at this time. Review of the Progress Note dated 07/09/24 revealed the resident had been severely unsteady on feet and gait, was unable to maintain a standing position independently and was sitting on couch and kept rolling body forward and unable to sit up independently. Cognition severely impaired causing resident to be unaware of safety precautions, unaware of need for assist, unable to use assuasive devices, and multiple falls in the past few days. Resident #46 attempts to ambulate; however, walks into walls, doors, and falling related to unsteady gait. Physician was notified and specialized tilt wheelchair with alarmed seatbelt was ordered. Resident was able to remove seatbelt and stood up from wheelchair; however, unsteady. Wheelchair and seat belt did not inhibit resident's self mobility, range of motion, able to propel self in wheelchair or sit up in chair. Review of the electronic Physician Orders dated 07/09/24 revealed a self-releasing seat belt while in wheelchair was ordered and on 08/06/24 a pressure sensitive alarm at all times except while in wheelchair was ordered. Review of the care plan: Potential for Complications related to Self-Releasing Seat Belt while in Wheelchair dated 07/09/24 revealed Resident #46 was able to release the seat belt on her own. Interventions included to ensure as needed that the resident was able to release the seatbelt on her own. Review of the care plan: Risk for falls revised 07/10/24 revealed pressure alarm at all times except in wheelchair to alert staff of self rising and as a gentle reminder to seek assistance. Review of the Occupational Therapy (OT) Discharge Summary dated 07/23/24 revealed goals met on 07/23/24 included the resident will demonstrate improved seating/positioning while in wheelchair indicating appropriate wheelchair fit with adequate supports and sufficient fall prevention measures. On 07/09/24 the resident was trialing a tilt/recline wheelchair with self-releasing seat belt secondary to falls, OT to address seating/positioning. At the time of OT discharge on 07/23/24 the resident can self release with cues or occasionally not needing cues. Observations on 08/05/24 at 9:09 A.M. and 11:45 A.M. revealed Resident #46 was sitting in a specialized wheelchair with a seat belt secured around the resident's waist. The chair was not observed at a 90 degree angle and a chair pressure alarm was observed attached to the back of the wheelchair. Resident #46 was observed trying to get out of chair by grasping table and placing feet with gripper socks on floor, twisting her body sideways and positioning her legs over the arm rest of the wheelchair. On 08/06/24 at 11:50 A.M., 1:53 P.M. and 2:23 P.M., and on 08/07/24 at 7:00 A.M., and 08/08/24 at 10:00 A.M., observations revealed Resident #46 would be fidgeting in the chair, attempting to push against the wheelchair/furniture in an attempt to sit upward and then would recline back against the backrest. An activated chair alarm was also observed attached to the back of the wheelchair on 08/05/24 and 08/06/24. On 08/07/24 at 6:31 P.M., interview with State tested Nurse Aide #102 verified Resident #21 and #46 cannot get out of their specialized wheelchairs by themselves when the wheelchairs are tilted/reclined. On 08/08/24 at 10:24 A.M., interview with Licensed Practical Nurse (LPN) #544 verified Resident #21's wheelchair seat should not be dropped to the point to where the resident's feet cannot touch the floor. At the time of the interview, LPN #544 was observing Resident #21 who was seated in the living area of the unit. LPN #544 stated the resident was capable to self-propel if her feet were on the floor and verified the resident appeared uncomfortable as the resident was lifting and extending her legs outward. LPN #544 verified the wheelchair seat being dropped kept her from self-propelling and getting out of the chair and that it would be considered a restraint. During the interview and observation of Resident #21, LPN #544 was observed walking over to STNA #112 and they positioned Resident #21's wheelchair to an upright position . At that time, Resident #21's feet were able to reach the floor and she was observed to be able to self-propel in the wheelchair. On 08/12/24 between 12:48 P.M. and 1:22 P.M., observation revealed Resident #46 ambulated 708 feet with a front wheeled walker with Physical Therapy Assistant (PTA) #700 and Certified Occupational Therapy Assistant (COTA) #701. Resident #46 was assisted back to her wheelchair for a rest period by PTA #700 who reattached the velcro alarming seatbelt. At 1:25 P.M., interview with PTA #700 stated the resident was able to release the seatbelt and it was requested that she ask Resident #46 if she could release the seatbelt. PTA #700 asked Resident #46 to release the velcro alarming seatbelt and the resident was unable to do so upon command three times. The surveyor asked the resident to release the seatbelt and the resident was unable to do so upon command three times. COTA #701 stated she could try and she asked Resident #46 to release the seatbelt and the resident was unable to release the seatbelt upon command. Interview with PTA #700 and COTA #701 at the time of the observation verified the resident was unable to release the alarming seatbelt upon command after seven requests and the velcro seat belt was restraining the resident at that time. On 08/12/24 at 2:45 P.M., interview with the DON verified Resident #21 and Resident #46's wheelchairs were considered restraints and Resident #46's inability to release the seat belt upon command was also a restraint. Review of the policy: Restraints (revised January 2024) revealed the resident had a right to be free from any physical or chemical restraint imposed for purposes of discipline and/or convenience. Restraints shall only be used as required to treat residents' medical symptoms. The purpose was to control movement to protect the resident in an emergency to permit medical treatment, control behavior to prevent the resident injuring himself or others and to improve the resident's mobility and independent function. Procedure included the decision to apply physical restraints was to be based on the assessment of each resident's capabilities and less restrictive alternatives were used whenever possible. The use of restraints will be justified through the care planning process and restraint enabler form. Restraints were to be removed at meal times and rest period as able to allow for restraint free time frames. The facility will provide the resident or resident's representative with appropriate information, obtain consent forms and a physician order. If the resident is able to remove the restraint independently it will not be considered a restraint rather a safety device. Review of the policy: Pressure Alarms (dated January 2024) revealed pressure alarms were used to alert staff of resident self-rising and as a gently reminder to have resident call for assistance. Procedures included to obtain an order, apply the pressure alarm as ordered i.e. while in bed, while in chair, at all times; replace pressure pad as directed by manufacturer guidelines, always test and check the battery before use, and battery checks every shift.

Based on observation, record review, policy and interview, the facility failed to ensure restorative services were initiated, assessed, reviewed and revised if needed. This affected three residents (#12, #21, and #46) of four residents reviewed for positioning, mobility and limited range of motion. Findings include: 1. Review of Resident #12's medical record revealed a 10/16/19 admission with diagnoses including Parkinson disease, end stage renal disease, Tourette's disorder, schizoaffective disorder, rheumatoid arthritis, neuromuscular dysfunction of bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and moderate intellectual disability. The resident had a plan of care initiated 04/28/22 for impaired self performance of bed mobility, Related to rheumatoid arthritis, Parkinson;s disease, age related osteoporosis, osteoarthritis, and dementia with behavioral disturbance. Interventions included 01/20/23 assistance with placement of soft palm guard to both hands at ALL times EXCEPT for meals & hygiene. Explain what you are going to do prior to program. Provide gentle passive range of motion (ROM) to upper extremity, after/before splint is removed/applied. Cleanse affected area of skin and dry thoroughly. Inspect skin for redness, irritation. Bed mobility program initiated 06/29/23 six to seven days per week at least 15 minutes per day, once a day. Prompt and assist to participate, once a day with two persons assist and frequent verbal cue for technique, encouragement, stay on task. Encourage resident to roll from one side of bed to the other reaching arm across to grab opposite side of bed for support. If program is initially refused, offer again at a later time that shift. Praise for efforts and success and provide encouragement through the entire program. Watch for fatigue and provide rest periods as needed. Active Assist ROM to bilateral upper extremities initiated 10/25/23. Do three sets, 10 reps daily, at least 15 minutes per day 6/7 days per week. Assist as needed and cue for proper technique and to stay on task. If program is initially refused, offer again at a later time that shift. Praise for efforts and success and provide encouragement through the entire program. Watch for fatigue and provide rest periods as needed. Active assist ROM to bilateral lower extremities initiated 06/13/24. Do three sets, 10 reps daily, at least 15 minutes per day six to seven days per week. Assist as needed and cue for proper technique and to stay on task. If program is initially refused, offer again at a later time that shift. Praise for efforts and success and provide encouragement through the entire program. Watch for fatigue and provide rest periods as needed. Review of the 06/26/24 quarterly Minimum Data Set Assessment (MDS) included the resident was moderately impaired for daily decision making, had an indwelling catheter and upper and lower extremity impairment on both sides. Observation on 08/05/24 at 1:12 P.M. revealed the resident was in bed with his eyes closed. Noted to have bilateral hand and wrist contractions without splints in place. Review of the aide TASK electronic documentation revealed the restorative programs were being signed off daily as completed with an occasional refusal. Review of restorative notes revealed the last note was 03/22/24. The restorative note included resident was current with restorative for bed mobility, range of motion extremities and bilateral palm guard placement. Transferred via Hoyer lift. Dependent with functional abilities and activities of daily living. Totally incontinent, able to feed self, dwelling catheter remains in place for abnormal muscular dysfunction of bladder. Goals are for patient to participate in care as able, not suffered decline in range of motion, and urinary tract infections. The restorative note did not address how the resident was tolerating and participating in the restorative programs. The note did not include whether the programs needed increased or decreased related to response. The note did not show the programs were being monitored to determine advancing as appropriate or decline. The facility was completing quarterly therapy screens and quarterly mobility screens but was not assessing each restorative program to determine continued appropriateness. Review of the restorative nursing services policy (reviewed 01/2024) included residents will receive nursing care as needed to help promote optimal, safety and independence. Restorative goals and objectives are individualized, resident centered and are outlined in the resident plan of care. The policy did not include conducting quarterly updates. Interview on 08/05/24 at 6:57 P.M. with Registered Nurse (RN) #522 verified the resident did not have palm guards on as ordered. She looked in the resident's room for the palm guards and found a left palm guard in the drawer and none for the right hand. Interview on 08/08/24 at 4:22 P.M. with Licensed Practical Nurse (LPN) #544 revealed she does not complete quarterly assessments of the restorative programs. Licensed Practical Nurse #544 included therapy screens and mobility assessments were competed to assess a decline in abilities. The restorative programs were not individually addressed. 28704 2. Medical record review revealed Resident #21 was admitted on [DATE] with diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, arthritis, hip fracture, psychotic disorder, and unsteadiness on feet. Review of the Restorative Nursing programs revealed the following: a. Active ROM (range of motion) to upper extremities dated 10/29/20 revealed to complete one set of 10 reps daily for 15 minutes at least six to seven days per week. b. Active ROM to lower extremities dated 06/06/23 revealed to complete one set of 20 reps daily for 15 minutes at least six to seven days per week. Review of the annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #21 was severely impaired for daily decision-making and had functional limitations of bilateral upper and lower extremities. Review of the electronic Task Documentation dated May, June and July 2024 revealed the restorative programs were provided for 15 minutes. There was no evidence in the medical record if cues were provided, if the resident was able to complete without rest periods, quarterly evaluations or evidence the program had been revised since the programs were initiated. Review of the care plan: At Risk for Impaired Functional ROM dated 10/29/2020 with goals to maintain or have no decline through 11/14/24. The programs written included Active ROM to bilateral upper and lower extremities once a day, one set of 10 repetitions for 15 minutes six to seven days a week with interventions included to reassess quarterly. 3. Medical record review revealed Resident #46 was admitted on [DATE] with diagnoses including non-Alzheimer's type dementia, anxiety and arthritis. Review of the Nursing Admission Evaluation dated 02/27/24 revealed the resident required supervision with bed mobility, transfers, mobility and personal hygiene. The resident had no balance concerns, was oriented to person and place, and continent of bowel and bladder. Review of the Physical Therapy (PT) Discharge Summary dated 03/27/24 revealed Resident #46 was discharged independent with transfer with no verbal cues, ambulating 350 feet independently using hand held assist on level surfaces and independent with bed mobility. Discharge recommendations included established/trained restorative programs for ambulation and transfers. The patient was currently able to walk in corridor, balance was steady and with restorative nursing program the patient will be able to walk in corridor with assist of none and balance stable by allowing her to take her time and encourage participation. The patient was currently able to perform stand pivot transfers with a restorative nursing program. The patient will be able to stand and pivot independently by performing the following restorative nursing interventions and document any change in abilities. Prognosis was good with consistent staff follow through. Outcome risks including lacks insight into condition and risk factors and PT/caregiver agreeable to PT plan of care and goals. Review of Licensed Practical Nurse (LPN) #544 Restorative Note dated 03/28/24 revealed Resident #46 was discharged from therapies as maximum potential was reached. The resident ambulates independently throughout the facility. Referred to restorative for ROM to extremities. There was no documentation as to why ambulation or transfer programs were not implemented as recommended. Review of the PT Discharge Summary dated 07/03/24 revealed Resident #46's baseline on 05/24/24 was 75 feet with partial/moderate assistance with ambulation, static standing was fair-/poor+, partial/moderate assistance to perform bed mobility with 50% verbal cues, and partial/moderate assistance with transfers. At the time of discharge on 07/03/24 the resident was ambulating 300 feet with supervision or touching assistance. Discharge Recommendations included restorative ambulation and transfer programs. Prognosis was good with consistent staff follow-through. Decline in mental, emotional or behavioral status in past three months and currently reports exhaustion. Review of the record revealed no evidence a restorative nursing ambulation or transfer program was written or implemented between 03/27/24 and 05/24/24 or between 07/03/24 and 08/07/24 as recommended by PT. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #46 was severely impaired for daily decision-making, required extensive assistance with transfers, bed mobility of two persons, and had no functional limitations of upper or lower extremities. The resident did not receive restorative ambulation or transfer programs and had received therapy between 05/24/24 and 07/03/24. Review of the care plan: Potential for Impaired ROM revised 03/28/24 revealed to complete active assist ROM to upper extremities and reassess quarterly and as needed. On 08/08/24 at 3:08 P.M., interview with LPN #544 stated she was the facility restorative nurse and recently found out that she was not completing restorative notes as required. LPN #544 verified she had not been evaluating the restorative programs, including Resident #21 and #46, for declines or improvements, the programs had not been changed or evaluated for effectiveness. On 08/08/24 at 5:21 P.M., reviewed the PT Discharge Summary dated 03/27/24 and 07/03/24 with LPN #544. LPN #544 stated when a resident was discharged from therapy services recommendations were reviewed, discussed and individualized to each resident as needed. LPN #544 stated Resident #46 was independent in ambulation, walked around everywhere and she felt the resident did not need a restorative program for ambulation or transfers; therefore, a program was not initiated as recommended. LPN #544 reviewed the record and verified there was no consistent staff follow through as recommended and no evidence as to when the resident started to decline in ambulation/mobility or transfers until a therapy screened the resident for a MDS assessment. LPN #544 also stated the resident was having behaviors and medication changes and that was the focus of her care. On 08/08/24 at 5:50 P.M., interview with the Director of Nursing (DON) and LPN #544 verified Resident #46 had declined twice in ambulation and transfers requiring physical therapy to restore her to her previous level of functioning. Once the resident had met maximum potential, therapy discharged the resident with recommendations for nursing restorative programs; however, the restorative therapy referral did not match what was written in the therapy discharge recommendations. The DON acknowledged therapy recommendations were made with no evidence of implementation and no documentation as to why the therapy recommendations were not implemented. On 08/12/24 between 12:48 P.M. and 1:22 P.M., observation revealed Resident #46 ambulated 708 feet with a front wheeled walker with Physical Therapy Assistant (PTA) #700 and Certified Occupational Therapy Assistant (COTA) #701. On 08/12/24 at 11:49 A.M., interview with LPN #544 verified Resident #46 had not received restorative ambulation and the record included a care plan to increased Assistance with an intervention for ambulation six to seven days but stated this was an auto-populated intervention and was not implemented or accurate. Review of the policy: Restorative Nursing Services (revised January 2024) revealed residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehab care. Restorative goals and objectives are individualized and resident-centered, and outlined in the plan of care.

Based on medical record review and interview, the facility failed to ensure residents were provided a written summary of the baseline care plan. This affected one resident (#106) of 18 residents reviewed for care planning. Findings include: During an interview on 08/05/24 at 9:51 A.M., Resident #106 stated she did not recall receiving a summary of her baseline care plan. Review of Resident #106's medical record revealed an admitted [DATE]. Diagnoses included muscle wasting and atrophy, hypokalemia, pain, age-related physical debility, hypothyroidism, cervical disc degeneration, right artificial knee joint, bilateral hearing loss, angina pectoris, depression, hypertension, hyperlipidemia, osteoarthritis, thyroid disorder, squamous cell carcinoma of skin, and anxiety disorder. Review of the baseline care plan dated 07/20/24 revealed there was an area at the bottom of the second page for a resident or representative to sign indicating they received a copy of the resident's medication list and a copy of the baseline care plan. Instead of a signature there was a note written to indicate the baseline care plan was reviewed verbally with Resident #106. On 08/06/24 at 3:00 P.M., during interview, Registered Nurse (RN) #522 verified the facility did not provide residents/responsible parties with written summaries of the baseline care plans.

Based on medical record review and interview, the facility failed to develop and implement care plans to maintain a resident's highest practicable well-being. This affected one resident (#46) of 18 residents reviewed for care plans. The census was 51. Findings include: Medical record review revealed Resident #46 was admitted on [DATE] with diagnoses including non-Alzheimer's type dementia, anxiety, breast cancer and arthritis. a. Review of the admission Fall Risk assessment dated [DATE] revealed Resident #46 was at moderate risk for falls. Further review revealed no evidence a care plan was developed between 03/04/24 and 06/05/24 to prevent falls. Review of the Nursing Notes dated 06/05/24 revealed Resident #46 had sustained a fall. This was the first documented fall for the resident. b. Review of the admitting History and Physical dated 02/06/24 and the electronic Diagnosis List revealed Resident #46 had health conditions/diagnoses including diabetes mellitus, breast cancer, arthritis, constipation and hypertension. Review of the electronic Physician Orders dated August 2024 revealed as needed (PRN) medications included dulcolax suppository 10 milligrams (mg) PRN for constipation, milk of magnesia 2400 mg per 30 milliliters PRN for constipation, fleets enema PRN for constipation, and extra strength Tylenol 500 (mg) PRN for pain. Review of the medical record revealed no comprehensive care plan had been developed related to diabetes mellitus (DM), pain, constipation or hypertension (HTN). c. Review of the Physician Progress Notes dated 03/11/24 revealed nurse practitioner (NP) #601 evaluated Resident #46 due to increased anxiety and confusion. NP #601's impression was generalized anxiety disorder and dementia with behaviors and her plan included to start Exelon 4.6 milligrams every 24 hours topically for cognition. Review of the Health Status Note dated 03/11/24 revealed Resident #46's daughter informed the nurse that the resident had been on Rivastigmine previously, and it had a negative effect on Resident #46 including worsening behaviors. NP #601 was notified and ordered to discontinue the medication. Exelon was listed as an allergy at that time. Review of the electronic Physician Orders dated August 2024 revealed Resident #46 was allergic to Exelon. There was no comprehensive care plan developed for the known allergy to Exelon. On 08/14/24 at 2:37 P.M., interview with Licensed Practical Nurse (LPN) #544 verified care plans had not been developed as indicated above for Resident #46 including falls, medication allergies, pain, HTN or DM. LPN #544 stated the constipation care plan was discontinued on 08/13/24 after pharmacy recommendations to discontinue even though additional PRN orders to treat constipation were in place. LPN #544 stated she does not develop a care plan unless the resident is receiving a medication, even if they have a medical diagnosis of the condition.

Based on observation, medical record review, policy review and interview, the facility failed to ensure proper positioning of residents during meals on the secured unit. This affected three residents ( #21, #25 and #46) of 14 residents on the secured unit. The census was 51. Findings include Medical record review revealed Resident #46 was admitted on [DATE] with diagnoses including non-Alzheimer's type dementia. Medical record review revealed Resident #21 was admitted on [DATE] with diagnoses including non-traumatic brain dysfunction, Alzheimer's disease and history of pneumonia. Medical record review revealed Resident #25 was admitted on [DATE] with diagnoses including non-traumatic brain dysfunction and non-Alzheimer's type dementia. Observations of meal service on the secured unit revealed the following: a. On 08/05/24 at 12:01 P.M., observation revealed State tested Nurse Aide (STNA) #105 and #108 distributed the lunch meals to residents on the secured unit. After distribution, STNA #108 sat at one of the dining room tables to assist Resident #21 and Resident #46 who were both seated in specialty tilt wheelchairs at 60 degree to 75 degree angles at the table. The table height reached Resident #21's chin and this remained throughout the meal. Resident #46 was being fed by STNA #108 who was also cueing Resident #21 to eat. Resident #21's wheelchair was positioned low to the ground which positioned her at chin height with the table. STNA #105 and STNA #108 did not intervene or reposition either resident during the meal observation. b. On 08/07/24 at 7:00 A.M., Resident #21 was observed sitting in a low wheelchair and the seat was in the dropped positioned. A chair alarm was attached to the wheelchair and the resident's feet and legs were dangling straight down from the edge of the seat due to there were no leg rests attached to the wheelchair. c. On 08/07/24 at 8:07 A.M., Resident #21's breakfast was delivered and placed on the dining room table. The resident remained in a low wheelchair at the table, the food was covered and not within the resident's reach as she was positioned along the side of the table and not in front of the table with her legs under the table. STNA #112 and STNA #244 were observed in the dining room assisting residents but did not intervene or reposition Resident #21 to the front of the table with her legs under the table during the meal. On 08/07/24 at 8:50 A.M., interview with STNA #244 verified Resident #21 was not positioned at the table properly and stated if Resident #21 was positioned in front of the table in her wheelchair, she would grab everything off the table and will spill or throw it. On 08/07/24 at 10:47 A.M., interview with the Director of Nursing verified residents should be upright, properly positioned and at an appropriate table height during meals. On 08/08/24 at 8:24 A.M., observation revealed Resident #25 was in the dining room in a specialty wheelchair in a semi-reclined position and was being fed by STNA #112. Review of the policy: Quality of Life - Dignity (revised January 2024) revealed each resident shall be cared for in a manner that promotes and enhances quality of life. dignity, respect and individuality.

Based on observation, record review, policy review, and interview, the facility failed to ensure dependent residents received nail and oral care. This affected two residents (#22 and #49) of two residents reviewed for activities of daily living. Findings include: 1. Review of Resident #22's medical record revealed a 03/09/24 admission with diagnoses including encounter for fitting and adjustment of urinary device, pressure ulcer of right lower back, encounter for palliative care, retention of urine, cerebral infarction, dementia, osteomyelitis of vertebra, need for assistance with personal care, and anxiety. Review of a Significant Change Minimum Data Set (MDS) dated [DATE] for initiation of hospice care included the resident was severely impaired for daily decision making, dependent for personal hygiene, dependent on rolling in bed, had bilateral lower leg functional impairment, and had a Stage IV pressure ulcer (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location). Review revealed a physician order 06/20/24 included inspect nails weekly and trim as needed, every dayshift. Observation on 08/05/24 at 11:20 A.M. revealed the resident was in bed, had fingernails bilaterally with debris embedded under the nails. Observation on 08/06/24 at 8:56 A.M. revealed the resident was in bed on her left side. Her fingernails on both hands were long with dirt under the nail beds. All the fingernails on the left hand including the thumb and two fingers on right hand had brown debris under the nail beds. Several of the nails were long. Review of the nail care policy reviewed 01/2024 included it must be performed and document. Review of TASK in the electronic aide documentation included a task since 03/09/23 was to inspect nails weekly and trim as needed. Review of the last 30 days included the aides were documenting yes daily that they were inspecting nails and trimming. However, the nails were not trimmed and clean. The resident was also under hospice care. The resident received aide services five days a week. Review of the aide documentation last submitted to the facility 07/31/24 included nail care was part of the routine duties. Interview on 08/06/24 at 6:24 P.M. with Registered Nurse #522 verified the resident's fingernails had embedded debris under them. Further verified, there was an odor noted when her hands were opened up for inspection. 2. Review of Resident #49's medical record revealed a 06/19/24 admission with diagnoses including protein calorie malnutrition, cognitive communication deficit, delusional disorders, tremor, edema, need for assistance with personal care, lack of coordination and anxiety. Physician orders 06/19/24 included to inspect nails weekly and trim as needed every dayshift. Review of the Admission 06/26/24 MDS included the resident was moderately impaired for daily decision making, moderate assist for personal hygiene, set up for oral hygiene, was on antipsychotic, anti-anxiety, antidepressant, and anti-platelet. Plans of care plan included a 06/26/24 plan for deficit in functional abilities/completing activities of daily living related to balance/mobility/range of motion impairments. Impaired cognition/confusion/poor decision making, Needs substantial/maximum assist with toileting hygiene. Needs partial/moderate assist with showers, dressing, personal hygiene, sit-stand, chair/tub/toilet transfers, and ambulating. Needs touching/supervision to roll left-right, sit-lying, lying-sit, and propel self in wheelchair. Needs set up/clean up with toileting hygiene. Observation on 08/05/24 at 11:02 A.M. revealed the resident was in a low bed, floor mat to left of bed, she said her mouth was dry, water on overbed table out of reach, bruising noted to right hand, and left thumb nail was dirty. Observation on 08/06/24 at 8:48 A.M. revealed the resident was in a low bed, call bell in reach, and mat to floor. The resident's fingernails on her right hand had debris under the nail beds. Her teeth had white around the gums and between teeth. Interview on 08/06/24 at 5:18 P.M. with State tested Nurse Aide (STNA) #202 included she had been taking care of the resident since 6:00 A.M. She revealed they gave her a bed bath this morning ad changed her. When asked about the resident's teeth and fingernails, STNA #202 stated she did not brush the resident's teeth this morning or provide nail care. She verified there was debris under the nails of the resident's right hand.

Based on observation, medical record review, and interview, the facility failed to implement physician orders for tubigrips (tubular bandages that provide light to moderate compression) to address edema. This affected one resident (#27) of 24 residents screened for edema (swelling). Findings include: Review of Resident #27's medical record revealed diagnoses including edema, hypertension, and type two diabetes mellitus. Resident #27 had a physician order dated 04/12/24 to apply tubigrips to both legs to be worn at all times except during hygiene as tolerated. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 was cognitively intact. Documentation on the electronic task bar indicated Resident #27 had tubigrips worn on 08/05/24 at 5:59 A.M. and refused on 08/05/24 at 9:47 A.M. Observation of Resident #27 on 08/05/24 at 3:35 P.M. revealed both of Resident #27's feet were swollen. Resident #27 stated she used to wear compression stockings but did not know where they were. Resident #27 had no compression stockings or tubigrips on. Resident #27 stated she elevated her feet at night while sitting in the recliner. A subsequent observation on 08/06/24 at 9:20 A.M. revealed Resident #27's feet remained swollen. No tubigrips were observed. On 08/06/24 at 9:40 A.M., State tested Nursing Assistant (STNA) #200 entered Resident #27's room asking if she could put the things on her legs. STNA #200 exited Resident #27's room in less than one minute and verified she had been unable to locate any tubi-grips in Resident #27's room. STNA #200 stated sometimes tubigrips were not returned from laundry. STNA #200 stated she would go to the nursing station because there were always tubigrips there. On 08/07/24 at 9:45 A.M., STNA #200 was interviewed regarding documentation of Resident #27 refusing tubigrips on 08/05/24 as she had not been observed providing care on Resident #27's unit that day. STNA #200 verified she was not working on Resident #27's unit on 08/05/24 and she did not offer to apply her tubigrips that day. STNA #200 stated she had a good relationship with Resident #27 and could generally get her to do whatever she requested.

Based on observation, record review and interview, the facility failed to ensure pressure relieving measures were in place as ordered. This affected one resident (#34) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #34's medical record revealed a 06/27/24 admission with diagnoses including pressure induced deep tissue damage of sacral region, systemic lupus erythematosus, age related osteoporosis with current pathological fracture, urinary incontinence, fracture of neck of right femur, joint replacement surgery, anemia, type 2 diabetes with polyneuropathy,, hyperglycemia,, vitamin D deficiency, depression, paroxysmal vertigo of right ear, hypertension, atrial fibrillation, peripheral vascular disease, panlobular emphysema, gastroesophageal reflux disease, duodenal ulcer, constipation, lack of coordination, repeated falls, cognitive communication deficit, fracture of one right rib, need for assistance with personal care, artificial left hip joint and cerebral infarction. The resident had a fall on 07/10/24 with fracture of right hip. The resident was readmitted from the hospital 07/15/24 with a suspected deep tissue injury (SDTI) (Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister), pressure ulcer to the sacrum 5 centimeters (cm), x 7cm x unable to determine depth. The pressure ulcer plan of care included an intervention dated 07/19/24 to encourage to float heels while in bed. Review of the 07/22/24 five day MDS included the resident was independent for daily decision making, had no behaviors, risk of pressure ulcers, one unstageable pressure ulcer, surgical wound, pressure reducing bed and chair, turning and repositioning, needs partial assist of one for bathing, toileting, dressing, walking, and uses a walker and wheelchair. The resident had no upper extremity functional impairment, and had bilateral lower extremity functional impairment. The resident was dependent for rolling in bed, sit to lying, lying to sitting and dependent for sitting to standing. A 07/28/24 Health Status Note included the discovery of a SDTI to left heel 6cm x 5.5 cm purple/maroon in color. Area intact and slightly mushy. Some complaints of discomfort to the area when being assessed. A 08/01/24 left heel assessment included the pressure ulcer was 5.3 cm x 6 cm x unable to determine SDTI, blood blister. Observation on 08/05/24 at 1:31 P.M. revealed Registered Nurse (RN) #528 and State tested Nurse Aide (STNA) #104 were applying hand sanitizer leaving the residents room after putting her into bed. The surveyor entered the room as the staff was exiting. Resident #34 stated her left heel is killing her. The resident's left heel was not floating off a pillow. Resident #34's heel was resting on a pillow not floating off the pillow. The resident had slipper socks on. The resident was verbally prompted to reposition her foot. She was unable to move her foot enough to reposition. STNA #222 was in the hall and was alerted Resident #34 needed assistance. On 08/05/24 at 1:36 P.M. STNA #222 verified the resident's heel was resting on the pillow not floating off the pillow as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00155816.

Based on medical record review, observation, and interview, the facility failed to ensure the comprehensive assessments were accurate related to alarms, falls and psychotropic medications. This affected one resident (#46) of 18 residents reviewed for comprehensive assessments. The census was 51. Findings include: Medical record review revealed Resident #46 was admitted on [DATE] from the community with diagnoses including non-Alzheimer's dementia, anxiety, major depressive disorder and diabetes mellitus type 2. Review of the electronic Physician Orders dated July 2024 revealed resident was ordered a self-releasing seat belt and a pressure sensitive alarm at all times except while in wheelchair. The resident also received a PRN (as needed) Haldol (antipsychotic) 1 milligram on 07/04/24 for anxiety. a. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #46 was severely impaired for daily decision-making and sustained one fall with no injury . Review of the Fall Investigation dated 06/13/24 revealed Resident #46 had an unwitnessed fall on 06/13/24 resulting in an abrasion. b. Review of the quarterly MDS assessment dated [DATE] revealed Resident #46 sustained two or more falls with no injuries, used a bed alarm daily and no other alarms, and no restraints. Review of the Fall Investigations dated 07/06/24, 07/08/24, 07/10/24 and 07/17/24 revealed the resident had a total of five falls and two of the four falls resulted in an abrasion and a skin tear. On 08/05/24 at 9:05 A.M., observation revealed Resident #46 was in a specialty tilt in space wheelchair with an alarmed, self-releasing seat belt and a pressure sensitive alarm to wheelchair. c. Review of the quarterly MDS assessment dated [DATE] revealed Resident #46 received antipsychotic medications on a routine basis only. Review of the electronic Medication Administration Record dated July 2024 revealed the resident was administered PRN Haldol 1 milligram (mg) on 07/04/24 and began receiving Rexulti 0.5 mg on 07/11/24. On 08/12/24 at 12:39 P.M., interview with the Director of Nursing verified the above findings and MDS assessment errors.

Based on medical record review, family interview, staff interview, review of the facility's policy on visitation and review of a Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo ,d+[DATE], the facility failed to permit family visitation for one resident (Resident #26) who had a decline in her health status due to a Covid-19 infection and was near the end of her life. This resulted in Immediate Jeopardy on [DATE] when Resident #26's family had requested visitation with their mother who was experiencing a significant decline in her health status and her family was not permitted to visit. This resulted in the likelihood of serious psychosocial harm when Resident #26 expired on [DATE] without visitation from her family. This affected one (Resident #26) of three residents reviewed for Covid-19 infections. The facility identified seven other residents who had Covid-19 infections and had expired. The facility's census was 25. On [DATE] at 4:14 P.M., the Administrator, Director of Nursing (DON) and Registered Nurse (RN) #16 were notified Immediate Jeopardy began on [DATE] when Resident #26's family requested visitation with their mother who was experiencing a significant decline in her health status from a Covid-19 infection and the family was not permitted to visit. Resident #26 expired in the facility on [DATE] without visitation from her family. Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: · On [DATE] the facility updated their facility visitation policy to allow residents who were on transmission-based COVID-19 restrictions to receive in-person compassionate care visits with adherence to transmission-based precautions. · On [DATE] and [DATE] the facility's DON/ Designee reiterated to staff the need to spend as much time with residents who were in end of life care situations as they could to help provide comfort to resident. · On [DATE] and [DATE] the DON and/or designee (RN) educated all staff on the updated visitation policy. This included: 7 RN's, 3 Licensed Practical Nurses (LPN's), 15 nurse aides, 6 housekeepers, 7 dietary staff, 2 maintenance, 2 laundry, 1 Human Resource, 1 activity, 2 receptionists and 1 Admissions. · On [DATE] Designee (RN) called each resident family/POA and updated them on the updated visitation policy. · Beginning [DATE], each time the facility has a new Covid-19 positive resident the nurse who was assigned to the COVID unit will evaluate those residents for a decline in condition/ end of life to ensure family was notified and given the opportunity to visit. · On [DATE] the DON or designee will monitor all COVID-19 resident's medical record three (3) times a week for four (4) weeks to ensure that if there is a decline in condition families are afforded the opportunity to visit. After four (4) weeks have expired, auditing will continue as random audits per quarter until resolved through the QA committee. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility was in the process of completing additional staff training, conducting audits to ensure the effectiveness of the staff training and ensure the implementation of visitation policies that had been updated. Findings include: A review of Resident #26's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #26's Admission Record face sheet revealed the resident had one daughter who was her Power of Attorney (POA) for healthcare and listed as Emergency Contact #1. Resident #26 had another daughter, who was listed as Emergency Contact #2 and a son, who was listed as Emergency Contact #3. Resident #26's code status identified on the face sheet was a Do Not Resuscitate Comfort Care (DNR CC). A review of Resident #26's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely able to make herself understood and was rarely able to understand others. She had both short- and long-term memory impairments and her cognitive skills for daily decision making were severely impaired. A review of Resident #26's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order originated on [DATE]. The resident also received an order to receive [MEDICATION(S)] (anti-anxiety medication) 0.25 mg po every four hours prn for anxiety originating on [DATE]. A review of Resident #26's care plans revealed they were updated on [DATE] to reflect all her medications were discontinued except for comfort care medications. The care plan was also updated to reflect the new orders for [MEDICATION(S)], [MEDICATION(S)], and oxygen as needed (prn) for comfort. A review of Resident #26's nurses' progress notes revealed the resident was tested for Covid-19 on [DATE]. Her Covid-19 test results were received on [DATE] and the resident was noted to be positive for Covid-19. A nurse's progress note dated [DATE] at 1:18 P.M. revealed Resident #26's family was notified of a decline in her condition. She was noted not to have a gag reflex and was not swallowing. The nurse practitioner was notified and discontinued all her medications except for her comfort medications. [MEDICATION(S)], [MEDICATION(S)] and oxygen was ordered on a prn basis for comfort. The nurse's progress note indicated the family was made aware of all orders and wished for the resident to be kept comfortable. A nurse's progress note dated [DATE] at 1:56 A.M. revealed Resident #26 was noted to have shallow respirations and her oxygen saturation (amount of oxygen in her blood) was 88% (92% or above is within normal limits) on 3 liters of oxygen. A nurse's progress note dated [DATE] at 4:49 A.M. revealed Resident #26's respirations were slightly labored and at 28 respirations per minute (normal ,d+[DATE]). She was given [MEDICATION(S)] as ordered on a prn basis for shortness of breath (SOB). A nurse's progress note dated [DATE] 6:56 A.M. revealed Resident #26 was noted to have labored breathing. Again, [MEDICATION(S)] was administered on a prn basis for SOB. A nurses' progress note dated [DATE] at 6:57 A.M. revealed Resident #26 was noted to have had increased anxiety. [MEDICATION(S)] was administered as ordered on a prn basis. A nurse's progress note dated [DATE] at 5:50 P.M. revealed Resident #26 had shallow breathing with 10 second periods of apnea (cessation of breathing). Her breathing was labored, and she did not have any intake or output that shift. Her family was indicated to be at her window. A nurse's progress note dated [DATE] at 3:07 A.M. revealed Resident #26's condition was poor. Her respirations remained shallow and she had periods of apnea [MEDICATION(S)] 3 seconds. The nurse was unable to palpate a radial pulse (pulse palpable at the wrist), her feet were cool to touch, her oxygen saturation (normally obtained by placing a pulse oximeter probe on her finger) was unobtainable and her face was flushed. Her daughter remained outside near her window. A nurse's progress note dated [DATE] at 6:30 A.M. revealed the resident's physician was notified her order for [MEDICATION(S)] was not helping with her labored breathing. The physician increased her dose from 5 mg po/ sublingual (SL) every hour prn to 10 mg po/ SL every hour prn. Her daughter was indicated to be present outside her window and was made aware. A nurse's progress note dated [DATE] at 9:24 A.M. revealed Resident #26 continued to decline. Mottling (blotchy, red-purplish marbling of the skin most frequently occurring on the feet then travels up the legs common before death and usually occurred during the final week of life) was noted to her bilateral legs. She continued to have labored, rapid breathing. A nurse's progress note dated [DATE] at 10:22 A.M. revealed Resident #26's nurse practitioner was notified the resident continued to have labored breathing and increased respirations. New orders were received to increase her [MEDICATION(S)] to 20 mg po/ SL every hour prn. Her daughter remained present at the window and was made aware. A nurse's progress note dated [DATE] at 12:35 P.M. revealed Resident #26 passed away at 12:00 P.M. with a nurse at her bedside. Her family was present at the window at the time of her death. The nurses' progress notes did not provide any evidence of the resident's family being afforded the opportunity to visit in person with the resident at her bedside when she was nearing the end of her life or when she passed. On [DATE] at 11:18 A.M., a phone interview with one of Resident #26's daughters revealed she visited the resident several times after her mother contracted the Covid-19 virus while in the facility. She denied she was permitted to visit the resident at her bedside and stated visits were only permitted through the window from the outside. She reported she received a call from the facility on [DATE] informing her the resident took a turn for the worse on that day. She indicated she returned to the facility the next day, which was a Tuesday, and stayed until the resident passed away on the following day, which was a Wednesday ([DATE]), around noon. She confirmed other family members were there as well and included her sister, her brother-in-law, and her brother. She stated she got upset on Wednesday ([DATE]) around 4:00 A.M. when her mother began shaking and no one was with her at the time. It was like she was having mini convulsions. They had to get the nurse's attention through the window before the nurse contacted the physician to get a new order. She stated the family wanted to be in there with her but were not permitted to do so. Her sister called the DON but was told they only had three people working the Covid unit and they were doing the best they could. They then requested to speak with the facility's Administrator but was told he was not there. He came to the facility about a half hour later and the family informed him that it was not acceptable that no one was there holding their mother's hand. She stated the Administrator then allowed a nurse to sit with their mother to be able to hold her hand. She passed away 40 minutes later. The daughter indicated the family had asked several times if they could visit in person with their mother but was told since she had Covid-19 the facility staff could not permit the visits. She indicated there would have been ample time for them to visit with her after she took a turn for the worse knowing the risk associated with their visits and the need to wear personal protective equipment. She just took turns standing at the window with her sister instead and stated it was cold outside. They took turns warming up in their cars while the other stood at the window to watch over her. She reported her mother was very anxious when no one was sitting with her and felt she was scared. It was heartbreaking for the family to see her alone in the final hours of her life. She stated their mother passed peacefully after the nurse sat with her. They tried to play the resident's favorite music through the window but doubted their mother could hear it. They eventually had the nurse play it when she was sitting with her and felt the difference was huge when she had someone with her. She indicated her mother needed touched to comfort her in her final hours as it seemed to make a big difference after the nurse was there to hold her hand. It was still heartbreaking that the family was not allowed to do that for her, but she was glad at least someone was with her. On [DATE] at 11:52 A.M., a phone interview with Resident #26's other daughter confirmed the family had made several requests to visit with their mom during the end of her life and not through her window. She stated they even asked the facility's Administrator and was told they could only visit through the window. She reported she screamed at the Administrator and asked him if he would want his mom to die like that and he replied no but again told the family he could not let them in. She then stated she spoke with the DON over the phone and told the DON her mother was dying by herself with no one there. She too stated they were told the facility only had three staff members working the Covid unit and did not know what else she could do. She reported, once the staff nurse was placed in the room with their mother and held her hand, rubbed her head, and played music, their mother calmed down right then. She did not feel the facility showed any compassion. She had promised her mom that she would be there for her and that they would get through the Covid-19 infection together but she was not permitted the ability to follow through with her promise as the facility would not allow her in. She was very tearful during the interview and stated she felt like breaking the window to her mother's room so she could be with her mom when she passed. On [DATE] at 12:55 P.M., an interview with the DON revealed the facility did deny Resident #26's family the ability for them to have a compassionate care visit with the resident during the end of her life. She stated they were not allowed to visit the resident due to the resident being positive for Covid-19. They were following the 5th Amended Director's order from the State Agency dated [DATE] instead of the CMS Memo QSO-,d+[DATE] for Nursing Homes dated [DATE]. The DON reported they were following the more stringent of the two orders. They hated to have to deny the family the ability to visit their mother towards the end of her life but did not feel they could permit such a visit in a facility that had Covid-19 based on the State Director of Health's 5th Amended Orders. She was not aware the facility should follow the CMS Memo that directed visitation in nursing homes over the information included in the Director of Health's 5th Amended Orders. A review of the facility's policy on Indoor/ Outdoor Visits dated [DATE] revealed the policy was consistent with the information provided in the 5th Amended (State) Director's Orders dated [DATE]. The information under indoor visitation revealed the facility should accommodate and support indoor visitation if there had been no new onset of Covid-19 cases in the last 14 days and the facility was not currently conducting outbreak testing. The information under compassionate care visits did not specifically address compassionate care visits for residents known to have Covid-19 and at the end of their life. The policy indicated each facility may still restrict visitation due a resident's Covid-19 status. A review of CMS Memo QSO-,d+[DATE] for Nursing Homes dated [DATE] revealed CMS was issuing new guidance for visitation in nursing homes during the Covid-19 public health emergency ([NAME]). The guidance provided reasonable ways a nursing home could safely facilitate in person visitation to address the psychosocial needs of residents. While CMS guidance had focused on protecting nursing home residents from Covid-19, they recognized that physical separation from family and other loved ones had taken a physical and emotional toll on residents. Residents may feel socially isolated, leading to increased risk for depression, anxiety, and other expressions of distress. Residents living with cognitive impairment or other disabilities may find visitor restrictions and other ongoing changes related to Covid-19 confusing or upsetting. CMS understood that nursing home residents derive value from the physical, emotional, and spiritual support they receive through visitation from family and friends. Considering that, CMS was revising the guidance regarding visitation in nursing homes during the Covid-19 [NAME]. The guidance under required visitation revealed residents who were on transmission-based precautions (TBP's) for Covid-19 should only receive visits that were virtual, through windows, or in person for compassionate care situations, with adherence to TBP's. This deficiency substantiates Complaint Number OH 166.

Based on observation, reviews of the medical record, an incident investigation report, hospital records, facility policy and staff interviews the facility failed to ensure adequate assistance and/or safety interventions were in place for Resident #40, Resident #46 and Resident #13 to prevent accidents. The facility failed to ensure Resident #46 and Resident #40 were provided proper transfer techniques/assistance to prevent fractures and failed to ensure fall interventions were in place for Resident #13. This affected three residents (Resident #13, #40 and #46) of seven residents reviewed for accidents. Actual Harm occurred when Resident #40, who was non-ambulatory and dependent on two staff for assistance with transfers using a mechanical (Hoyer) lift sustained a fractured cheekbone and subsequent increased pain when the resident was struck in the face by the swivel bar of the lift device during a transfer with only one staff member present. Actual Harm occurred when Resident #46, who was dependent on staff for transfers and had a physician order [REDACTED]. Findings include: 1. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed as dependent on staff for all activities of daily living and required a mechanical (Hoyer) lift for all transfers. Resident #40 had severe cognitive impairment. Review of an incident investigation, dated 06/30/18 revealed a state tested nurse's aide (STNA) was walking by Resident #40 after lunch when she noticed the resident had a light blue bruise on her right forehead. Upon further examination a purple bruise with a couple of scratches were noted on the top center of the resident's head. Staff reported the bruises had not been there at lunchtime when staff assisted her with her meal. The investigation revealed staff were re-educated on the proper use of Hoyer lift for transfers and proper placement of the sling. The facility investigation contained only one written statement, a statement from STNA #32 who reported she had noticed a bump on Resident #40's head when she was walking by her and notified the nurse right away. There was no evidence of any other resident or any other staff members' statements, including from staff who had provided care to Resident #40. Review of Resident #40's progress notes revealed a late entry dated 06/30/18 that indicated an STNA walked by the resident and noticed a light blue bruise on her right forehead. In addition, the resident had a purple bruise with a couple scratches noted on the top center of her head. Upon talking with staff, including the staff on C-Hall, on how the resident got the bruises it was undetermined at that time. Staff reported the bruises were not on her forehead a lunch time, not even a red mark. On 07/01/18 the area on tip of Resident #40's head was deeper purple and larger than the previous day. The area on right forehead was larger and blue. A late entry entered on 07/07/18 for 07/02/18 indicated there was a bruise to the top of the heard and right side of face noted. No complaints of pain. On 07/03/18 during a follow up investigation, staff stated the Hoyer lift had been making strange noises when lifting residents up. Maintenance was notified of the problem with the lift and it was removed from the floor, checked, and repaired. Staff were re-educated with proper Hoyer lift transfers and to notify nursing or maintenance if the lift was not working properly or making noise. At 12:28 P.M. on 07/03/18, Resident #40 had been crying and had complaints of pain in the head when moving or transferring. The physician was notified and ordered a computed tomography (CT) scan of the head. At 1:34 P.M., the resident was sent to the emergency room for evaluation due to increased crying from back pain and increased bruising to the top of the head and right face. The resident now had a swollen area on her right cheekbone. Resident #40 was transported by emergency medical services (EMS) and report was called to the emergency room . At 5:35 P.M., the nurse spoke to the emergency room and Resident #40 was going to be transported back to the facility. The resident was diagnosed with [REDACTED]. Review of Resident #40's hospital records, dated 07/03/18 revealed the resident was brought to the emergency department with apparent head trauma. An unknown injury occurred on Saturday, resulting in a hematoma to the top right parietal area and bruising and swelling to right temporal area and jaw line. The resident was confused, markedly demented, and gave very little history. A CT of the maxillofacial area showed a nondisplaced right zygomatic (cheekbone) fracture with adjacent soft tissue swelling. Review of an additional investigation report dated 07/05/18 and completed by the sister facility Director of Nurse, Registered Nurse (RN) #49 revealed an investigation was completed for Resident #40 related to a bruise of unknown origin. She had observed the resident being transferred to the bed and again to wheelchair using a Hoyer lift with two staff assist. During the process it was noted that the resident kept her head to the left and required staff to monitor the position of the Hoyer swing bar while transferring. One staff was operating the Hoyer while the other kept the resident's head/face safe from possible contact with the Hoyer swing bar. When speaking with staff they also noted that the residents head/face was at times near the Hoyer lift swing bar. At the end of the investigation it was determined the Hoyer swing bar swung free while unhooking the Hoyer pad loops and unintentionally hit the resident on the right side of the face. There was no evidence staff admitted or physically witnessed the swing bar hit the resident in the face/head during the time of the incident. Review of Resident #40's medication administration records dated 06/2018 and 07/2018 revealed the resident was ordered [MEDICATION NAME] 325 milligrams (mg) two tablets every four hours as needed for pain. In (MONTH) (YEAR) the resident did not receive the [MEDICATION NAME] however in (MONTH) (YEAR) the resident received one dose on 07/01/18 and two doses on 07/0318. On 07/05/18 new orders were received to administer the [MEDICATION NAME] scheduled twice daily for seven days. Interview on 10/10/18 at 2:15 P.M., with RN #49 revealed she was asked to come to the facility on [DATE] because the facility DON was on medical leave to investigate injuries involving Resident #40. RN #49 reported after observing staff transfer the resident she noted the resident was leaning to one side. Staff reported they always had to hold the swivel bar on the Hoyer lift when transferring the resident. RN #49 indicated she concluded Resident #40's injures were related to the swivel/swing bar hitting the resident in the face due to the alignment of the injury to the position of the swing bar. RN #49 reported she had reviewed the nurse's documentation regarding the Hoyer lift not being in proper working condition, however the former maintenance director and housekeeping staff had reported there was nothing wrong with the actual Hoyer lift. Interview on 10/10/18 at 2:41 P.M. with STNA #32 revealed on 06/30/18 she was pulled from C-Hall to work another hall. She stated as she was walking by Resident #40 in the lobby she noticed a knot on the side of the resident's head and the resident was observed holding it with her hand. She stated as she got closer she saw bruising on the resident's forehead and at the top of her hairline. She stated the knot was the size of a baseball and purplish. She reported no one had witnessed any incident or admitted to causing any injuries. STNA #32 stated the resident was difficult to transfer and required two staff to assist with the Hoyer lift. She reported STNA #12 and STNA #50 had provided care to Resident #40 on 06/30/18 prior to the discovery of the injuries. Interview on 10/10/18 at 3:25 P.M., with Licensed Practical Nurse (LPN) #7 revealed she was working on the Resident #40's hall the day the injuries were noted. She stated STNA #32 had reported Resident #40 had a knot on the top of her head and her scalp was bruised. She stated STNA #50 and STNA #12 were the STNAs who had worked that day on the resident's hall. She stated STNA #50 had left before the injuries were noted and STNA #12 was not aware of the injuries or how they occurred. LPN #7 indicated her first impression was the resident had got injured by the Hoyer lift, however STNA #12 denied any complications during transfers. Interview on 10/11/18 at 9:30 A.M., with STNA #29 revealed she had worked the day the Resident #40 sustained the head injury. She reported the resident had a big knot sticking out of her forehead larger than a fifty-cent piece. She also had an indentation and bruising on the top of her head. She was not working on the resident's hall prior to the injuries. She reported STNA #50 had left around noon that day and STNA #12 was the staff member assigned to the resident's hallway. Interview on 10/11/18 at 10:10 A.M. with STNA #50 revealed at first he reported, STNA #12 had helped him transfer Resident #40 in and out of bed with the Hoyer lift. A second interview, on 10/11/18 at 10:30 A.M. revealed STNA #50 had transferred Resident #40 using the Hoyer lift by himself on 06/30/18. He confirmed he worked until noon on that date and then STNA #12 was responsible for the residents on C-Hall the remainder of the shift. Interview on 10/11/18 at 10:12 A.M., with STNA #12 revealed she had worked on Resident #40's hall on 06/30/18. She reported she was not state tested at the time or in a nurse aide training program. She stated that morning she had gone in Resident #40's room and STNA #50 was in the room and had already got Resident #40 out of bed with the Hoyer lift and had her in the wheelchair by himself. She confirmed STNA #50 had left at noon and she continued to provide personal care for the resident. She stated around 2:00-2:30 P.M. she noted Resident #40 had a big knot and bruising on her forehead. She also had an indentation on the top of her head that looked like someone hit her on top of the head with something. She stated no one knew what happened to Resident #40 to cause the injuries. Interview on 10/11/18 at 9:26 A.M., 10:28 A.M., and 11:28 A.M., with RN #49 revealed she was not aware STNA #50 had transferred Resident #40 by himself on 06/30/18. She stated the facility policy was for two staff members to complete Hoyer lift transfers. She had confirmed the investigation of the injuries sustained by Resident #40 lacked any pertinent resident and staff statements. RN #49 reported when she initially examined Resident #40 on 07/05/18 she was unaware of the knot on the forehead or indentation on the top of the head. She stated she was focused on what caused the cheekbone fracture. Review of Hoyer lift policy, dated 08/08/18 revealed the usage of the Hoyer lift allowed a resident to be lifted and transferred with a minimum of physical effort. The reason for using a lift for transfers included the resident was too heavy to be transferred without the assistance of a lifting device. Preventing injury to the caregiver or resident while transferring the resident was a component of the policy. The procedure included to use two assistants when operating the Hoyer lift on a resident. Do not use the Hoyer lift without training. Use the Hoyer lift for all ordered residents. 2. Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED].M. revealed the resident had an order for [REDACTED]. Review of the nurse's notes revealed Resident #46 arrived to the facility from home on 07/27/18 at 2:30 P.M. Upon admission, the resident's sister stated at home the resident was lifted manually by his arms and legs from the wheeled recliner to the bed. STNA #16 and STNA #23 positioned their arms under the resident while in the wheeled recliner to transfer him to bed. Upon transferring the resident a pop was heard. Upon assessment of the resident's hips and legs the left thigh was noted to have a lump which the resident's sister stated was not present before. Resident #46 was moaning in pain. As needed Tylenol was administered. The family wished for Resident #46 to be sent to the emergency room for evaluation. At 3:15 P.M. Resident #46 was taken by EMS to the emergency room . A 07/27/18, 6:41 P.M. nursing progress note revealed Resident #46 was admitted to the hospital with [REDACTED]. On 10/10/18 at 1:44 P.M. interview with the DON revealed she did not get witness statements from the staff in the room and only had the nurse's incident report. The DON indicated Resident #46 had arrived from home and was to only be a short term stay while his sister had surgery. On 10/10/18 at 2:12 P.M. interview with Admissions Staff #42 revealed she was in the room at the time of the transfer. They called in STNA #16 and STNA #23, who were male STNAs, to do a two man lift transfer. She stated they had their arms under the resident's thighs and under his arms around his back. When they had him lifted over the bed they heard a crack. Resident #46's sister said he may have fractured something. Admissions Staff #42 revealed the staff did not try to put a Hoyer pad under the resident to do a mechanical Hoyer lift. On 10/10/18 at 4:05 P.M. the DON verified Resident #46 was ordered to be a mechanical Hoyer transfer at the time of admission. The DON verified two STNA staff did a manual lift resulting in the resident sustaining a fractured left thigh. The DON verified the fracture occurred during a manual two man lift when Resident #46 had a physician order [REDACTED].>Review of Hoyer lift policy, dated 08/08/18 revealed the usage of the Hoyer lift allowed a resident to be lifted and transferred with a minimum of physical effort. The reason for using a lift for transfers included the resident was too heavy to be transferred without the assistance of a lifting device. Preventing injury to the caregiver or resident while transferring the resident was a component of the policy. The procedure included to use two assistants when operating the Hoyer lift on a resident. Do not use the Hoyer lift without training. Use the Hoyer lift for all ordered residents. 3. Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 07/11/18 Significant Change Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, required extensive assist of one for bed mobility, transfers, walking in hall, walking in room, walking off unit, toilet and personal hygiene with impairment on one side of upper extremity. The assessment revealed Resident #13 had two or more falls since the prior assessment. Record review revealed the resident had sustained ten (10) falls since admission. Review of the physician's orders [REDACTED]. A fall plan of care, initially developed 11/20/17 revealed interventions including: On 12/06/17 to make sure non-skid footwear was worn when up, on 04/16/18 non skid shoes or socks on in the morning to prevent sliding when ambulating, on 05/30/18 a floor mat on the right side of the bed between the recliner and bed while in bed and to place a wood block between recliner and wall to prevent recliner sliding back when getting in and out of recliner. The 07/10/18 Fall Risk Evaluation revealed Resident #13 was at moderate risk for falls related to falls in the last six months, medication use, poor memory recall, frequent incontinence, occasional behaviors, assistive device for ambulation and passive range of motion only to right extremity from contractures related to a frozen shoulder. A 07/10/10 Mobility Evaluation revealed poor range of motion to right shoulder, elbow, hand, wrist, poor muscle strength, moderate strength to shoulder, frozen right shoulder with contractures to right upper extremity, moderate ability to roll to left and poor ability to roll to right, moderate to poor ability to sit or stand unassisted, not steady for walking, turning, moving on and off toilet seat, and from surface to surface. Review of the resident's falls revealed on 02/04/18 at 8:30 A.M. the resident was found on the floor between the bed and recliner leaning up against the wall. There was no evidence if non- skid socks were on. On 03/19/18 the resident was found on the floor on her back with head towards recliner and feet toward heater. There was no evidence of non skid socks being on. On 09/08/18 the resident was found on right side near wheelchair in room. There was no evidence if non skid socks were on. Observation on 10/09/18 10:30 A.M. revealed Resident #13 was in bed and a mat was not between the bed and the recliner. A floor mat was observed in the corner of the room. On 10/09/18 at 2:52 P.M. Resident #13 was observed in a recliner with no wood block between recliner and wall. On 10/10/18 at 6:20 P.M. Resident #13 was observed in bed on right side. There was not a floor mat between the bed and recliner. On 10/11/18 at 10:06 A.M. Resident #13 was observed up in her recliner without the wood block behind the recliner so it would not slide. Interview with STNA #59 on 10/09/18 at 10:35 A.M. revealed she was new and did not put Resident #13 to bed. However, STNA #13 verified the floor mat was in the corner and not next to the bed between the bed and the recliner and Resident #13 was in the bed. On 10/11/18 at 8:45 A.M. the DON revealed STNA #16 had assisted Resident #13 to bed and did not place the floor mat between her and the recliner. The DON also verified there was no wood block between the recliner and the wall. On 10/11/18 at 10:08 A.M. the DON verified Resident #13 was up in her recliner without the wood block behind the recliner to prevent sliding of the chair. The DON verified there were three (of ten) falls without evidence of Resident #13 wearing non-skid socks at the time of the falls as care planned for safety.

Based on record review and interview the facility failed to ensure Resident #41 was free from physical and verbal abuse by contracted staff. This affected one resident (Resident #41) of three residents reviewed for abuse. Actual harm occurred to Resident #41 when during treatment; the contracted dentist grabbed the resident's face, forced her mouth open and removed a denture mold from her mouth. The dentist also called Resident #41 a derogatory name with both acts resulting in extreme agitation from Resident #41. Findings include: Review of Resident #41's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/17 revealed the resident had severe cognitive impairment for daily decision making. The resident required supervision with bed mobility, ambulation and limited assistance of one staff member with transfers, locomotion on and off the unit, eating, toilet use and personal hygiene. No behaviors such as hitting, kicking, pushing, scratching or grabbing were identified during the assessment period. Review of the nursing progress notes dated 10/19/17 at 7:19 P.M. revealed Dentist #50 was in to see the resident and attempted to try the resident with a wax mold. Once the mold was in the resident's mouth, the resident did not want to return the mold to the dentist. A nurse and state tested nursing assistant (STNA) were present as well as a dental assistant. Resident #41 kept the top wax mold in her mouth and the bottom wax mold in her hand, refusing to give them back. Dentist #50 then aggressively grabbed the wax mold out of Resident 41's hand. Resident #41 screamed for the dentist to get away from her. Dentist #50 then aggressively and with unnecessary force grabbed the top wax mold out of Resident #41's mouth causing the resident to become very agitated. Resident #41 was returned to the secured unit and was calmed down using therapeutic talking and coloring activities. The resident's daughter was notified. Review of a facility self reported incident (SRI) tracking number 4 dated 10/19/17 revealed at 5:00 P.M. Dentist #50 and his assistant arrived at the facility several hours late. The nurse on duty informed Dentist #50 it was dinner time and the dentist stated, We are already behind and we need to get started. We will be quick. The dentist was informed Resident #41 had advanced [MEDICAL CONDITION] and could easily become combative and easily agitated. Dentist #50 stated, That's fine. During the encounter with Resident #41, Dentist #50 became extremely aggressive and forceful with the resident. The facility substantiated mistreatment and verbal/emotional abuse. Review of Registered Nurse (RN) #3's statement, dated 10/19/17 revealed at 5:00 P.M. Dentist #50 and Dental Assistant (DA) #7 arrived at the facility. DA #7 stated they were two hours behind schedule. RN #3 informed them it was dinner time for the residents and the DA responded they were already behind, needed to get started and would be quick. Dentist #50 and DA #7 set up in the facility exam room and requested Resident #41 first. RN #3 informed the dentist and DA #7 the resident had advanced [MEDICAL CONDITION] with anxiety and could be very combative and easily agitated. The dentist stated, That's fine. After completing her meal, Resident #41 was taken to the exam room with RN #3 and STNA #4 present. The resident was confused and began resisting care. The DA was calm with the resident and was able to get the upper and lower wax molds into the resident's mouth. However, Resident #41 became very agitated and would not allow the dentist or DA #7 to assess the fit of the wax molds. The resident began to slap RN #3 and STNA #4's hands away when they attempted to help remove the wax molds. The DA was able to get the resident to remove the bottom mold from her mouth but the resident held the mold in her left hand and would not give the mold to the DA or remove the upper mold from her mouth. The DA continued for the next 10 to 15 minutes to calmly attempt to remove the upper mold from the resident's mouth. At that time, it was very clear the resident was too agitated to continue with the procedure. RN #3 and STNA #4 attempted to calm the resident when suddenly Dentist #50 lunged in between the DA and RN #3 to get to Resident #41. The dentist grabbed the resident's hand using excessive force and took the mold out of the resident's hand stating, These are mine and you will give them back to me. The dentist threw the mold onto the side table and quickly grabbed the resident by the face/jaw area with his right hand and forcefully shoved his fingers into the resident's mouth and yanked the upper mold out of her mouth. Resident #41 jerked back, grabbing Dentist #50's arms, trying to push him away. The resident swung at the dentist and kicked him saying, You stop that you (expletive). The dentist responded, I'm a (expletive)? No, you're a (expletive). You will not talk to me in that way. STNA #4 stood between the resident and the dentist. The dentist was pressed up against the STNA's back and continued to yell at the resident but RN #3 was unsure exactly what he said. RN #3 stood up, assisted the resident to her feet and told the dentist, That is enough. While RN #3 and STNA #4 were assisting the resident out of the exam room the dentist said, if you pussy foot around like that we would be here for eight hours. Review of STNA #4's statement, dated 10/19/17 revealed RN #3 asked STNA #4 to assist with Resident #41 in the exam room for a dental visit. The recount of the incident reflected 15-20 minutes of trying to get the resident to remove the upper mold when the dentist lunged at Resident #41 and jerked the bottom wax mold out of the resident's hand stating, That's mine and I will take it back. The dentist tossed the mold onto the stand in the exam room. He then went back to the resident and with excessive force grabbed her face and forced his fingers of his left hand to forcefully remove the wax mold. As the dentist was removing the mold he said, You don't like me? Well, I don't like you. The resident became very combative and called the dentist a (expletive). The dentist then came to the chair and began to argue with the resident. STNA #4 stood between the resident and the dentist. The dentist was pressed against STNA #4 yelling at Resident #41, I'm a (expletive)? You're a (expletive). The dentist then said, If they continue to pussy foot around we will be here for eight hours. On 11/02/17 at 9:12 A.M. interview with RN #3 verified she completed a statement regarding the above incident involving Resident #41 on 10/19/17. RN #3 stated the dentist grabbed the resident's cheeks/jaw to force her mouth open. He took his other hand, using excessive force, and grabbed the upper wax mold from the resident's mouth. DA #7 kept repeating, Doctor, this isn't necessary, doctor stop. RN #3 stated the STNA stood between the dentist and the resident and RN #3 told the dentist that was enough. It was very difficult to get the resident out of the room due to her agitation. The resident was screaming incoherently, kicking and punching on the way back to the secured unit. RN #3 shared the staff was able to calm the resident by giving her a drink and her doll. RN #3 stated the dentist was asked to leave the facility by DA #7 after he saw Resident #18. RN #3 stated Resident #18 had entered the room while she and STNA #4 had taken Resident #41 back to the unit but DA #7 had been in the room and RN #3 returned to the exam room once Resident #41 was safely back on the unit. Lastly, RN #3 stated Resident #18 denied any concerns with the dentist during her visit. RN #3 indicated three residents were to be seen that day but only two were seen due to the incident. Further interview with RN #3 revealed Dentist #50 physically and verbally abused the resident and did not treat the resident with dignity and respect. On 11/02/17 at 9:39 A.M. interview with STNA #4 revealed DA #7 was very calm and patient with Resident #41 and after 10-15 minutes trying to get the molds out of the resident's mouth, the dentist lunged out of the chair at Resident #41. The dentist grabbed the lower mold out of the resident's hand stating, That's mine and I'm going to take it. The dentist threw the mold onto the table in the exam room and lunged at the resident again. He grabbed her face, pushing her head back against the exam chair and jammed his fingers into her mouth, grabbing the upper mold. The resident called him a (expletive) and he responded by saying he wasn't a (expletive, she was a (expletive). Further interview revealed STNA #4 had stood between the dentist and the resident with the dentist pressed up against her back while he was yelling at the resident. STNA #4 stated RN #3 told the dentist that was enough and the two staff assisted the resident from the exam room. The resident was yelling and swinging at the staff during the walk back to the unit. STNA #4 stated when she returned from the secured unit, the dentist was standing in the hallway near the exam room and stated to STNA #4, I'm sorry. I didn't hurt her, I just hurt her feelings. STNA #4 stated she told the dentist she was not the one he should be apologizing to and returned to her duties. STNA #4 verified what she witnessed was verbal, physical and emotional abuse towards Resident #41. STNA #4 also verified the dentist did not treat the resident with dignity and respect during the incident. On 11/02/17 at 1:00 P.M. interview with the Director of Nursing (DON) revealed the facility substantiated the allegation of abuse and determined mistreatment and emotional/verbal abuse had occurred. The DON shared the facility filed a complaint with the dental board, notified the contracting dental company, notified the facility's legal representation and educated the staff regarding abuse and treating residents with respect and dignity. The DON verified the dentist was a contracted individual working in the facility at the time of the incident. Review of the facility Abuse, Mistreatment, Neglect and/or Misappropriation of Resident Property policy with revision of 07/18/12 revealed the facility ensured each resident had the right to be free from abuse, corporal punishment and involuntary seclusion. Residents would not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends or other individuals. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting physical harm, pain or mental anguish. Verbal abuse was defined as the use of oral, written or gestured language that willfully included disparaging and derogatory terms to the resident or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Physical abuse included hitting, slapping, pinching or kicking. Review of the facility dignity policy dated 2001 and revised 08/2009 revealed each resident shall be cared for in a manner that promoted and enhanced quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Staff shall speak respectfully to residents at all times. This deficiency substantiates Control Number OH 233.

Based on record review and interview, the facility failed to ensure the physician was properly notified of significant weight losses and failed to implement additional interventions to prevent further weight loss. This affected two (Residents #34 and #20) of three residents reviewed for weight loss. The facility census was 43. Harm occurred to Resident #20 on 02/04/13 when the facility obtained a weight which reflected severe weight loss over a one month period, no new nutritional interventions were implemented, and the resident continued to lose weight. Findings include: 1. Resident #20 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Monthly weights for Resident #20 for a six month period were: 08/03/12 - 136; 09/03/12 - 137; 10/02/12 - 135; 11/02/12 - 130; 12/.07/12 - 130; 01/04/13 - 127; 02/04/13 - 117 and 03/05/13 - 111. Resident #20 sustained a six pound weight loss between February and March resulting in a significant weight loss of 5.4%. Resident #20 lost 19 pounds in the last 90 days resulting in a severe weight loss of 17.1% and over the last 180 days she lost 26 pounds resulting in a severe weight loss of 23.4%. Review of the nutritional note by registered dietician (RD) # 8 on 09/28/12 indicated Resident #20's body mass index (BMI) was 23.06 (normal range is between 18.5 to 25, underweight is less than 18.5 and overweight is greater than 25) and that she tolerated her regular diet with ground meats with intakes averaging 37%. On 11/07/12, registered dietary technician (DTR) #7 indicated Resident #20 lost five pounds between October and November 2012 but was not a significant weight loss. No interventions to prevent further weight loss were implemented and no orders were written to recheck Resident #20's weight or to monitor Resident #20's weight more frequently than monthly. On 12/21/12, the dietary note written by dietary manager in training (DMT) #9 indicated the minimum data set or comprehensive assessment was completed and the team discussed Resident #20's medical record, care plan, and goals. DMT #9 indicated Resident #20 weighed 130 pounds and she had lost seven pounds for a 5.1% weight loss. DMT #9 indicated Resident #20 fed herself in the dining room and ate an average of 50% of her meals. This note indicated Resident #20 received a small high protein snack at 10:00 A.M. and 7:00 P.M. and fortified milk at all her meals and usually consumed these "good". Resident #20 also received yogurt at lunch and dinner and intake varied from poor to good. Lab tests completed on 12/07/12 revealed a low [MEDICATION NAME] level of 3.1 (normal is 3.5 to 5.0), a low total protein level of 5.3 (normal is 6.3 to 8.2). No additional nutritional interventions were initiated. There was also a dietary note written by RD #8 on 12/21/12 indicating Resident #20's BMI was 21.08 and indicated the resident lost seven pounds or 5.1% in the review period. She documented Resident #20's intakes were an average of 50%. No additional nutritional interventions were implemented and there were no orders to obtain Resident #20's weight more frequently. On 01/24/13, the next nutritional note was written by DMT #9. She indicated the team discussed Resident #20's medical record, care plan, and goals. She documented Resident #20 had lost three more pounds. Some laboratory tests were completed on 01/14/13. However, no repeat levels were obtained for total protein or [MEDICATION NAME] levels. On 01/30/13, RD #8 documented a nutritional note which indicated Resident #20 had lost 11 pounds or 7.9% in the last six months. No additional nutritional interventions were ordered and no orders to obtain more frequent weights were implemented. On 02/07/13, the only nutritional note written in February was by DTR #7 which indicated nursing staff had requested a small cranberry juice for one week since Resident #20 had cloudy urine. There was no documentation of the ten pound weight loss Resident #20 sustained from January 2013 to February 2013, no notification to the physician and responsible party, and no interventions to maintain her current weight and/or prevent further weight loss. On 03/05/13, the weight log for Resident #20 reflected an additional weight loss of six pounds. There were no nutritional notes written until 03/25/13. On this date, RD #8 documented a significant weight loss of six pounds between February and March 2013, 5.1% and Resident #20 now weighed 111 pounds. RD #8 indicated she faxed the physician to request an appetite stimulant since Resident #20 did not eat well. This was the first entry indicating Resident #20 did not eat well. Interviews were conducted with DTR #7 on 03/26/13 at 3:15 P.M. and 4:40 P.M. She stated she and RD #8 worked on Resident #20 together. She verified the nutritional supplements in place and the date they were implemented: a small high protein shake twice a day (started on 04/30/12), fortified milk at all three meals (started on 05/09/12) and yogurt at breakfast, lunch and dinner (started on 07/05/12). DTR #7 indicated the yogurt at breakfast was discontinued in August 2012 because Resident #20 didn't want yogurt for breakfast. DTR #7 verified she and RD #8 discussed the weight loss concerns with Resident #20 last night (03/25/13) and RD #8 wrote up the fax for the physician and they sent it this morning (03/26/13) and as of the time of the interview, no appetite stimulant or any other nutritional intervention had been attempted with Resident #20. DTR #7 indicated the restorative aide obtained the resident's monthly weights and put the list in the bin for DMT #9. DMT #9 was to record the weight in the workbooks and then either she or RD #8 would address the weight. DTR #7 indicated she visited the facility once a week to review the RD's documentation and that RD #8 visited the facility three times a week. She verified Resident #20's significant weight losses had not been addressed promptly when they occurred and staff had not completed any documentation and/or nutritional interventions to address the weight losses and prevent further weight loss. On 03/27/13 at 11:50 A.M., DTR #7 provided a weight loss policy dated 09/06/07 which indicated residents were weighed once a month. The policy indicated if a resident lost four to six pounds or more per month or if they lost weight when they were below ideal body weight the resident was to be weighed more frequently as deemed necessary according to team discussions with the input of the registered dietician, physician, registered dietary technician, and speech therapy. This policy indicated a medical record review would be completed for possible reasons for the weight loss and necessary intervention would be implemented and the physician and family would be notified only if the resident was less than 105% of their ideal body weight. An interview was conducted with DTR #7 on 03/27/13 at 12:10 P.M. She verified staff did not follow their own policy to hold an interdisciplinary team meeting to establish the frequency of weights, to complete a medical record review to evaluate reasons for the weight loss and to implement necessary interventions. 2. Resident #34 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Record review revealed the following monthly weights for Resident #34: 09/04/12 - 146; 10/02/12 - 151; 11/02/12 - 155; 12/07/12 - 154; 01/04/13 - 152; 02/08/13 - 148; and 03/05/13 - 141. The quarterly dietary note dated 02/13/13 indicated Resident #34's weight was 152, the weight record listed her weight as 148 on 02/08/13. This dietary note indicated Resident #34's weight had increased 14 pounds or 10.1% but no time frame was given for the weight gain. A second dietary note written on 02/13/13 indicated Resident #34 had been receiving cookies at 10:00 A.M. and 2:00 P.M. and were discontinued per the family's request. The next dietary note on 03/02/13 indicated Resident #34's diet was changed to mechanical soft with ground meats moistened and restricted carbohydrates due to oral dysphagia. On 03/23/13, after a trial of nine days, speech therapy placed Resident #34 on a puree diet with restricted carbohydrates. On 03/02/13, registered dietician (RD) #8 sent a fax to Resident #34's physician indicating she had a significant weight gain of 10.1% in the last six months. In review of the last six months on the weight record Resident #34's weight was 145 on 08/03/12 and was 148 pounds on 02/08/13 and was only a gain of three pounds and was not a significant weight gain of 10.1%. RD #8 reported to the physician that Resident #34's weight had been 138 pounds and was now 152, which was not accurate. RD #8 indicated Resident #34's weight had leveled off in the last three months and stated Resident #34 seemed to be doing well. The physician documented "OK" on the fax and sent it back to the facility. No new orders were given by the physician. Resident #34's weight was recorded three days later on 03/05/13 and was 141 pounds, down seven pounds since 02/08/13. Resident #34's seven pound loss in one month resulted in a significant weight loss of 5%. Her weight loss over three months was also significant at 9.2%. There was no notification to the physician or responsible party regarding the significant weight loss and no interventions to address and prevent further weight loss. On 03/26/13 at 2:55 P.M., registered dietary technician (DTR) #7 revealed the facility does not have a policy or procedure regarding re-weights when a resident loses a certain amount of weight in a month. She indicated no other weights had been taken since 03/05/13 when Resident #34 had a seven pound loss. The fax to the physician from RD #8 informing the physician of a weight gain was reviewed with DTR #7. She verified the fax was sent well past the previous weight gain and now was inaccurate since Resident #34 had sustained a significant weight loss. On 03/27/13 at 11:50 A.M., DTR #7 provided a weight loss policy dated 09/06/07 which indicated residents were weighed once a month and if a resident lost four to six pounds or more per month or lost weight when they were below ideal body weight the resident was to be weighed more frequently as deemed necessary according to team discussions with the input of the registered dietician, physician, registered dietary technician and speech therapy. This policy indicated a medical record review would be completed to evaluate for possible reasons for the weight loss and necessary intervention would be implemented and the physician and family would be notified only if the resident was less than 105% of their ideal body weight. An interview was conducted with DTR #7 on 03/27/13 at 12:10 P.M. She verified staff did not follow their own policy to hold an interdisciplinary team meeting to establish the frequency of weights, to complete a medical record review for reasons for the weight loss, and to implement necessary interventions. Review of laboratory testing completed for Resident #34 in the last six months revealed no total protein, [MEDICATION NAME] or pre-[MEDICATION NAME] levels were done in order to assess her nutritional status/protein stores.

Based on medical record review and staff interview, the facility failed to ensure necessary treatment and services to promote healing were provided to one resident (Resident #35) whey they failed to follow recommendations of the wound nurse practitioner regarding use of gel cushions and frequency of dressing changes. Two residents were reviewed for pressure ulcers. The facility identified three residents with pressure ulcers. Findings include: 1. Record review for Resident #35 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the TAR revealed that on 09/04/11 the resident developed a reddened area to the inner buttocks. The area was monitored weekly. On 11/02/11 the reddened area deteriorated to a Stage II pressure ulcer that was too small to measure, described as small pinpoint hole. On 11/15/11 the resident was seen by the consultant wound nurse. Review of the consultant wound nurse report revealed that on 11/15/11 a recommendation was made for a gel cushion to her wheelchair and a wound treatment of [REDACTED]. Another consult was made on 12/06/11 and also had the same recommendations. Review of the physician's orders [REDACTED]. Observations of Resident #35 on 12/08/11 at 2:40 P.M. revealed the resident using a foam wheelchair cushion rather than the recommended gel cushion per the consultant wound nurse. Interview with Registered Nurse (RN) #5 on 12/08/11 at 3:05 P.M., verified the resident did not have a gel cushion to her wheelchair as recommended by the consultant wound nurse.