Every finding on record at Briarfield Manor

Based on review of staffing schedules, employee punch detail reports, and interview, the facility failed to ensure a registered nurse (RN) was present for eight consecutive hours each day as required. This had the potential to affect all 69 residents residing in the facility.Findings include:Review of the staffing schedule and employee punch detail reports for the week of 07/26/26 through 08/01/26 showed the facility did not have an RN on duty for eight consecutive hours on 07/29/26 and 07/30/26.During an interview on 08/26/26 at 10:20 A.M., the Administrator and Human Resources representative confirmed that an RN was not on duty for eight consecutive hours on 07/29/26 and 07/30/26.This deficiency represents non-compliance investigated under Complaint Number 3131880.

Based on observation, interview and record review the facility failed to ensure showers and bed baths were given to three residents (#41,#70, #75) of six residents reviewed for activities of daily living (ADL) and choices. The facility census was 69.Findings include: 1. Record review of Resident #41 revealed an admission date on 07/10/19 with diagnoses of spondylosis, major depressive disorder, and normal pressure hydrocephalus. Review of the Minimum Data set (MDS) 3.0 assessment 06/03/26 revealed the resident was cognitively impaired and was dependent on staff for ADL. Review of Resident #41's care plan 06/05/26 revealed she preferred to have showers on Monday, Wednesday, Friday during dayshift. Record review of shower sheets provided revealed Resident #41 did not receive showers on 07/01/26, 07/03/26, 07/08/26, 07/10/26, 07/13/26, 07/17/26, 07/22/26, 07/24/26, 08/07/26, 08/12/26, 08/17/26, 08/19/26, and 08/21/26. Record review of progress notes for Resident #41 revealed on 08/05/26 she refused a shower. There were no other refusals documented. During an interview on 08/24/26 at 1:59 P.M., Resident #41 revealed she had not been getting her showers on a consistent basis. During an interview on 08/27/26 at 7:34 A.M., Licensed Practical Nurse (LPN) #18 revealed the nurses were notified of resident refusals of showers/bed baths, and they were to encourage the resident to take one. LPN #18 stated the aides fill out a sheet for showers/bed baths. During an interview on 08/27/26 at 7:41 A.M Certified Nursing Assistant (CNA) #58. revealed they offer showers/bed baths on residents scheduled days, and if they refuse, they get the nurse to help encourage the resident to take one. During an interview on 08/27/26 at 9:21 A.M., the Administrator and Director of Nursing (DON) verified Resident #41 did not receive showers or bed baths as preferred and scheduled. 2. Record review of Resident #70 revealed an admission date of 10/07/19 with diagnoses of radiculopathy, type II diabetes mellitus with diabetic autonomic neuropathy, major depressive disorder. Review of the MDS 3.0 assessment 08/05/26 revealed Resident #70 was cognitively intact and was dependent on staff for ADL. Review of the care plan 08/07/26 revealed Resident #70's care plan revealed a preference of showers on Monday, Wednesday, and Friday during dayshift. Record review of shower sheets provided revealed Resident #70 did not receive showers on 07/01/26. 07/03/26, 07/06/26, 07/08/26, 07/13/26, 07/15/26, 07/17/26, 07/24/26, 07/29/26, 08/05/26, 08/07/26, 08/12/26, 08/19/26, and 08/21/26. Interview with LPN #18 on 08/27/26 at 7:34 AM revealed the nurses are notified of resident refusals of showers/bed baths and they go and encourage the resident to take one. LPN #18 stated the aides fill out a sheet for showers/bed baths. During an interview on 08/27/26 at 7:41 A.M. CNA #58 revealed they offer showers/bed baths on residents scheduled days, and if they refuse, they get the nurse to help encourage the resident to take one. The staff fill out a sheet for showers/bed baths. During an interview on 08/27/26 at 9:21 A.M., the Administrator and DON verified Resident #70 did not receive showers or bed baths as preferred and scheduled. 3. Review of the medical record revealed Resident #75 was admitted on [DATE] with diagnosis of intervertebral disc degeneration, thoracolumbar region, adult failure to thrive, morbid (severe) obesity due to excess calories, asthma, essential (primary) hypertension, autonomic neuropathy in diseases classified elsewhere, mood disorder due to known physiological condition with mixed features, generalized anxiety disorder, major depressive disorder, recurrent, chronic pain, muscle weakness (generalized), and difficulty walking. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #75 was cognitively intact and had no impairment in functional limitation in range of motion, she required set up or touching assistance for ADL. Resident #75 was ordered bed baths every night before treatments for fungal rashes per physician and showers twice weekly. Review of the care plan dated 07/06/26 revealed Resident #75 had a self-care deficit in ADL and mobility. Resident #75 to be well groomed, clean, and neat. Resident #75's care plan revealed at risk for skin breakdown and an intervention to complete skin assessments every four weeks. Review of the shower/bath sheets revealed Resident #75 did not receive nightly bed baths as ordered from 08/01/26 to 08/03/16, 08/05/26, 08/06/26, 08/08/26 to 08/13/26, 08/14/26, 08/16/26, 08/17/26, and 08/21/26 to 08/26/26. During an interview on 08/24/26 at 11:11 A.M., Resident #75 revealed she has not been getting bed baths every night as ordered. During an interview on 08/27/26 at 7:34 A.M., LPN #18 revealed the nurses were notified of resident refusals of showers/bed baths, and they were to encourage the resident to take one. LPN #18 stated the aides fill out a sheet for showers/bed baths. During an interview on 08/27/26 at 7:41 A.M. CNA #58 revealed they offer showers/bed baths on residents scheduled days, and if they refuse, they get the nurse to help encourage the resident to take one. The staff fill out a sheet for showers/bed baths. During an interview on 08/27/26 at 9:21 A.M., the Administrator and DON verified Resident #70 did not receive nightly bed baths as ordered. Review of the undated facility bathing policy revealed all residents will be assessed for their preferences related to bathing, frequency of bathing including days and times of bathing. The bathing schedule is able to be adjusted at any time per resident needs and requests. This deficiency represents non-compliance investigated under Master Complaint Number 3134111 and Complaint Number 3075479.

Based on observation, record review and interview, the facility did not consistently ensure narcotic medication was properly reconciled. This had the potential to affect 17 residents (Residents #1, #11, #17, #23, #27, #30, #45, #46, #47, #48, #49, #51, #54, #58, #60, #69 and #75) of 17 residents who receive narcotic medications from the facility including . The facility census was 78.Findings include:Review of Station #1's narcotic Controlled Substance Count Sheet form from 02/01/26 to 03/20/26 revealed a second nursing signature was not on the form for the date of 02/09/26.Review of Station #2's narcotic Controlled Substance Count Sheet form from 02/01/26 to 03/20/26 revealed a second nursing signature was not on the form for the dates of 02/11/26, 02/17/26 and 02/21/26.Review of Station #4's narcotic Controlled Substance Count Sheet form from 02/01/26 to 03/20/26 revealed a second nursing signature was not on the form for the dates of 02/05/26, 02/09/26 and 03/06/26.Interview on 03/20/26 at 1:10 P.M. with the Administrator confirmed the above findings.Review of the undated Controlled Substance Shift to Shift Count Policy revealed the purpose was to ensure all narcotic medications that were being counted by two nurses on staff during any shift-to-shift handoff and that the count was then signed off by two nurses to verify the narcotic count was correct.This deficiency represents non-compliance investigated under Complaint Number 2786595.

Based on record review and interview, the facility failed to ensure Resident #81 was free from significant medication error. This affected one resident (Resident #81) of five resident records reviewed for medication administration. The facility census was 78.Findings include:Review of Resident #81's medical revealed the resident was admitted on [DATE] and discharged on 01/30/26 with diagnoses including small b-cell lymphoma unspecified site, difficulty in walking, need for assistance with personal care and cardiomegaly.Review of Resident #81's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #81's physician orders revealed an order dated 01/07/26 (discontinued 01/13/26) for Ibrutinib (a targeted cancer medication to treat lymphoma) oral capsule 140 mg give three tablets by mouth at bedtime; an order dated 01/15/26 for Ibrutinib oral capsule 140 mg give three tablets by mouth at bedtime (hold from 01/17/26 to 01/24/26) and discontinued 01/31/26).Review of Resident #81's mediation administration records (MARS) from 01/07/26 to 01/31/26 revealed Ibrutinib medication was not administered on 01/07/26, 01/08/26, 01/15/26, 01/25/26, 01/26/26 and 01/27/26. The medical record did not contain evidence to why the medication was not administered.Interview on 03/20/26 at 1:56 P.M. with the Director of Nursing (DON) revealed the pharmacy did not have the medication available and she felt the oncologist had stopped it. The DON confirmed the medical record did not have evidence of this information.Review of the undated Medication Administration Policy revealed medications were administered in accordance with written orders of the prescriber.This deficiency represents non-compliance investigated under Complaint Numbers 2786595 and 2704190.

Based on record review and interview, the facility failed to ensure medication refrigerators were maintained at an appropriate temperature. This had the potential to affect all residents in the facility. The facility census was 78. Findings include:Review of Station #1 Unit Temp Log Check form from 03/01/26 to 03/20/26 revealed no evidence the temperatures of the medication refrigerator were obtained on 03/05/26, 03/13/26 and 03/19/26.Review of Station #2 Unit Temp Log Check form from 03/01/26 to 03/20/26 revealed no evidence the temperatures of the medication refrigerator were obtained on 03/10/26, 03/02/26, 03/03/26, 03/04/26, 03/05/26, 03/07/26, 03/08/26, 03/09/26, 03/12/26, and 03/13/26.Review of Station #4 Unit Temp Log Check form from 03/01/26 to 03/20/26 revealed no evidence the temperature of the medication refrigerator was obtained on 03/17/26.Interview on 03/20/26 at 1:10 P.M. with the Administrator confirmed the above findings.Interview on 03/20/26 at 1:56 P.M. with the Director of Nursing (DON) confirmed the refrigerator temperature logs from 02/01/26 to 02/28/26 were missing and unable to be located.Review of the undated Medication Refrigerator Temperature Check Policy revealed the purpose was to ensure all medication storage refrigerators were within proper temperature range and all medication refrigerators were to be checked daily.This deficiency represents non-compliance investigated under Complaint Number 2786595.

Based on record review, staff interview, review of personnel records and facility policy review, the facility failed to ensure the integrity and security of controlled substances and failed to maintain accurate narcotic destruction records as required, when Licensed Practical Nurse (LPN) #694 forged LPN #677's signature on a controlled drug record for Residents #483. This affected one resident (#483) of three residents reviewed for controlled medications. The facility census was 68.Findings include:Review of Resident #483's medical record revealed an admission date of 09/26/25 with diagnoses including fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, presence of right artificial hip joint, malignant neoplasm of overlapping sites of colon, malignant neoplasm of pancreas, unspecified, type II diabetes mellitus with diabetic autonomic (poly)neuropathy, essential (primary) hypertension, mixed hyperlipidemia, other acute postprocedural pain, pain in right hip, neoplasm related pain (acute)(chronic),trigeminal neuralgia, major depressive disorder, recurrent, unspecified, generalized anxiety disorder, autonomic neuropathy in diseases classified elsewhere, history of falling, muscle weakness (generalized), personal history of transient ischemic attack (TIA), cerebral infarction without residual deficits, and personal history of other venous thrombosis and embolism, long term (current) use of anticoagulants.Review of Resident #483 progress notes dated 09/12/25 revealed Resident #483 began palliative services.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #483 had impaired cognition and functional limitation in range of motion (ROM) to one side in the lower extremities. Resident #483 was dependent on staff for mobility and frequently incontinent.Review of the September 2025 medication administration record (MAR) for Resident #483 revealed an order dated 09/12/25 (discontinued 09/26/25) for oxycodone w/acetaminophen (APAP) 5/325 milligrams (mg) (opioid pain medication) one tablet by mouth every four hours for pain.Review of the controlled drug record revealed on 09/16/25 an oxycodone w/APAP 5/325 was signed as wasted by LPN #694 and initialed by (LPN #677) as witnessing LPN #694 waste the medication. Interview on 12/04/25 at 11:42 A.M. with the Director of Nursing (DON) revealed on 09/16/25 LPN #694 signed that she wasted a narcotic forging another nurse's (LPN #677) initials as a witness. The DON was not made unaware of this until 09/19/25. At that time, LPN #694 was suspended and an investigation began. LPN #694 was suspended from 09/20/25 through 09/23/23. LPN #677 was on shift; was aware LPN #694 wasted narcotic and did not get back to station to witness the wasting of the narcotic and initial as a witness in the controlled drug record with LPN #694. LPN #677 was disciplined for medication wasting policy and was written up and educated on 10/08/25. One-on-one education and competencies were completed with all nurses.Interview on 12/04/25 at 12:37 P.M. via telephone with LPN #694 revealed she wasted a narcotic for a resident (Resident #483) on 09/16/25 and asked another nurse, LPN #677, to waste it with her. LPN #677 said, just put my initials, I trust you. LPN #694 indicated she put LPN #677's initials and wasted the narcotic in the shred box. LPN #694 indicated this was the only incident. Review of personnel records for LPN #694 revealed a disciplinary form dated 09/24/25, stating LPN #694 did not follow the facility's medication administration and wasting policy. LPN #694 was placed off duty during the investigation and was suspended from 09/20/25 through 09/23/25 and returned on 09/24/25 after a negative drug test. Review of personnel records for LPN #677 revealed a disciplinary form dated 10/08/25, stating LPN #677 did not follow the facility's medication administration and wasting policy. LPN #677 was given a written warning.Review of the facility's medication administration policy, dated 03/20/19, revealed the DON, nurse, and/or pharmacist witnessing the destruction ensures the following information entered on the individual controlled substance accountability record book to include date of destruction, resident's name, name and strength of medication, prescription number, amount of medication destroyed, and signatures of witness.This deficiency represents noncompliance investigated under Complaint Number 2639628.

Based on record reviews, fall investigation reviews, interviews and facility policy review, the facility failed to ensure falls were thoroughly investigated for Residents #17 and #72. This affected two residents (#17 and #72) of three residents reviewed for falls. The facility census was 70. Findings include:1. Review of the medical record for Resident #17 revealed an admission date of 03/07/25. Diagnoses included history of falling, protein calorie malnutrition, hypertension, high cholesterol, gastroesophageal reflux disease (GERD), glaucoma, delirium, muscle weakness and hearing loss. Review of the fall risk assessment dated [DATE] revealed Resident #17 was at moderate risk for falls. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired. She required supervision for eating, partial to moderate assistance for oral hygiene and showering and was dependent on staff for toileting and dressing. She was frequently incontinent of urine, always incontinent of bowel and was dependent on staff for rolling left to right, sitting to lying, lying to sitting on one side of the bed and sitting to standing or chair to bed transfers. Review of the physician's orders for August 2025 revealed an order for two quarter top positioning bars when up in bed to aid in positioning which began on 03/10/25, an alarm to the bed and wheelchair for safety which began on 05/08/25, a perimeter mattress which began on 05/23/25, and an order for one person assist with bed mobility, transfers and toileting using a front wheeled walker which began on 08/14/25. Review of the nursing note dated 05/22/25 at 5:51 P.M. revealed Licensed Practical Nurse (LPN) #201 was notified by Certified Nurse Aide (CNA) #207 that Resident #17 was out of bed. LPN #201 observed Resident #17 with both legs on the floor and her left arm in between the mattress and the bed railing facing into the mattress. When asked what happened, Resident #17 was unable to respond appropriately and stated, they are calling my mother. Vital signs were obtained, and the resident's blood pressure was 159/98, heart rate 88, pulse ox 94%, temperature 98.2 degrees Fahrenheit (F) and range of motion was within normal limits. The resident denied pain, and no injuries were noted. Resident #17's family, physician and the Director of Nursing (DON) were notified. The call light was noted to be in reach, the bed was in the lowest position, and an intervention of a perimeter mattress and floor mat were put into place. Review of the facility incident report dated 05/22/25 revealed Resident #17 was observed with both legs out of bed, with her left arm wedged in between the mattress and the arm rail. No injuries were noted. The resident was noted to be confused, incontinent with an unsteady gait, impaired memory, recent medication changes and weakness. She was oriented to person only. No predisposing factors were identified. There was no documented evidence of when she had last been toileted. Review of the care plan dated 05/25/25 revealed Resident #17 was at risk for falls due to gait and balance problems, history of falling and glaucoma. Interventions included a bed alarm, ensuring the call light within reach, a chair alarm and two quarter top positioning bars when up in bed to aid in positioning. Review of the nursing note dated 06/13/25 at 2:18 P.M. revealed LPN #202 was outside Resident #17's room when she heard her yelling for help. She went into the room to find the resident holding on to the side rail but still on the bed with her legs hanging out of the bed with blood on the floor and sheets. She called for assistance and CNAs #206 and #208 came into the room and assisted in applying pressure to Resident #17's lower extremity. The resident was assisted back into bed and presented with a large deep laceration into the fatty layers of her upper thigh. An ambulance was already in the facility for another resident; however, it was determined Resident #17's needs were greater, therefore she was taken to the emergency department (ED). Resident #17's daughter was notified; her vital signs were not able to be obtained before ambulance transport. The resident returned from the ED approximately 6:00 P.M. with 15 stitches to the laceration on the inside of her right thigh. Review of the facility incident report dated 06/13/25 revealed Resident #17 was yelling for help and found almost out of bed with blood all over. CNAs #206 and 208 assisted in getting the resident back into bed while LPN #202 attended to and addressed the injury, a deep laceration to inner right thigh. The resident was oriented to person in place, hearing impaired and did not use her call light for assistance. She was immediately sent to the ED. There was no description of the condition of the room, no indication if the bed alarm was in use or activated, no information regarding a perimeter mattress or floor mat and no evidence that the call that was within reach. Witness statements obtained as part of the investigation revealed LPN #202 was outside Resident #17's room when she heard her yell for help. The resident was found halfway out of her bed with the upper half of her body in her bed holding onto the side rail. Blood was noted on the sheets on the floor. Additional staff came to the room and assisted in getting Resident #17 back into bed. The resident was transported to the ED by ambulance. There was no documented evidence to determine if the call light was in reach, if the perimeter mattress was in place, what the room looked like, or when Resident #17 had last been toileted in the witness statements. Interview on 08/25/25 at 9:57 A.M. with LPN #202 revealed she happened to be walking by Resident #17's room when she heard her scream, so she entered her room. She said her tray table was at the end of her bed and she looked around but could not locate any source that may have caused the laceration to her leg. Interview on 08/25/25 at 10:12 A.M. with LPN #205 revealed Resident #17 was incontinent of both bowel and bladder at the time of the fall on 06/13/25. She confirmed Resident #17 should have been toileted every two hours and she believed the last time she had seen the resident was approximately 15 to 20 minutes prior to the incident. She confirmed there was a bed alarm on Resident #17's bed; however, it had not been activated because the resident was still halfway on the bed. She revealed the residents' bedside table was between the middle and the head of the bed at an angle and there was no indication of what may have caused the injury. Interview 10/25/25 at 10:20 A.M with CNA #206 revealed she had helped Resident #17 into bed approximately 10 minutes before the incident and toileted her at that time. She heard the resident scream and found her on her bed with her elbows propped up on the bed and her legs on the floor. She revealed that tray side table was over the top of her legs, but no blood was noted on the tray side table. She stated Resident #17 was incontinent of both bowel and bladder at the time of the fall. She could not confirm if a perimeter mattress was in place at the time but confirmed her call light was within reach. Interview on 08/25/25 at 12:14 P.M. with the DON verified the facility's fall investigations likely needed to be updated to ensure accuracy and thoroughness and should have included all interventions in place at the time of the falls for Resident #17 to determine a root cause analysis of the fall. 2. Review of the medical record for Resident #72 revealed an admission date of 04/14/25 and a discharge date of 07/17/25. Diagnoses included urinary tract infection, osteoporosis, hypertension, vitamin D deficiency, anxiety, muscle weakness and history of falling. Review of the fall risk assessment data 04/14/25 revealed Resident #72 was at moderate risk for falls. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #72 was moderately cognitively impaired. She required supervision for eating oral and personal hygiene and partial to moderate assistance with toileting and showering. She was occasionally incontinent of urine and bowel. Review of the care plan dated 04/21/25 revealed Resident #72 was at risk for falls due to muscle weakness, history of falls, and difficulty walking. Interventions included ensuring the call light was within reach, maintaining a clear pathway and two quarter top positioning bars when up in bed to aid in positioning. Review of the nursing note dated 05/15/25 at 3:00 P.M. revealed Resident #72 was found on the floor in front of her wheelchair in her room. She said she was attempting to self-ambulate and was unable to keep her balance. She said she hit her head on the floor. A red area to her left hip and left upper head were noted. Here vital signs were noted to be within normal limits; however, they were not documented. The resident was assisted to her wheelchair, and her physician, the DON and daughter were notified. Her daughter asked that the resident be sent to the ED. Review of the facility incident report dated 05/15/25 revealed Resident #72 was attempting to self-ambulate when she lost her balance, there was an alarm (no order for an alarm) sounding at the time of the incident. The resident was assessed and both neurological checks and vital signs were stated to be within normal limits; however, neither were included in the report. Resident #72 was listed as confused but oriented to person. Predisposing factors were listed as weakness, gait imbalance and ambulating without assistance. The investigation revealed no evidence of the residents' call light being in reach. Review of the nursing note dated 07/11/25 at 10:58 A.M. revealed Resident #72 was found on the floor with no signs of injury. The resident was confused and unable to answer questions, could not follow the light with her eyes. The resident was sent to the ED, and both her daughter and son were notified as well as the physician and DON. Review of the facility incident report dated 07/11/25 revealed Resident #72 was found on the floor by LPN #205 and was assisted into her wheelchair along with an unnamed CNA. A skin assessment was completed, and no visible signs of injury were noted. The resident could not indicate if she hit her head but was unable to answer questions or follow direction. The resident's vital signs were obtained with a blood pressure of 116/70, pulse ox 99%, temperature 97.9 degrees F, heart rate 80, and no pain. Neurological checks were reported as within normal limits; however, there was no documented evidence of the neurological checks. The resident was sent to the ED for an evaluation. The resident was confused with predisposing factors of incontinence, gait imbalance and not using her call light for assistance. The investigation did not reveal if the resident's call light was within reach or when she was last toileted. Interview on 08/25/25 at 12:14 P.M. with the DON revealed Resident #72 had no physician's order or care plan addressing a bed or chair alarm. She verified the facility's fall investigations likely needed to be updated to ensure accuracy and thoroughness and should have included all interventions in place at the time of the falls for Resident #72 to determine a root cause of the fall. Review of the undated facility policy titled Fall Prevention Procedure/Policy revealed the facility would document and evaluate any fall that occurred while the patient resided at the facility including when and where and observations of the event. The facility would assess, and document vital signs, recent injuries, neurological status, precipitating factors and details of how a fall occurred. The nurse would assess the patients' vital signs, range of motion and any injuries as well as identify environmental factors that may have contributed to the fall. This deficiency represents noncompliance investigated under Complaint Number 2584229.

Based on observation, record review, facility policy review, and interview, the facility failed to develop and implement a comprehensive, individualized and effective pain management program for Resident #273 and Resident #66. This affected two residents (#273 and #66) of two residents reviewed for pain. The facility census was 67. Actual harm occurred beginning on 02/20/25 when the facility failed to ensure narcotic (pain) medication (that Resident #273 had been receiving prior to admission) was ordered and provided at the time of and timely following admission to manage the resident's pain. On 02/21/25 and 02/22/25 the resident reported constant pain, all over that limited his functional abilities during therapy evaluations. On 02/23/25 the resident refused therapy due to pain and was teary-eyed. On 02/24/25 at 10:01 A.M., Resident #273 stated he was in constant pain all over. The resident was tearful and covered his face with his hands and was lying in bed with his knees bent and stated he couldn't straighten his legs because it hurt too bad. The resident reported staff told him they were unable to give him anything stronger than Tylenol for pain until he was evaluated by a physician, and the resident had not yet been seen by the physician. Findings include: 1. Review of the medical record for Resident #273 revealed an admitted [DATE] with diagnoses of osteoarthritis (OA), chronic gout, major depressive disorder, chronic pain, pain in right and left ankles and feet. Review of medical record revealed Resident #273 was admitted from another nursing facility with active order for Norco Oral tablet 5/325 mg (opioid pain medication) every six hours as needed for pain. In review of the admission orders, there was no order for Norco on admission. Review of Resident #273's admission assessment dated [DATE] revealed Resident #273 was alert and oriented to person, place, time and situation and that he was verbally appropriate. The admission assessment also revealed Resident #273 relayed no pain upon admission. An admission falls assessment dated [DATE] stated Resident #273 required assistance with activities of daily living (ADL) self-performance, had an unsteady gait and used an assistive device for mobility. Review of Resident #273's Physical Therapy (PT) Evaluation dated 02/21/25 revealed Resident #273 rated his pain at rest at seven on a pain scale of zero to ten, ten being the worst, and pain with movement at nine, frequency and duration of the pain as constant and location of the pain as all over, all my joints, everywhere. The PT eval also revealed that Resident #273 verbalized pain and that the pain limits his functional abilities. Clinical Impressions in the PT assessment summary reveal severe pain limiting activity tolerance and functional mobility. Review of Resident #273's Occupational Therapy (OT) Evaluation dated 02/22/25 reveals Resident #273 rated his pain at rest at six and pain with movement at nine, frequency and duration of the pain as constant and location of the pain as all over. The OT eval also revealed that Resident #273 verbalized pain and that the pain limited his functional abilities. Review of the PT notes dated 02/23/25 reveal Resident #273 was teary-eyed throughout the therapy session and reported frustration with pain and Resident #273 declined further therapeutic exercises on that date. Review of the medical record revealed Resident #273 was ordered Tylenol 325 mg (analgesic) two tablets by mouth every four hours as needed for pain beginning on 02/24/2025 at 6:30 P.M. Review of the Medication Administration Record (MAR), he was given his first dose of Tylenol on 02/24/25 at 8:38 P.M. Interview with Resident #273 on 02/25/25 at 12:17 P.M. revealed Resident #273 was awake and lying in bed. He rated his pain at five, and he was tearful. The resident was hiding his face in his hands and stated he was in pain overnight but was offered nothing for pain. He also stated he had not yet seen a doctor. Observation of Resident #273 on 02/26/25 at 8:23 A.M. revealed he was awake and lying in bed. The surveyor observed Certified Nursing Assistant (CNA) #462 check on Resident #273 who stated he was in a lot of pain; CNA #462 stated that he would tell the nurse. Interview with Licensed Practical Nurse (LPN) #497 on 02/26/25 at 10:43 A.M. revealed Resident #273 expressed pain a lot but would not take Tylenol because he stated it doesn't help. LPN #497 was on her way to help the CNAs weigh the resident and stated she would assess his pain at that time. LPN #497 also stated Resident #273 was last medicated for pain with Tylenol on 2/24/25 at 8:38 P.M. which Resident #273 stated was effective; this was verified by record review. Interview with LPN #497 on 02/26/25 at 11:08 A.M. revealed Resident #273 refused to take Tylenol that morning and said, I tried it before and it doesn't work. LPN #497 stated she planned to reach out to the physician for further intervention. Interview with Nurse Practitioner (NP) #506 on 02/26/25 at 2:43 P.M. revealed she saw Resident #273 that afternoon and when she entered his room, he was lying in bed on his phone and was not expressing any non-verbal signs of pain. She stated that during her examination, Resident #273 stated he had burning pain in his feet and could not straighten out his legs due to pain. She prescribed Tramadol 50 mg (opioid analgesic) every six hours as needed since Resident #273 said the Tylenol does not help him. Review of Resident #273's medical record on 02/26/25 at 4:32 P.M. and review of pain assessment in Treatment Administration Record (TAR) show no pain identified for Resident #273 during all but two shifts since admission. Interview with LPN #497 confirmed this at the time of the review and stated the resident expressed pain a lot and could not account for why there were so many zeroes marked in the TAR regarding Resident #273's pain. Review of the care plan dated 02/27/25 revealed Resident #273 was at risk for pain and the goals were that the pain and discomfort would be controlled as evidenced by no signs or symptoms of pain and no complaints of pain. The care plan interventions included staff should note if pain medications were effective and notify medical doctor (MD) as indicated. Observation of Resident #273 on 02/27/25 9:28 A.M. revealed the resident was awake and alert in bed. The resident stated his pain was not too bad this morning and expressed his feeling that the new medication that was ordered had helped. He stated he hoped to participate in therapy later that day. Observation of Resident #273 on 03/03/25 at 9:05 A.M. revealed complaints of pain in both feet and stated his pain was at seven. Resident #273 stated he had been taking pain medication but did not feel any different. He was lying in bed moaning with pained facial expression. He stated the nurse was aware of his pain that morning, and she had just left his room after medicating him with Tramadol. Interview with the Director of Nursing (DON) on 03/03/25 at 12:19 P.M. revealed when residents were admitted from another facility, the admission orders were taken from the other facility's order summary and verified with the physician. A follow-up interview with DON on 03/03/25 at 3:36 P.M. confirmed Norco orders did not transfer to admission orders because this facility's doctors do things differently than other facility's doctors, and there was no chronic condition indicated for the use of Norco. The DON was unable to state where in the chart that would be documented. Interview with LPN #510 on 03/03/25 at 3:48 P.M. confirmed Resident #273's pain inhibited his ability to walk to the bathroom and his willingness to get up to use the commode. Observation of Resident #273 on 03/03/25 at 3:50 P.M. revealed the resident was lying in bed on his back, knees bent. He was awake and alert and stated he was in some pain. He stated he took a pain pill earlier. Interview with CNA #401 on 03/03/25 3:54 P.M. revealed Resident #273 doesn't allow her to touch him due to pain. He resists getting dressed or bathed because he is in too much pain. Interview with Resident #273 on 03/04/25 10:48 A.M. revealed he was about the same and rated his pain at six. He was lying on his bed with a pained facial expression and his knees were bent. Review of the undated facility pain policy revealed if the presence of pain was identified or the resident has an order for pain medication, an assessment would be completed to determine the intensity, location and interventions required. The pain policy also stated ineffective pain control, or the onset of new pain would trigger a further assessment of the pain and interventions used. 42013 2. Review of Resident #66's medical record revealed an admitted [DATE] with diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the left non-dominant side, aphasia (language disorder that affects the ability to communicate effectively) following cerebral infarction, dysphagia (difficulty swallowing), dysarthria (slurred speech) following cerebral infarction and vascular dementia. Review of Resident #66's care plan dated 01/12/25 included Resident #66 was at risk for pain related to cerebral vascular accident (CVA) with left sided weakness. Resident #66 would display signs of comfort and would have no signs and symptoms or complaints of pain or discomfort. Resident #66 would report pain was resolved with medication and other interventions. Interventions included assessing symptoms of pain on occurrence and documenting location and pain scale as reported by the resident; notifying the physician as indicated; providing pain medication as prescribed. Review of Resident #66's physician orders dated 01/23/25 revealed acetaminophen tablet 325 mg, give two tablets by mouth every four hours as needed for general discomfort. Review of Resident #66's progress notes dated 01/31/25 at 6:42 A.M. included the nurse entered Resident #66's room to help transfer him into his wheelchair so he could be assisted to the dining room for breakfast. Resident #66 stated he did not want to get up in the chair or go to the dining room due to his left knee hurting. Review of Resident #66's Medication Administration Record (MAR) dated 01/31/25 did not reveal pain medication including acetaminophen was administered. Resident #66's MAR on 01/31/25 from 6:42 A.M. through 7:00 P.M. did not reveal evidence his pain was rated on a scale of zero to ten, zero being no pain and ten being the worst pain. Review of Resident #66's MAR dated 02/01/25 through 02/26/25 revealed there was no evidence Resident #66's pain was evaluated on 02/07/25 day shift, 02/08/25 day shift and 02/14/25, 02/15/25, 02/23/25 day shift. On 02/26/25 during day shift, Resident #66's pain was rated at a zero on a pain scale with zero being no pain and ten being the worst pain. Review of Resident #66's PT evaluation and plan of treatment dated 02/08/25 included Resident #66's pain at rest was rated as a five out of a ten, zero being no pain and ten being the worst pain. Resident #66's pain was intermittent, he had left sided hypersensitivity, and the pain was described as shooting pain. Resident #66's pain with movement was rated as a ten out of ten on a zero to ten pain scale. Resident #66's pain was intermittent, he had left sided hypersensitivity, and the pain was described as shooting. Resident #66 communicated pain using the faces pain rating scale. Pain limited Resident #66's functional activities. Resident #66 received pain medications on a scheduled program, and Resident #66 received pain medications as needed. Upon evaluation, Resident #66 presented with impaired bilateral lower extremity (BLE) strength the left greater than the right, left sided hemiparesis, hypersensitivity and neglect, impaired functional mobility compared to baseline, impaired balance, impaired activity tolerance and pain. Due to documented physical impairments and associated functional deficits, Resident #66 was at risk for increased tone, limiting functional movement and increased pain. Review of Resident #66's OT evaluation and plan of treatment dated 02/09/25 included Resident #66's pain at rest was a four out of a ten, on a zero to ten pain scale, the pain was located in the left knee, was constant and described as sharp. Resident #66's pain with movement was a seven out of ten on a zero to ten pain scale, the pain was in the left knee, was constant and described as sharp pain. Resident #66 verbalized his pain level and the pain limited Resident 366's functional activities. Resident #66's pain interventions were unknown. Review of Resident #66's MAR dated 02/08/25 and 02/09/25 did not reveal pain medication including acetaminophen was administered. Further review of the MAR dated 02/09/25 revealed Resident #66's pain was rated as zero. Review of Resident #66's progress notes dated 02/08/25 and 02/09/25 did not reveal documentation related to pain. Review of the 5-day Medicare Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 was cognitively intact. Resident #66 was dependent on staff for toileting hygiene and lower body dressing. Resident #66 required substantial to maximal assistance with bathing. Resident #66 had an indwelling catheter and was always incontinent of bowel. Resident #66 did not reject care during the seven-day assessment look-back period. Resident #66 was not on a scheduled pain regimen. He received as needed (PRN) pain medications and did not receive non-medication pain regimen. The MDS states a pain assessment interview should not be conducted because the resident was rarely/never understood. The staff assessment for pain stated Resident #66 had indicators of pain in the last five days including facial expressions (grimaces, winces, wrinkled forehead, furrowed brows, clenched teeth or jaw) observed one to two days. Review of Resident #66's physician orders dated 02/21/25 revealed Baclofen oral tablet 10 mg (muscle relaxant), give one tablet by mouth every eight hours as needed for spasms. Review of Resident #66's MAR dated 02/21/25 through 02/26/25 did not reveal Resident #66 was administered Baclofen 10 mg. Interview on 02/25/25 at 2:42 P.M. of Director of Rehab (DOR) #509 revealed Resident #66 received PT, OT, and Speech Therapy (ST). DOR #509 stated Resident #66 had difficulty with expressive and receptive communication and they were working on things like word retrieval, following commands, auditory processing and yes and no accuracy. PT and OT were working on lower and upper extremity strengthening. DOR #509 stated Resident #66 used a mechanical lift for transfers. Observation on 02/26/25 at 9:58 A.M. of Resident #66 revealed CNA #462 and CNA #491 were preparing Resident #66 to be transferred to his wheelchair using a mechanical lift. LPN #402 was standing at Resident #66's bedside along with CNA's #462 and #491. Observation of Resident #66 revealed he had facial grimacing, grunted, and cried out in pain when the mechanical lift started to lift him out of the bed. Resident #66's left leg was pulled up towards his upper body and when CNA #491 attempted to straighten it during the transfer Resident #66 cried out in pain and he had a worried look on his face. CNA #491 did not continue attempting to strengthen his leg. CNA #462 stated Resident #66 used to want to come out of his room much more when he first arrived at the facility than he did now. LPN #402 instructed the aides that when Resident #66 was uncomfortable and in pain during mechanical lifts they should get a staff person from therapy to assist them with Resident #66's positioning during transfers. Interview on 02/26/25 at 12:12 P.M. of Occupational Therapy Assistant (OTA) #508 and PT #507 revealed they worked with Resident #66 on things like simple grooming and hygiene, unsupported sitting, passive stretching, gentle range of motion. OTA #508 stated Resident #66 was having quite a bit of pain in his left arm and left leg. PT #507 stated Resident #66's left leg had a lot of tone and was drawn in, and he babied his left arm because it hurt. PT #507 stated she thought Resident #66 was receiving a muscle relaxant. PT #507 stated pain was a dominant thing that was limiting Resident #66's participation in therapy, and his tolerance for therapy was limited. PT #507 stated Resident #66 used to be up a lot but was now spending more time in bed. PT #507 and OTA #508 stated they had been in communication with the nursing staff regarding Resident #66's pain, but they could not remember which nurses they told about Resident #66's pain. PT #507 stated Resident #66 laid on his left side, he favored it, and it was hard to get him positioned so he does not lay like that. OTA #508 stated Resident #66 was cooperative with his therapy and wanted to do well, but his pain interfered with therapy. OTA #508 and PT #507 stated they did not document Resident #66's pain every day when he had therapy because his pain was constant and chronic and everyone knows he had a lot of pain including the nurses. PT #507 stated Resident #66 could not verbalize the type of pain he was having, but had facial grimacing, and you could tell he was in pain. PT #507 stated Resident #66's pain could be the reason he did not want to come out of his room. Interview on 02/26/25 at 3:23 P.M. of NP #506 revealed she evaluated Resident #66's pain and stated when someone moved him he was in pain and when he was laying still he did not have pain. NP #506 stated Resident #66 was ordered Baclofen 10 mg tablet as needed but the nurses were not giving it to him. NP #506 stated she ordered Baclofen 5 mg tablet to be given on a schedule three times a day. Review of Resident #66's MAR dated 02/26/25 did not reveal pain medication including acetaminophen was administered. Review of Resident #66's physician orders dated 02/26/25 revealed Baclofen oral tablet 5 mg, give one tablet by mouth three times a day for spasms. Interview on 02/27/25 at 8:37 A.M. of CNA's #420 and #444 revealed Resident #66's left leg was bent and pulled up towards his chest and CNA #420 stated he could not straighten his leg because it caused pain when they tried to straighten it. CNA #420 stated on 02/24/25 and 02/25/25 Resident #66 was in pain and not tolerating much in the way of care, but today his pain seemed better. Review of Resident #66's MAR dated 02/24/25 and 02/25/25 revealed Resident #66's pain for day and night shift was rated as a zero on a scale of zero to ten, zero being no pain and ten being the worst pain. Interview on 03/03/25 at 9:35 A.M. of LPN #402 revealed Resident #66 was uncomfortable and in pain when she was in his room on 02/26/25 assisting with his transfer using a mechanical lift. LPN #402 stated she was not the nurse assigned to Resident #66 on 02/26/25 and she did not remember if she told the nurse assigned to him if he was having pain. Interview on 03/03/25 at 12:05 P.M. of LPN #497 revealed she did not know why on 02/26/25 she put a zero for Resident #66's pain rating and could not remember details. Interview on 03/04/25 at 11:06 A.M. of PT #507 revealed Resident #66 was still in pain and she could just see it in his face when he received therapy. PT #507 stated she wished the facility would at least try a pain medication to see if it was effective. Interview on 03/04/25 at 11:30 A.M. of the DON revealed after the surveyor told her PT #507 stated Resident #66 was still in pain when he received therapy, the DON indicated she would reach out to NP #506 for pain medication and maybe they could try Botox. Review of the facility policy which was untitled and undated included the purpose of the policy was to safely control a resident's prolonged pain and maintain a pain free existence in achieving an optimal level of comfort. It was the policy of the facility to assess residents for the presence of pain and provide pain relief measures. All residents would be assessed for pain on admission and on an on-going basis. If the presence of pain was identified or the resident had an order for pain medication an assessment would be completed to determine the intensity, location and interventions required.

Based on observations, interviews, record review, and review of the facility menu spreadsheets and facility policy, the facility failed to follow the menu for dinner on 02/25/25 for all residents on a regular texture and mechanical soft diet. This affected all residents receiving meals from the kitchen excluding 11 residents (#10, #11, #13, #21, #28, #40, #43, #57, #59, #61, and #225) the facility identified as receiving a pureed diet, one resident (#52) who received nothing by mouth (NPO) and Resident #22 who the facility identified as having a special preference noted to receive bread and margarine at the dinner meal. The facility census was 67. Findings include: Review of the facility spreadsheet for Tuesday week three dinner (02/25/25) revealed residents on a regular texture or a mechanical soft diet were to receive one number six scoop (five and one third ounces) of cheese tortellini with marinara sauce, one four ounce spoodle (a type of serving utensil which was a combination between a spoon and a ladle) of steamed Brussel sprouts, one slice of bread with one teaspoon of margarine, and one two-inch by two-inch piece of chocolate cream cake. Observation on 02/25/25 from 3:35 P.M. to 5:00 P.M. revealed there was no bread or margarine near the tray line for the meal. No residents on a regular texture or mechanical soft diet received a slice of bread with margarine, except Resident #22 who had a slice of bread and margarine listed as a preference for the meal. Review of the medical record for Resident #18 revealed an admitted [DATE]. Diagnoses included diabetes mellitus, hypertension (high blood pressure), and dysphagia (difficulty swallowing). The resident was severely impaired cognitively, was on a No Concentrated Sweets (NCS) diet, regular texture and regular/thin liquids, and was able to feed himself after meal set up. The resident was at nutritional risk related to being morbidly obese and by not making choices in the best interest of his nutrition. Interview on 02/25/25 at 5:02 P.M. with Resident #18 revealed he would have liked bread with his meal. Review of the medical record for Resident #122 revealed an admitted [DATE]. Diagnoses included diabetes mellitus, intestinal obstruction, congestive heart failure (CHF), and gastrointestinal reflux disease (GERD). The resident was moderately impaired cognitively, was on a No Concentrated Sweets (NCS) diet, regular texture and regular/thin liquids; received a house supplement twice a day and received assistance and cueing for meals as needed. Interview on 02/25/25 at 5:03 P.M. with Resident #122 revealed he would have liked a piece of bread with dinner Review of medical record for Resident #29 revealed an admitted [DATE]. Pertinent diagnoses included incomplete paraplegia, pressure ulcer of sacral region, chronic obstructive pulmonary disease, major depressive disorder, and generalized anxiety disorder. The resident was cognitively intact, was on a No Added Salt (NAS) diet, regular texture, regular/thin liquids, received super cereal (fortified oatmeal) once a day and Juven two times a day, and was able to feed self after meal set up. Resident #29 was at nutritional risk related to impaired skin integrity, being obese, and by making choices which were not always in the best interest of the resident. Interview on 02/25/25 at 5:05 P.M. with Resident #29 revealed he would have loved a nice piece of bread with margarine to soak up the sauce. Review of the medical record for Resident #47 revealed an admitted [DATE]. Pertinent diagnoses included gastroesophageal reflux disease (GERD), hypokalemia (low potassium in the blood), and dysphagia (difficulty swallowing). The resident was cognitively intact, was on a regular diet, regular texture, regular/thin liquids, was able to feed self after meal set up. Resident #47 was at nutritional risk secondary impaired medical status. Interview on 02/25/25 at 5:07 P.M. with Resident #47 revealed he would have liked a piece of bread with the meal. Interview on 02/27/25 at 12:18 P.M. with Food and Nutrition Services Manager (FNSM) #473 confirmed bread and margarine had not been served for dinner on 02/25/25 and stated she had missed that bread and margarine had been on the menu so there was none offered as indicated on the planned menu. Review of facility policy Food and Nutrition History, revised 04/01/22, revealed menus were planned and choices were offered and available.

Based on observation, interview and record review, the facility failed to ensure tube feeding and intravenous (IV) poles were clean and sanitary. This affected five residents (#13, #43, #52, #57 and #226) of five residents observed for tube feeding and IV poles. The facility census was 67. Findings include: 1. Review of Resident #13's medical records revealed an admitted [DATE]. Diagnoses included gastrostomy (feeding tube), dysphasia (difficulty swallowing) and malnutrition. Review of the care plan dated 12/24/24 revealed Resident #13 required enteral feeding (nutrition received through a feeding tube). Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had no cognition score due to resident was rarely understood. Review of the physician orders for February 2025 revealed Resident #13 received enteral feedings from 5:00 P.M. to 5:00 A.M. daily. Observation on 02/24/25 at 9:38 A.M. revealed Resident #13 was sleeping in bed with a tube feeding pole positioned at the foot of his bed. Further observation revealed a large amount of dried tube feed on the base of the pole. The observation was confirmed by Certified Nursing Assistant (CNA) #434 on 02/25/25 at 2:25 P.M. She stated she was unsure who was supposed to clean the poles. 2. Review of Resident #43's medical records revealed an admitted [DATE]. Diagnoses included gastrostomy and dysphasia. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #43 had intact cognition and required the use of enteral feeding for nutrition. Review of the physician orders for February 2025 revealed Resident #43 received continuous enteral feeding at 45 milliliters (mL) per hour (hr). Observation on 02/25/25 at 8:50 A.M. revealed Resident #43 was resting in bed with tube feeding infusing. Further observation revealed a large amount of dried tube feed on the pole as well as the base. At time of observation Social Services Designee (SSD) #425 entered Resident #43's room and confirmed the dried tube feed on the pole. SSD #425 stated an outside company was responsible for the cleaning of equipment and stated he would inform the company. 3. Review of Resident #57's medical records revealed an admitted [DATE]. Diagnoses included Methicillin-resistant Staphylococcus aureus (MRSA) (bacterial infection). Review of the MDS 3.0 assessment dated [DATE] revealed Resident #57 had intact cognition. Review of the care plan dated 02/19/25 revealed Resident #57 received IV therapy related to an acute infection. Review of the physician orders for February 2025 revealed Resident #57 was ordered Vancomycin (antibiotic) IV one time a day. Observation on 02/25/25 at 9:30 A.M. revealed Resident #57 was sleeping in bed with an IV pole at the foot of her bed. The IV pole appeared to have a large amount of dried debris on the bottom portion of the pole. The observation was confirmed by CNA #434 on 02/25/25 at 2:25 P.M. She stated she was unsure who was supposed to clean the poles. 4. Review of Resident #226's medical records revealed an admitted [DATE]. Diagnosis included gastrostomy. Review of the care plan dated 12/24/24 revealed Resident #226 was at risk for nutritional issues and received supplemental tube feedings. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #226 had impaired cognition. Review of the physician orders for February 2025 revealed Resident #226 was ordered tube feed at 50 ml/hr. Observation on 02/24/25 at 9:40 A.M. revealed Resident #226 was in bed sleeping, and a tube feed pole was on the side of Resident #226's bed. Further observation revealed a large amount of dried tube feed on the bottom portion of the pole. The observation was confirmed by CNA #434 on 02/25/25 at 2:25 P.M. She stated she was unsure who was supposed to clean the poles. 42013 5.Review of Resident #52's medical record revealed an admitted [DATE] with diagnoses including type two diabetes mellitus with ketoacidosis without coma, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and acute kidney failure. Review of the care plan dated 01/21/25 included Resident #52 had a self-care deficit regarding activity of daily living (ADL) and mobility. Resident #66's dignity would be maintained. Resident #52 would be well-groomed, clean and neat through the next assessment. Resident #52 would participate in therapy and improve ADL, mobility and self-care. Interventions included ambulation, bed mobility, continence and oral care. Review of the Admission MDS 3.0 assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) which was not conducted for Resident #52 due to Resident #52 was rarely or never understood. Resident #52 was dependent on staff for bathing, toileting hygiene, and required substantial to maximal assistance for personal hygiene. Resident #52 received tube feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Review of Resident #52's physician orders dated 01/31/25 revealed enteral feed, two times a day, DiabetaSource (nutritional supplement) at 65 cubic centimeters (cc) per hour, continuous. Observation on 02/25/25 at 8:50 A.M. with Licensed Practical Nurse (LPN) #446 of Resident #52's IV and tube feeding pole on wheels next to Resident #52's bed revealed the pole appeared to have a large amount of rust or dried tube feeding on the lower one third of the pole and a large amount of rust or dried tube feeding on the base of the pole by the wheels. Interview on 02/25/25 at 8:50 A.M. of LPN #446 confirmed Resident #52's IV and tube feeding pole had either a large amount of rust or dried tube feeding on it. Observation on 02/25/25 at 9:27 A.M. of Housekeeper #515 with LPN #446 revealed he was cleaning Resident #52's IV and tube feeding pole. Housekeeper #515 stated he had to really scrub the pole using a non-scratch cleaning pad and a disinfectant solution on a cloth, and the pole mostly had a large amount of dried tube feeding on it with a little rust. Observation of the IV and tube feeding pole revealed it was clean and the lower third of the pole and the base by the wheels was clean and free of dried tube feeding and rust. LPN #446 confirmed the IV and tube feeding pole was clean and free of dried tube feeding and rust.

Based on observation, interviews, record review, review of the facility Fall and Winter menus, and review of the facility policy, the facility failed to ensure there was a nutritionally equivalent alternate for residents who disliked Brussel sprouts. This affected nine residents (#2, #8, #15, #32, #45, #59, #272, #276, and #278) the facility identified as having a dislike of Brussel Sprouts out of 66 residents receiving meals from the kitchen. The facility identified one resident (#52) as receiving nothing by mouth (NPO). The facility census was 67. Findings include: Review of the facility spreadsheet for Tuesday week three dinner (02/25/25) revealed residents on a regular and mechanical soft diet were to receive one number six scoop (five and one third ounces) of cheese tortellini with marinara sauce, one four ounce spoodle (a type of serving utensil which was a combination between a spoon and a ladle) of steamed Brussel sprouts, one slice of bread with one teaspoon of margarine, and one two-inch by two-inch piece of chocolate cream cake. Observations on 02/25/25 from 3:45 P.M. to 5:00 P.M. of the dinner meal service revealed on the steam table were Brussel Sprouts and pureed Brussel Sprouts. There were no alternative cooked vegetables prepared for the meal. Observation of the facility's dinner tray line revealed residents who had Brussel sprouts listed as a dislike on their tray ticket didn't receive the Brussel sprouts or another comparable alternate vegetable. Interview during the observation with Food and Nutrition Services Manager (FNSM) #473 confirmed for the nine residents who were identified to dislike Brussel sprouts for the meal, the facility did not replace it with another vegetable. Interview on 02/26/25 at 4:16 P.M. with Resident #8 revealed for dinner the previous night, she had received no vegetable, she disliked Brussel sprouts and she had been hungry after the meal. Interview on 02/26/25 at 4:21 P.M. with Resident #15 revealed for dinner the previous night she received no vegetable, she disliked Brussel Sprouts and would have liked to have received another vegetable instead of no vegetable. Interview on 02/26/25 at 4:49 P.M. with Resident #45 revealed for dinner the previous night he had not received a vegetable and he disliked Brussel sprouts. He went on to state that the previous night's dinner was not enough for him, and he had been hungry after the meal. Review of the facility four-week cycle Fall and Winter 2024 to 2025 menu revealed a wide of variety of meal items were offered and for each week of the cycle there were three additional entrees listed as being available if a resident didn't like the menu entree, however, there was no alternate vegetables listed as being available if a resident didn't like the main vegetable. Review of facility policy Food and Nutrition History, revised 04/01/22, revealed menus were planned and choices were offered and available.

Based on observation, interview and record review the facility failed to ensure Resident's #52 and #66's care planned interventions for grooming were implemented. This affected two residents ( #52 and #66) of three residents reviewed for grooming. The facility census was 67. Findings include: 1. Review of Resident #66's medical record revealed an admitted [DATE] with diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the left non-dominant side, aphasia (language disorder that affects the ability to communicate effectively) following cerebral infarction, dysphagia (difficulty swallowing), dysarthria (slurred speech) following cerebral infarction, and vascular dementia. Review of the care plan dated 01/08/25 included Resident #66 had a self-care deficit regarding activities of daily living (ADL) and mobility. Resident #66's dignity would be maintained. Resident #66 would be well-groomed, clean and neat through the next assessment. Interventions included bed mobility required assistance of two staff members; Resident #66 preferred to be bathed on day shift on Monday, Wednesday, and Friday. Review of Resident #66's progress notes dated 01/27/25 through 02/26/25 did not reveal any written evidence Resident #66 refused to have his fingernails trimmed or that staff encouraged him to allow his fingernails to be trimmed. Review of the 5-day Medicare Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 was cognitively intact. Resident #66 was dependent on staff for toileting hygiene and lower body dressing. Resident #66 required substantial to maximal assistance with bathing. Resident #66 had an indwelling catheter and was always incontinent of bowel. Resident #66 did not reject care during the seven-day assessment look-back period. Interview on 02/25/25 at 2:42 P.M. of Director of Rehab (DOR) #509 revealed Resident #66 had difficulty with expressive and receptive communication, had difficulty with yes and no accuracy, auditory processing and following commands. Review of Resident #66's care plan initiated 02/25/25 included Resident #66 refused, resisted treatment, to comply with safe regulations, and to participate in therapy. Resident #66 would comply with the plan of treatment and care by the next evaluation. Resident #66 would have less than four episodes per week of resisting care. Interventions included determining the reason for refusal; educating regarding health, safety consequences of refusal; encouraging Resident #66 to participate in care. Further review did not reveal evidence a care plan was initiated for Resident #66 being resistive to care prior to 02/25/25. Observation on 02/26/25 at 9:58 A.M. of Resident #66 with Certified Nursing Assistant (CNA) #462 revealed the resident's fingernails on the right hand were about one half inch to three quarters of an inch long. The fingernails were yellow and had a lot of brownish colored material observed underneath them. CNA #462 confirmed Resident #66's fingernails were long, yellow and had brownish material underneath them and stated the nurse's usually cut resident fingernails because the aides did not know if a resident was a diabetic or on blood thinners or things like that. Interview on 02/26/25 at 9:59 A.M. of Licensed Practical Nurse (LPN) #446 revealed he noticed Resident #66's fingernails were long, dirty and yellow with brown material underneath them. LPN #446 stated he would look at Resident #66's fingernails today and had not got that far yet today. LPN #446 confirmed the nurse's usually cut resident fingernails, but the aides could do it if the resident was not a diabetic. Interview on 02/26/25 at 12:12 P.M. of Certified Occupational Therapy Assistant (COTA) #508 revealed she worked with Resident #66 on simple ADL, simple grooming and hygiene and unsupported sitting. COTA #508 stated Resident #66 had quite a bit of pain in his left arm and left leg and the left leg was drawn in and had a lot of tone. COTA #508 stated Resident #66 babied his left arm because it hurt. COTA #508 indicated Resident #66 wanted to do well but his pain interfered with his therapy and working on things like ADL. Review of Resident #66's Resident Shower Documentation Sheets (provided to the surveyor by email on 03/05/25) dated 02/03/25, 02/11/25, 02/13/25, 02/20/25, 02/24/25, and 02/26/25 revealed Resident #66 refused nail care. (However, the MDS 3.0 assessment stated Resident #66 had not rejected care from 02/08/25 through 02/14/25). There was no further evidence provided by the facility that nail care had been re-attempted by a nurse or certified nursing assistant (CNA) on any other days between 02/03/25 and 02/26/25 to ensure the resident was receiving assistance with nail hygiene and grooming. There was no documented evidence that the physician and/or Resident #66's responsible party were notified that Resident #66 refused nail care. 2. Review of Resident #52's medical record revealed an admitted [DATE] with diagnoses including type two diabetes mellitus with ketoacidosis without coma, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and acute kidney failure. Review of the care plan dated 01/21/25 included Resident #52 had a self-care deficit regarding ADL and mobility. Resident #66's dignity would be maintained. Resident #52 would be well-groomed, clean and neat through the next assessment. Resident #52 would participate in therapy and improve ADL, mobility and self-care. Interventions included ambulation, bed mobility, continence and oral care. Review of the Admission MDS 3.0 assessment dated [DATE] included a BIMS was not conducted because Resident #52 was rarely or never understood. Resident #52 was dependent on staff for bathing, toileting hygiene, and required substantial to maximal assistance for personal hygiene. Observation on 02/25/25 at 9:29 A.M. of Resident #52 with LPN #446 revealed Resident #52 had long fingernails on both hands about one half inch to three quarters inch. Resident #52's fingernails were yellow and had a lot of brown material underneath the nails. Three to four of Resident #52's fingernails were short and very thick, and LPN #446 stated he could not cut those, but he would make sure the other long fingernails were clipped. LPN #446 confirmed Resident #52's fingernails were dirty. LPN #446 asked Resident #52 if he could cut his fingernails, and Resident #52 nodded his head yes.

Based on observation, interview, record review and facility policy review, the facility failed to ensure treatments were administered according to physician orders for Residents #40 and #58. This affected two residents (#40 and #58) of three residents reviewed for physician orders. The facility failed to adequately document abnormal vital signs for Resident #57 exhibiting a change in condition resulting in hospitalization . This affected one resident (#57) of three residents reviewed for change in condition. The facility census was 67. Findings include: 1. Review of Resident #40's medical records revealed an admitted [DATE]. Diagnoses included chronic heart failure (CHF), hypertension and muscle weakness. Review of the care plan dated 01/09/25 revealed Resident #40 was at risk for edema. Interventions included Tubi grips (a tubular bandage that provides compression and support for arms and legs) per physician order. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 had intact cognition. Review of the physician orders for February 2025 revealed Resident #40 was ordered Tubi grips to be worn on lower extremities while out of bed and to be removed at bedtime. Interview on 02/24/25 at 9:13 A.M. with Resident #40 revealed she would like her compression stocking applied, and she stated she had been told they had been ordered, and she had not had them for about a week. Observation at the time of the interview revealed Resident #40 was not wearing compression stockings and bilateral legs appeared to be swollen. Interview on 02/25/25 at 8:16 A.M. with Resident #40 stated she had not been given her compression stockings the previous day and she had requested them to be placed on. Observation of Resident #40 at the time of the interview revealed she was not wearing compression stockings. Interview on 02/25/25 at 12:12 P.M. with Licensed Practical Nurse (LPN) #510 revealed she was unaware Resident #40 had not been given Tubi grips. LPN #510 stated the facility had Tubi grips in the supply room and stated she would obtain a pair and place them on Resident #40. Observation at the time of the interview revealed LPN #510 had obtained a box of Tubi grips from the supply room and applied the stocking to Resident #40's bilateral extremities. Review of physician orders with LPN #510 after applying Resident #40's Tubi grips revealed physician orders had been placed in the computer system incorrectly and stated the orders had an indication that documentation was not required regarding Resident #40's Tubi grips. LPN #510 stated due to the incorrect orders, the application of Resident #40's Tubi grips had not shown in the computer system as a treatment that was to be completed daily. 2. Review of Resident #57's medical records revealed an admitted [DATE]. Diagnoses included respiratory failure, chronic obstructive pulmonary disease (COPD) and hypertension. Review of the care plan dated 12/24/24 revealed Resident #57 required respiratory treatments. Interventions included provide respiratory treatments as ordered. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #57 had impaired cognition. Review of the progress note dated 02/07/25 timed 9:30 A.M. authored by LPN #485 revealed Resident #57 was transported by ambulance to an area hospital, vital signs were unstable with periods of confusion. Review of Resident #57's medical records revealed no documentation of Resident #57's vital signs on 02/07/25. Review of progress note dated 02/17/25 timed 11:30 P.M. authored by Registered Nurse (RN) #472 revealed Resident #57 had arrived to facility at approximately 11:30 P.M. Interview on 03/03/25 at 11:18 A.M. with LPN #485 revealed she could not recall which of Resident #57's vital signs were abnormal and stated she had not recorded Resident #57's vital signs in the electronic medical records. 46195 3. Review of the medical record for Resident #58 revealed an admitted [DATE]. Diagnoses included chronic kidney disease, chronic diastolic (congestive) heart failure (CHF), atherosclerotic heart disease, and hyperlipidemia. Review of the physician orders for Resident #58 revealed a physician order, dated 10/22/24, for Furosemide (generic for Lasix which was a diuretic used to treat fluid overload in adults with CHF) one 40 milligram (mg) tablet with instructions to administer one tablet one time a day; and another physician ordered, dated 01/03/25, for Lasix oral tablet 20 mg with directions to give one 20 mg tablet every 24 hours as needed if the resident's weight increased more than two pounds in a day. Review of the modification of annual MDS 3.0 assessment dated [DATE] revealed Resident #58 was cognitively intact and had received a diuretic during the assessment reference period. Review of the care plan, created on 08/02/24, revealed Resident #58 was at risk for edema related to CHF and renal disease. Interventions included provide medication per physician order. Review of Resident #58's January 2025 and February 2025 Medication Administration Record (MAR) revealed Resident #58 had been substantially weighed daily with some resident refusals. On 01/05/25 the resident weighed 204.6 pounds and on 01/06/24 weighed 206.8, which was a 2.2 pound weight increase in 24 hours; on 02/02/24 the resident weighed 203.1 pounds and on 02/03/25 the resident weighed 205.8 pounds, which was an increase of 2.7 pounds increase in 24 hours; on 02/19/25 the resident weighed 204.2 pounds and on 02/20/25 weighed 208.9 pounds, which was an increase of 4.7 pounds in a 24 hour period; and on 02/25/25 the resident weighed 204.7 pounds and on 02/26/25 weighed 209.4, a weight increase of 4.7 pounds in a 24 hour period. Resident #58 had been administered the scheduled one 40 mg tablet of furosemide daily but had not been administered one 20 mg tablet of Lasix for a weight increase of more than a two in a day during the months of January and February. Interview on 03/02/25 at 8:04 P.M. with LPN #487 confirmed on 01/06/25 and on 02/03/25, when she input Resident #58's daily weight in the MAR, she should have administered one 20 mg tablet of Lasix since the resident had gained more than two pounds in a 24 period. She confirmed she had not administered one 20 mg tablet of Lasix for the weight increase on 01/06/25 and 02/03/25 since she hadn't realized the resident had an order to administer one 20 mg tablet of Lasix if the resident gained more than two pounds within a 24-hour period. Interview on 03/03/25 at 5:30 P.M. with Certified Nurse Practitioner (CNP) #500 revealed she was aware Resident #58 had an order in place to administer a diuretic if the resident gained more than two pounds in a day, and she would expect the facility to administer the medications as ordered. Review of the undated facility policy Medication Administration Policy revealed medications would be administered in accordance with written orders of the prescriber.

Based on observation, medical record review and staff interviews, the facility failed to ensure incontinence care was provided in a timely manner for Resident #67. This affected one resident (#67) of two residents reviewed for incontinence care. The facility census was 67. Findings include: Record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, other fracture of head and neck of left femur, subsequent encounter for closed fracture with routine healing, difficulty in walking. Review of the Brief Interview for Mental Status (BIMS) dated 12/30/24 revealed Resident #67 scored 14 out of 15, indicating she was cognitively intact. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was always incontinent of bowel and bladder. The care plan dated 01/12/25 stated resident was on a scheduled toileting program and the goal was that the resident's incontinent episodes happen less than once per week; usually continent. The care plan interventions included toileting program: 6:00 A.M., 10:00 A.M., 1:00 P.M., 4:00 P.M., 7:00 P.M. and prior to bed if up later and as needed, continue to check and change throughout night, *prompt to use bathroom* every shift. An order dated 01/06/25 stated the resident was to be on a scheduled toileting program: 6:00 A.M., 10:00 A.M., 1:00 P.M., 4:00 P.M., 7:00 P.M. and prior to bed if up later and as needed, continue to check and change throughout night, *prompt to use bathroom* every shift. Interview with Resident #67 on 02/25/25 at 9:15 A.M. who stated she was incontinent of bowel and bladder and doesn't understand why. She stated this was new since her admission to the facility. She stated her urine and feces just comes out. She stated she puts on her call light when she needs someone to clean and change her. Interview with Certified Nursing Assistant (CNA) #455 on 02/25/25 at 4:09 P.M. who stated Resident #67 will press her call button if she needed toileting assistance or incontinence care. Observation of Resident #67 on 02/26/25 at 8:17 A.M. showed her sitting up in bed awake and alert. She stated she had not been toileted or checked and changed yet that morning. Observed Resident #67 ask CNA #401 to change her before therapy and asked CNA #401 to let nurse know she wanted something for pain before going to therapy. CNA #401 confirmed she was going to perform incontinence care at that time, and Resident #67 asked the surveyor to check on her later. Interview with Resident #67 on 03/03/25 at 9:15 A.M. who stated she was unaware she was on a scheduled toileting program and that staff was not toileting her per schedule. She stated staff provided incontinence care when she asked for them to do so. Resident #67 further stated that aides do not take her into the bathroom, and that they provide incontinence care to her while she is in bed. Observation of incontinence care provided to Resident #67 on 03/03/25 at 9:23 A.M. by CNA #401. The resident says she is satisfied with her care, always wears an incontinence brief, and stated the femur fracture causes pain. Resident #67 stated she has been incontinent the last ten days but was noticing improvement and was starting to get control back. Observation of bowel movement, formed, brown, no skin breakdown, or redness. CNA #401 stated if the resident requested to go to bathroom she would take her. CNA #401 also stated she did not take the resident to the bathroom on a schedule at 6:00 A.M.,10:00 A.M., 1:00 P.M., 4:00 P.M., 7:00 P.M. She would have Resident #67 sit on toilet midday if she needed changed and does not want to lay her down. Resident #67 stated she was not taken to bathroom on schedule, but hoped it got to that point, urine would just come out and was starting to get control back and was very happy about that. Interview with Certified Occupational Therapy Assistant (COTA) #508 on 03/04/25 8:47 A.M. who stated therapy was aware of Resident #67's scheduled toileting program but therapy was not working on that specifically. COTA #508 stated therapy does work on the toileting task with the resident but not as it directly relates to the schedule. COTA #508 stated the resident does not retain things from one day to the next and needed to be reminded daily how to perform therapy exercises she already learned. Interview with CNA #401 on 03/04/25 at 10:29 A.M. stated she provided incontinence care Resident #67 on 03/04/35 at around 9:00 A.M. and confirmed the resident was wet. CNA #401 also stated the resident was wet at least 90% of the time when incontinence care was provided. Interview with Licensed Practical Nurse (LPN) #510 on 03/04/25 at 10:30 A.M. confirmed the order for toileting schedule in Medication Administration Record (MAR)/Treatment Administration Record (TAR) for 03/03/25 was marked complete; she stated she asked her aides who stated the toileting schedule was followed. The incontinence task in Resident #67's chart for 03/03/25 stated incontinence care was provided at 6:41A.M., 10:07 A.M., 4:46 P.M.

Based on record review, interviews, and review of facility policy, the facility failed to accurately and consistently monitor and record a physician ordered fluid restriction for Resident #58 and #29. This affected two residents (#29 and #58) out of nine residents reviewed for nutrition. The facility census was 67. Findings include: 1. Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses including chronic kidney disease, chronic diastolic (congestive) heart failure (CHF), atherosclerotic heart disease, and hyperlipidemia. Review of the modification of the annual Minimum Data Set (MDS) 3.0 assessment, dated 12/13/24, revealed Resident #58 was cognitively intact, received a therapeutic diet, had no significant weight changes, and had received a diuretic during the assessment reference period. Review of the care plan, created on 08/02/24, revealed Resident #58 was at risk for nutritional issues secondary to impaired medical status. Interventions included: provide medical nutrition therapy interventions per order and monitor, document, and evaluate meal and fluid intakes consumed. Review of the document titled After Visit Summary, date 12/26/24, revealed Resident #58 had a visit with a cardiologist who gave instructions for her to restrict fluid intake to less than 2.2 liters (the equivalent of 2200 milliliters) per day. Review of Resident #58's physician orders revealed an order dated 12/26/24 for a 2,000 milliliter (ml) fluid restriction with dietary providing 1080 ml a day and nursing providing 920 ml a day. Review of Resident #58's January 2025 and February 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed there was no documentation of the actual fluid amounts offered and consumed from the 920 ml nursing portion of the fluid restriction for Resident #58. An interview on 02/27/25 at 8:24 A.M. with Resident #58 confirmed she needed a fluid restriction due to congestive heart failure and the facility staff brought her fluids. Interview on 02/27/25 at 8:47 A.M. with Certified Nursing Assistant (CNA) #426 revealed the aides were aware of who was on a fluid restriction by their report sheets. CNA #426 indicated Resident #58 was on a 2,000 ml fluid restriction. He stated dietary was providing the fluids which were listed on her meal ticket, and he would usually give Resident #58 one four-ounce plastic cup (120ml) of water three to four times a day (360 ml to 480 ml/day), and he would let the nurse know what fluids he had provided. Interview on 02/27/25 at 10:04 A.M. with Licensed Practical Nurse (LPN) #466 revealed Resident #58 was on a 2,000 ml fluid restriction and nursing was allowed to give 920 ml/day. She stated she usually gave 60 ml with medications twice a day (120 ml/day) during her shift and the aides would tell her if they had given fluids. After reviewing Resident #58's February 2025 MAR and TAR during the interview, LPN #466 confirmed the 920 ml fluid allotment for nursing was not being documented anywhere on the MAR, and without nursing documenting how much they had provided, there was no way to determine if nursing had adhered to the fluid restriction. LPN #466 confirmed the MAR was where it should be documented, but the fluid restriction was not listed on the MAR. Review of undated facility policy titled Fluid Restriction, revealed the total fluid restriction amount would be divided between nursing and dietary. The dietary allotment was provided to the resident according to their beverage preferences and was noted specifically by the amount on their meal card, and the nursing allotment would be found on MAR. 2. Review of the medical record for Resident #29 revealed an admitted [DATE] with diagnoses including heart failure, old myocardial infarction, depressive disorder, and attention-deficit hyperactivity disorder. Review of Resident #29's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/18/25, indicated the resident was cognitively intact, was able to feed self after tray set up, had no significant weight changes, and was on a therapeutic diet. Review of the care plan, created on 01/26/25, revealed Resident #29 was at risk for compromised nutritional status secondary to impaired skin integrity, would make choices which were not always in the best interest of the resident, and was obese and on a fluid restriction. Interventions included providing medical nutritional therapy as ordered, monitor, document, and evaluate meal and fluid intakes, fluid restriction per order, and providing nutrition education, counseling, and nutritional discharge planning as needed. Review of the physician orders revealed an order, dated 02/11/25, for a No Added Salt diet (NAS), regular texture, regular/thin liquids and an order, dated 02/11/25, for a 1500 milliliter (ml) fluid restriction with the order revised on 02/18/25 to reflect dietary would provide 1080 ml per day and nursing would provide 420 ml per day for the 2,000 ml fluid restriction. Review of the facility document titled Medical Nutrition Therapy Review, dated 02/12/25, revealed Resident #29 was on a NAS diet and 1500 ml per day fluid restriction. The fluid restriction was new from readmission, and the resident was not receptive to the fluid restriction. Education was provided, and the resident was not agreeable to remove the large tumbler (that he used for water pitcher) from the room. It was indicated in the medical nutrition therapy review that the resident may not be compliant despite education, and the facility would honor the resident's informed decision and encourage and educate when appropriate. Review of the February 2025 MAR for Resident #29 revealed the 1500 ml fluid restriction with a start date of 02/12/25 was documented on the MAR, however, there was only a check mark to indicate the nurse had signed it off each shift without accurately documenting how much fluid had been consumed by Resident #29 on each shift. This was discontinued on 12/17/25 and on 12/18/25 the order for 1500 ml per day, dietary 1080 ml per day, nursing 420 ml per day was added, but again only a check mark by the nurse was marked and not an accurate amount of how much fluid was consumed. Review of the February 2025 TAR revealed no documentation of the 1500 ml per day fluid restriction. An interview on 02/25/25 at 12:12 P.M with Resident #29 revealed he was not aware of being on fluid restriction. An interview on 02/27/25 at 10:18 A.M. with LPN #466 revealed Resident #29 was on a fluid restriction and nursing was allowed 420 ml fluids in a 24-hour period which meant each 12-hour nursing shift was allowed 210 ml each shift. She stated Resident #29 received medications at 9:00 A.M, 11:00 A.M., 2:00 P.M., and at 4:00 P.M. and each time she gave the resident his medications she would give the medications along with a half-full four-ounce cup of water (60ml) for a total of approximately 240ml being given with his medications. After looking at Resident #29's MAR, LPN #466 confirmed that the MAR indicated that nursing was allotted 420 ml in a 24 period, but there was no place to document how many ml of fluid had been provided each shift. LPN #466 indicated without nursing documenting the amount of fluids they provided during each 12-hour shift for Resident #29, there was no way to monitor how much fluids had been provided by nursing in a 24-hour period. Review of undated facility policy titled Fluid Restriction, revealed the total fluid restriction amount would be divided between nursing and dietary. The dietary allotment was provided to the resident according to their beverage preferences and was noted specifically by the amount on their meal card, and the nursing allotment would be found on MAR.

Based on record review, interviews, review of the long term care facility compliance agreement, and review of communication sheets from dialysis, the facility failed to ensure communication between the facility and the dialysis center was being received after every dialysis treatment as required for Resident #31. This affected one resident (#31) out of one resident reviewed for dialysis. The facility identified Resident #31 as the only resident receiving dialysis. The facility census was 67. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE]. Diagnoses included end stage renal disease, diabetes mellitus with hyperglycemia (high blood sugar), dependence on renal dialysis, anemia in chronic kidney disease, and renovascular hypertension (a condition in which high blood pressure is caused by the kidneys' hormonal response to the narrowing of arteries in the kidneys). Review of Resident #31's physician orders revealed an order dated 10/24/24 for dialysis Monday, Wednesday, and Friday at a dialysis center with a chair time of 10:45 A.M. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #31 was cognitively intact, was mostly dependent on staff for mobility and for activity of daily living and received dialysis. Review of the care plan initiated on 08/03/20 revealed Resident #31 was at risk for complications from dialysis. Interventions included: hemodialysis as outpatient at an outside facility on Monday, Wednesday, and Friday; be alert to signs of fluid retention; check access site every shift and after each dialysis; lab work per physician order; monitor mental status change every shift and after each dialysis; monitor shunt for presence of bruit (swishing sound caused by turbulent blood flow through an artery) /thrill (palpable vibration on the skin over the area of turbulent blood flow), redness, bleeding or swelling at site; and monitor vital signs per physician order and as needed. Interview on 02/26/25 at 4:33 P.M. with License Practical Nurse (LPN) #451 revealed the facility would send a face sheet and a list of Resident #31's medications with the resident when she went to dialysis; however, the dialysis center didn't always send back a communication sheet with the resident. She stated when there was no communication sheet sent back from the dialysis center with Resident #31, she would call the dialysis center to see if there had been any changes and the only time she would document the call in Resident #31's medical record was if there had been changes. Interview on 02/27/25 at 10:26 A.M. with LPN #466 stated she always sent a face sheet and a list of medications with the resident when she went to dialysis; however, Resident #31 didn't always come back with a communication sheet from the dialysis center. When she noticed the resident hadn't been sent back with a communication sheet, she would call the dialysis center to have the form faxed to the facility and would give the faxed form to Medical Records #482 so it could be uploaded into the resident's electronic medical record. She went on to state she felt the communication between the facility and the dialysis center could be better. Interview on 02/27/25 at 11:00 A.M. with Medical Records #482 revealed all the information which had been sent back from the dialysis center had been uploaded into Resident #31's medical record. She went on to state there were days when Resident #31 didn't come back with a communication form from the dialysis center and confirmed there were missing communication forms in Resident #31's electronic medical record from the dialysis center. Interview on 02/27/25 at 11:10 A.M. with the Administrator revealed the normal procedure would be for the dialysis center to send back communication with Resident #31. If no communication had been sent from the dialysis center, the facility should call the dialysis center to have the communication paper faxed to the facility, so it could be uploaded into Resident #31's electronic medical record. Interview with Representative #511 from the dialysis center on 03/03/24 at 11:09 A.M. confirmed the Resident #31's chair time was on Monday, Wednesday, and Fridays; however, during the weeks of Christmas and New Year's Day, the resident went to dialysis on Sunday, Tuesday, and Friday. Review of the uploaded items in Resident #31's medical record revealed from the time frame between 12/01/24 and 2/27/25 there were uploaded communication sheets from the dialysis center for treatments on 12/02/24, 01/08/25, 01/15/25, 01/22/25, and 02/12/25. There were no communication sheets from the dialysis center for treatments on 12/04/24, 12/06/24, 12/09/24, 12/11/24, 12/13/24, 12/16/24, 12/18/24, 12/20/24, 12/22/24, 12/24/24, 12/27/24, 12/29/24, 12/31/24, 01/02/25, 01/06/25, 01/10/25, 01/13/25, 01/17/25, 01/20/25, 01/24/25, 01/27/25, 01/29/25, 01/31/25, 02/03/25, 02/05/25, 02/07/25, 02/10/25, 02/14/25, 02/17/25, 02/19/25, 02/21/25, 02/24/25, and 02/26/25. Further review of Resident #31's medical record revealed there was nothing documented in the progress notes between 12/01/24 and 02/27/25 indicating the facility had reached out to the dialysis center when the facility had not received a communication sheet from the dialysis center to see if there had been any changes with the resident. Review of the LTCF (long term care facility) Compliance Agreement, dated 07/01/23, between the facility and the dialysis center, revealed the parties agreed to coordination of care which included information transmitted to the dialysis center by the LTCF prior to dialysis and information transmitted to the LTCF by the dialysis center after dialysis.

Based on observation, interview, record review, review of the Centers for Disease control and Prevention (CDC) guidelines and facility policy review, the facility failed to ensure infection control logs were accurate and appropriate isolation precautions were in place for Resident #57. This affected one resident (#57) of three residents reviewed for infection control. The facility census was 67. Findings include: Review of Resident #57's medical records revealed an admitted [DATE]. Diagnosis included Methicillin-resistant Staphylococcus aureus (MRSA) (bacterial infection). Review of the care plan dated 12/24/24 (revised 02/25/25) revealed Resident #57 had received intravenous (IV) therapy related to an acute infection. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 had impaired cognition. Resident #57 was dependent on staff for toileting and required maximum assistance with personal hygiene. Review of the physician orders for February 2025 revealed Resident #57 was ordered Vancomycin (IV antibiotic) every 48 hours for MRSA infection and enhanced barrier precautions (EBP) (due to the central line IV catheter in her upper right chest). Review of Resident #57's hospital paperwork with an encounter date of 02/07/25 revealed Resident #57 had MRSA detected in blood work. Review of infection control logs for February 2025 revealed Resident #57 was on EBP related to osteomyelitis (bone infection). Observation on 02/24/25 at 9:30 A.M. revealed no signs posted to the entrance of Resident #57's room related to isolation precautions. Further observation revealed an IV pump and pole in Resident #57's room. Observation on 02/25/25 at 12:09 P.M. revealed no signs posted to the entrance of Resident #57's room related to isolation precautions, and the IV pump and pole remained in Resident #57's room. Observation of Resident #57 on 02/25/25 at 12:12 P.M. with Licensed Practical Nurse (LPN) #510 revealed Resident #57 had a central line IV catheter in her upper right chest. LPN #510 stated Resident #57 had received IV antibiotics for pneumonia treatment. LPN #510 stated she was unaware of Resident #57 on any type of isolation precautions. Interview on 03/03/25 at 12:05 P.M. with Director of Nursing (DON)/infection preventionist confirmed the infection control log for February 2025 indicated Resident #57 had an osteomyelitis infection; however, it had been inaccurate due to Resident #57 having an MRSA infection. The DON stated Resident #57 should have been placed on contact precautions related to the MRSA infection and EBP for the central line IV catheter in her upper right chest. Review of the CDC guidance for Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/24, revealed EBP should be in place for a resident with an indwelling medical device. An indwelling medical device provides a direct pathway for pathogens in the environment to enter the body and cause infection. Examples of indwelling medical devices include, but are not limited to, central vascular catheters (including hemodialysis catheters, peripherally-inserted central catheters (PICCs)), indwelling urinary catheters, feeding tubes, and tracheostomy tubes. Review of the facility policy titled Isolation Precautions, revised 01/21, revealed residents with an MRSA infection required contact isolation precautions.

Based on observation, interview and record review, the facility failed to notify Resident #32's representative of a new skin impairment. This affected one resident (#32) of three residents reviewed for changes in condition. The facility census was 67. Findings include: Review of Resident #32's medical records revealed an admitted [DATE]. Diagnoses included Alzheimer's, dementia and muscle weakness. Review of the care plan dated 12/24/24 revealed Resident #32 had self-care deficits. Interventions included assisting Resident #32 with transfers, toileting and bed mobility. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 had impaired cognition. Review of progress note dated 02/21/25 timed 6:52 P.M. authored by Licensed Practical Nurse (LPN) #497 that stated during transfer to the toilet, Resident #32 had difficulty standing, and had fallen back into the wheelchair and received a skin tear to her right wrist. The skin tear was cleansed with normal saline and a foam dressing was applied. The progress note did not include notification of the family regarding the skin tear. Observation on 02/24/25 at 9:23 A.M. revealed Resident #32 was in a wheelchair in her room and had a foam bandage to her right wrist. Interview with Resident #32 revealed she was confused and unaware how the injury occurred. Interview with LPN #497 at time of observation revealed on 02/21/25 she was assisting Resident #32 to the toilet, and Resident #32's legs became weak, and Resident #32 flung her arms out and hit her hand on the wheelchair. Telephone interview on 02/24/25 at 10:54 A.M. with Resident #32's daughter revealed she had not been aware of Resident #32 having a skin tear. Follow up interview on 02/24/25 at 1:32 P.M. with LPN #497 revealed she could not recall calling Resident #32's daughter to inform of the skin tear. Review of progress notes with LPN #497 at time of interview confirmed progress note had not included documentation of notification to Resident #32's daughter and stated she should have called to inform of the injury.

Based on medical record review and interview, the facility failed to ensure fall interventions and orders were implemented to prevent falls for two residents (#43 and #77) of four residents reviewed for falls. Findings include: 1. Review of Resident #77's medical record revealed diagnoses included hemiplegia and hemiparesis following a stroke, congestive heart failure (CHF), type two diabetes mellitus (DM), heart disease, chronic pain syndrome, and osteoarthritis. A physician order dated 04/07/21 indicated two assists were to be utilized for bed mobility and for transfers with a Hoyer lift (mechanical lift). A fall risk assessment dated [DATE] indicated Resident #77 was at low risk for falls. Risk factors included need for assistance with activities of daily living and incontinence of bowel and bladder. The assessment indicated Resident #77 used the call light appropriately. An activities of daily living (ADL)/functional assessment dated [DATE] indicated Resident #77 required extensive assistance of two staff with bed mobility and was dependent on two staff for toileting. The plan was to check and change Resident #77 every two hours. The ADL assessment indicated Resident #77 had flaccidity to the left side of the body. A nursing note dated 11/19/22 at 6:55 P.M. indicated the assistant director of nursing, physician and daughter were notified Resident #77 slid out of bed during hands on care and was lowered to the floor to her knees. Resident #77 was observed on the right side of her bed on her knees holding onto the bed rail. The note indicated staff assisted Resident #77 to the bed by lying her on the floor on a sheet and five staff lifting her into the bed. Resident #77 complained of her knees hurting with a pain severity of seven on a scale of zero to ten. On 02/04/23 at 1:52 P.M., Licensed Practical Nurse (LPN) #100 revealed she was administering medications on 11/19/22 when she heard State tested Nursing Assistant (STNA) #110 yelling for help. Resident #77 was on the floor holding onto the siderails. STNA #110 stated he was providing personal care and Resident #77's legs slid out of the bottom of the bed. Resident #77 was supposed to have two assists while providing incontinence care and bed mobility. LPN #100 stated STNA #110 had not asked her for assistance in providing care for Resident #77. On 02/04/23 at 3:27 P.M., STNA #110 stated on the evening of 11/19/22 Resident #77 had repetitively rang her call light requesting incontinence care, but everyone was busy, so he decided to change her by himself. Resident #77 was on her side. When he pulled the brief, Resident #77 started to slide out of bed and was hanging onto the bedrail. Resident #77 had to be lowered to the floor. 2. Review of Resident #43's medical record revealed diagnoses included Alzheimer's disease, type two DM, osteoarthritis, hypertension, depression, neuropathy, and chronic kidney disease. Orders for chair and bed alarms were dated 02/27/21. An order dated 03/07/22 indicated two assistants were to be provided for transfers and toileting and one assist for bed mobility. A fall risk assessment dated [DATE] indicated Resident #43 was at moderate risk for falls. An ADL functional assessment dated [DATE] indicated Resident #43 transferred with extensive assistance of two, required extensive assist of two for bed mobility, was full weight bearing, and used bed and chair alarms and soft mats to the floor. A nursing note dated 11/19/22 at 11:12 A.M. indicated Resident #43 was observed on the floor in the bathroom in front of the toilet on her buttocks. Resident #43 stated she was trying to use the bathroom and appeared to be visibly soiled. No injury was noted. The note indicated Resident #43's chair alarm was not in place. Continuing education was completed with staff on performing two-hour rounds and making sure alarms were properly sounding and in place. On 02/04/23 at 12:30 P.M., the note from 11/19/22 was discussed with the Director of Nursing (DON) who verified it indicated Resident #43's alarm had not been in place at the time of the fall. This deficiency represents noncompliance investigated under Complaint Number OH00139875.

Based on observations, review of the medical record, resident interviews, staff interviews and review of the facility policy the facility failed to maintain a comfortable temperature of 71 to 81 degrees Fahrenheit (F) on Unit 1. This had the potential to affect all 11 residents (Resident #12, #24, #35, #41, #43, #47, #49, #50, #51, #54, and #57) on Unit 1. Findings included: 1. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, chronic pulmonary disease, congestive heart failure, dementia, chronic kidney disease, hypertension, major depressive disorder, benign prostatic hyperplasia, osteoarthritis, intermittent explosive disorder, insomnia, transient ischemic attacks, cerebral infarction, and prostate cancer. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #49 had severely impaired cognition. Review of the progress notes from 12/24/22 to 01/17/23 revealed no documentation Resident #49 was offered a new room due to his room being cold. On 01/18/23 at 4:30 P.M. an interview with the Administrator revealed they had a sprinkler pipe break on Christmas Eve, they moved the resident out of rooms [ROOM NUMBERS] closest to the break. Observation on 01/18/23 at 4:40 P.M. with Maintenance Director #102 revealed the temperature at the Unit 1 Nurse's station was 67.9 degrees Fahrenheit (F), outside the room of Resident #49 was 67.9 F and inside the room was 69.0 F. Interview at this time Maintenance Director #102 stated he did not know when the work on the broken pipe and ceiling would be completed. He stated he would need to call the contractor. He indicated he had not been doing temperature in the rooms or in the hallway and the last temperature he had taken was prior to the pipe breaking on 12/15/22. Review of the progress note dated 01/19/22 at 8:27 A.M. revealed Resident #49 had a cough and was wheezing after drinking his coffee. A new order was obtained to get a chest x-ray and speech therapy would be notified. Review of the physician's orders revealed Resident #49 had an order dated 01/19/23 for a chest x-ray. 2. Review of the facility census revealed Resident #12, #24, #35, #41, #43, #47, #49, #50, #51, #54, and #57 resided on Unit 1. On 01/18/23 at 4:15 P.M. an interview with Licensed Practical Nurse #100 revealed the facility had a pipe break on Christmas Eve. She stated it was cold and some of the residents have complained off and on about how cold it was. On 01/18/23 at 4:24 P.M. an interview with Resident #25 revealed it was cold but she has been keeping her door closed which did seem to help some, even though she does not like her door closed. On 01/18/23 at 4:30 P.M. an interview with the Administrator revealed they had a sprinkler pipe break on Christmas Eve, they moved the resident out of rooms [ROOM NUMBERS] closest to the break. Observation on 01/18/23 at 4:40 P.M. with Maintenance Director #102 revealed the temperature at the Unit 1 Nurse's station was 67.9 degrees F, outside the room of Resident #35 was 67.1 F and inside the room with the door closed was 70.3 F, outside the room of Resident #51 was 69 F and inside the room was 69 F, outside the room of Resident #54 was 67.3 F and inside the room was 68.1 F, outside the room of Resident #47 was 68.1 F and inside the room was 68.5 F. Interview at this time Maintenance Director #102 stated he did not know when the work on the broken pipe and ceiling would be completed. He stated he would need to call the contractor. He indicated he had not been doing temperature in the rooms or in the hallway and the last temperature he had taken was prior to the pipe breaking on 12/15/22. On 01/18/23 at 4:50 P.M. an interview with Resident # 49 revealed he was cold. On 01/18/23 at 5:00 P.M. an interview with Family Member # 200 revealed she has been keeping the door closed to the room and it stayed warm in her mother's room. On 01/18/23 at 5:05 P.M. an interview with Resident #51 revealed he was cold. On 01/18/23 at 5:20 P.M. an interview with State tested Nursing Assistant #103 revealed the residents were not complaining too much today about it being cold. She stated it was worst three days ago when they had all the fans blowing in the hallway to dry the carpets. She stated she had complaints from the residents then about it being cold. On 01/18/23 at 5:30 P.M. an interview with the Director of Nursing (DON) revealed they had taken temperatures of the rooms on the affected hallway and they were never below 71 F so they did not do any type of interventions. No one was sent out due to the cold. On 01/19/23 at 9:15 A.M. an interview with the Administrator revealed they resident who wanted to move off the unit were moved and they had statements signed by the resident who declined to be moved. She indicated all the temperature throughout the night were above 71 F. On 01/19/23 at 10:10 A.M. an interview with Maintenance Director #102 revealed he had turned the boiler all the way up, placed another tarp up in the attic to stop the cold air and kept the resident's doors closed to the rooms. Observation on 01/19/23 at 10:00 A.M. of temperature on Unit 1 with Maintenance Director #102 revealed all temperature were above 71 F in the remaining resident rooms. This deficiency represents non-compliance investigated under Complaint Number OH00139486.

Based on observations, record review, and staff interview the facility failed to ensure one resident (Resident #41) was provided the assistance as assessed during personal care resulting in the resident falling and failed to maintain fall prevention interventions in place Actual harm occurred when Resident #41 fell from bed during personal care and sustained a fractured right ankle. This affected one resident (Resident #41) of three residents reviewed for falls. Findings include: 1. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #41 was readmitted to the facility on [DATE] with a displaced bimalleolar [MEDICAL CONDITION] lower leg. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 10/17/19 (prior to the fall) revealed Resident #41 was cognitively impaired, required extensive assistance with two staff members for transfers, bed mobility, dressing, and toilet use. She had no falls and was frequently incontinent of bladder and bowel. Review of the quarterly Activities of Daily Living (ADL) Functional/Restorative assessment dated [DATE] revealed Resident #41 required two assist for transfers, was full weight bearing on bilateral lower extremities, and required extensive assistance of two staff for dressing. Review of the plan of care dated 01/22/18 revealed Resident #41 was at risk for falls/injury related to confusion, gait/balance problems, incontinence and psychoactive drug use. Interventions included bed alarm (11/26/19), call light within reach (01/22/18), Geri-hips at all times (05/16/19), mat to the floor (05/16/19), low bed (05/16/19), chair alarm (11/26/19) and two quarter rail positioning bars to be up while in bed to aide in positioning (01/22/18). Review of the Kardex report dated 11/30/19 revealed fall interventions were not listed. Review of physician orders for November, 2019 identified orders for alarms to the bed and chair for safety, a mat for the floor, Geri-hips at all times, non-skid slippers when out of bed, and low bed. Review of the nursing notes dated 11/18/19 at 5:45 [NAME]M. revealed at 5:15 [NAME]M. while getting dressed, Resident #41 was on the edge of the bed and attempted to stand. The aide quickly tried to assist the resident back into the bed, but the resident's ankle twisted, and she fell to the ground. The resident had a complete break in her right ankle and the resident went into shock. The resident was alert and showed no signs of pain. When asked if she was in pain the resident stated she had a little pain in her foot. Review of the fall investigation dated 11/18/19 revealed at 5:15 [NAME]M. while getting dressed, Resident #41 tried to stand and twisted her ankle. The nurse aide quickly attempted to assist her to the bed but could not, only to the ground. Resident #41's right ankle was completely broke with the bone visible. Emergency Medical Services (EMS) was notified, and Resident #41 was transported to the hospital. Review of State tested Nurse Aide (STNA) #503's statement dated 11/20/19 revealed on 11/18/19 while assisting Resident #41 with dressing the resident began to slide off the bed. STNA #503 had attempted to lower the resident down to the floor. The STNA reported once the resident was lowered to the floor, she got the nurse to assess the resident due to the resident's leg was under her during the lowering. The STNA reported the second STNA was going to assist with the transfer after the resident was dressed but the resident slid from the bed prior to the second STNA coming to provide assistance. Interview on 11/30/19 at 5:45 [NAME]M. with STNA #503 revealed on 11/18/19 she had been getting Resident #41 dressed around 5:00 [NAME]M. and the resident's dress became caught in the back. STNA #503 indicated she sat the resident up in the bed to pull her dress down in the back. The resident swung her legs around to the edge of the bed and started to stand up. STNA #503 indicated the resident slid off the side of the bed on to the floor. STNA #503 indicated she had a hold of the resident the whole time and it did not seem like the resident fell very hard but the resident was a bigger woman so she hit the ground kind of hard . The STNA indicated the resident had been a one to two person assist with a walker for transfers. The STNA said the facility had a Kardex to let the staff know each resident's level of care. She indicated the resident had fallen a few times prior to this fall but she could not remember if the resident had fall interventions in place. Observations on 11/30/19 at 5:30 [NAME]M. and 6:30 [NAME]M. revealed Resident #41 was in bed. Resident #41 had a floor mat leaning up against the wall, her bed was in a high position, with bilateral padded side rails and a bed alarm to the bed. Interview on 11/30/19 at 6:32 [NAME]M. with Registered Nurse (RN) #506 verified the resident's mat was not on the floor and the bed was not in the low position. Observation of Resident #41 on 11/30/19 at 7:15 [NAME]M. with STNA #507 and STNA #508 revealed Resident #41 did not have her Geri-hips on. STNA #508 indicated she had never seen the Geri-hips on the resident and did not even know where they were. Review of the facility policy, Fall Prevention Protocol, dated 05/23/12 revealed based on previous evaluations and present information, the staff would identify interventions related to the resident's specific risks and attempt to prevent the resident from falling and or minimizing complications from falling. This deficiency substantiates Complaint Number OH 498.

Based on observation, interview and record review the facility failed to implement interventions and assessments for a facility acquired Stage II pressure ulcer of the coccyx for one resident (Resident #10). This resulted in Actual Harm when the pressure ulcer declined to a Stage IV pressure ulcer (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures) and Resident #10 developed a new Stage IV pressure ulcer to the left gluteal fold. This affected one of three residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #10 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's admission assessment for skin integrity, dated 12/31/18, revealed bilateral heel wounds with the left heel scabbed and the right heel opened. Resident #10 had a reddened buttock with no measurements documented. Review of Resident #10's care plan, dated 01/03/19 revealed the resident was at risk for impaired skin integrity due to limited mobility and incontinence. Interventions included monitor for incontinence and provide incontinent care every two hours and as needed, pressure reduction mattress, pressure reduction cushion to wheelchair, and turn and reposition every two hours. Review of the 30-day Minimum Data Set (MDS) 3.0 assessment, dated 01/28/19, revealed Resident #10 had impaired cognition and required extensive assistance of two persons with bed mobility and transfers. The resident required total dependence of two persons with toileting. Review of the skin wound nursing note, dated 03/12/19, revealed the area to the coccyx was getting worse. The note indicated to apply cream as ordered and the wound nurse was notified. The nursing note contained no measurements or description of the wound. Review of the facility form titled, Pressure Ulcer Wound Log, dated 03/11/19 to 03/15/19, revealed Resident #10 had a facility acquired in-house pressure area to the coccyx that was observed on 03/11/19. The coccyx area measured 2.0 centimeters (cm) in length by 2.6 cm in width, with a depth of 0.1 cm. A treatment was initiated for the ulcer. There was no other description of the wound. Review of the facility form titled, Pressure Ulcer Wound Log, dated 03/18/19 to 03/22/19, revealed Resident #10's pressure area to the coccyx had increased in size and was classified as a Stage III (full-thickness skin loss). The coccyx area measured 2.0 cm in length by 4.8 cm in width with a depth of 0.2 cm. The form indicated treatment and interventions were in place, but there was no description of the wound or notification to the physician of the decline in the wound status. Review of the facility form titled, Pressure Ulcer Wound Log, dated from 03/25/19 to 03/29/19, revealed Resident #10's pressure area to the coccyx had increased in size and remained a Stage III ulcer. The coccyx area measured 2.0 cm in length by 4.9 cm in width with a depth of 0.3 cm. The form indicated consult would be made with the wound nurse practitioner. Review of the care plan, dated 03/26/19, for Resident #10 revealed ulceration and interference with structural integrity of layers of skin with a Stage III pressure area to the coccyx. Interventions included turn and reposition with skin care every two hours. Review of the wound care Certified Nurse Practitioner (CNP) #900, 04/01/19, revealed Resident #10 had an unstageable pressure ulcer to the coccyx area which was identified by staff on 03/11/19. The length was 7.5 cm, width of 3.0 cm, and depth of 2.5 cm. The area had undermining (tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge), which at 12 o'clock measured a length of 3.0 cm, width 3.0 cm, and depth 1.5 cm. Six o'clock measured a depth of 2.5 cm and nine o'clock measured a depth of 2.5 cm. The wound contained 100 percent grey slough with a heavy malodorous (distinctly sour odor) with purulent (pus) drainage. The wound edges were not adherent to the wound base. CNP #900 debrided the area with a scalpel. Post-debridement the coccyx measured depth of 4.2 cm with exposure to the bone. Review of the skin wound nursing note, dated 04/02/19, revealed there was a new open area to Resident #10's left gluteal fold, which was found when the dressing change to the coccyx was being done. The nursing note contained no measurements or description of the new wound. Observation of the dressing change on 04/03/19 at 7:59 A.M. completed by Registered Nurse (RN) Wound Nurse #607 and RN Supervisor #608 revealed Resident #10 had a wound to her coccyx. RN #607 described the wound as a Stage IV pressure ulcer, as the bone was exposed. RN #607 indicated the wound had yellow slough and tunneling with redness surrounding it. RN #607 stated Resident #10 had a pressure ulcer to her left gluteal area that was found on 04/02/19. RN #607 revealed the wound to her left gluteal fold was unstageable and measured 2.5 cm in length by 2.5 cm in width with 100 percent yellow slough. Interview on 04/03/19 at 8:21 A.M. with RN #607 revealed Resident #10 was not getting turned every two hours as she needed. She indicated she worked 2:00 A.M. to 10:00 A.M. and third shift had not had enough staff to ensure Resident #10 was turned as needed. RN #607 indicated that it could be why Resident #10's coccyx area declined, and the resident developed a new area on the left gluteal fold. Interview on 04/03/19 at 8:23 A.M. with RN #608 revealed she had picked up several night shifts and that third shift had been staffing challenged recently. RN #608 revealed sometimes staff were unable to keep Resident #10 turned every two hours as needed. Interview on 04/03/19 at 11:01 A.M. with Clinical Nurse Consultant #613 and RN #607 verified that there are no wound measurements or assessments of Resident #10's pressure areas in the clinical record. They revealed they only have measurements on facility wound logs which they verified was not part of Resident #10's clinical record. Clinical Nurse Consultant #613 revealed RN #607 was new and that she was in the process of training her. Clinical Nurse Consultant #613 verified wound measurements and wound assessments should be completed weekly and documented in the clinical record. Review of facility policy titled, Pressure Ulcer Prevention and Management, dated 10/18/11, revealed prevention and management of pressure ulcers will be achieved through systemic evaluation, assessment and monitoring. Weekly assessments of the resident's condition and response to treatment would be completed on pressure areas present. Identification of a new pressure area indicated the nurse would document in the nursing notes in detail and complete a pressure ulcer investigation report. The documentation of the pressure area would include length, width in centimeters, drainage (amount and description), and description of how the area was suspected to have occurred. This deficiency substantiates Complaint Number OH 356.

Based on interview and record review the facility failed to maintain sufficient levels of nursing staff to ensure Resident #10 was turned and repositioned every two hours. This resulted in Actual Harm when a coccyx pressure ulcer declined from a Stage II pressure ulcer to a Stage IV pressure ulcer (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures), and Resident #10 acquired a new unstageable pressure ulcer (obscured full-thickness skin and tissue loss) to the left gluteal fold. This affected one resident (Resident #10) of three residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #10 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's admission assessment for skin integrity, dated 12/31/18, revealed Resident #10 had a reddened buttock with no measurements documented. Review of Resident #10's care plan, dated 01/03/19 revealed the resident was at risk for impaired skin integrity due to limited mobility and incontinence. Interventions included to turn and reposition every two hours. Review of the 30-day Minimum Data Set (MDS) 3.0 assessment, dated 01/28/19, revealed Resident #10 had impaired cognition and required extensive assistance of two persons with bed mobility and transfers. The resident required total dependence of two persons with toileting. Review of the skin wound nursing note, dated 03/12/19, revealed the area to the coccyx was getting worse. The nursing note contained no measurements or description of the wound. Review of the facility form titled, Pressure Ulcer Wound Log, dated 03/11/19 to 03/15/19, revealed Resident #10 had a facility acquired in-house pressure area to the coccyx that was observed on 03/11/19. The coccyx area measured 2.0 centimeters (cm) in length by 2.6 cm in width, with a depth of 0.1 cm. Review of the facility form titled, Pressure Ulcer Wound Log, dated 03/18/19 to 03/22/19, revealed Resident #10's pressure area to the coccyx had increased in size and was classified as a Stage III (full-thickness skin loss). The coccyx area measured 2.0 cm in length by 4.8 cm in width with a depth of 0.2 cm. Review of the facility form titled, Pressure Ulcer Wound Log, dated 03/25/19 to 03/29/19, revealed Resident #10's pressure area to the coccyx had increased in size and remained a Stage III ulcer. The coccyx area measured 2.0 cm in length by 4.9 cm in width with a depth of 0.3 cm. Review of the care plan, dated 03/26/19, for Resident #10 revealed ulceration and interference with structural integrity of layers of skin with a Stage III pressure area to the coccyx. Interventions included turn and reposition with skin care every two hours. Review of the Wound Care Certified Nurse Practitioner (CNP) #900 notes, dated 04/01/19, revealed Resident #10 had an unstageable pressure ulcer to the coccyx area which was identified by staff on 03/11/19. The length was 7.5 cm, width of 3.0 cm, and depth of 2.5 cm. The area had undermining (tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge), which at 12 o'clock measured a length of 3.0 cm, width 3.0 cm, and depth 1.5 cm. Six o'clock measured a depth of 2.5 cm and nine o'clock measured a depth of 2.5 cm. The wound contained 100 percent grey slough with a heavy malodorous (distinctly sour odor) with purulent (pus) drainage. The wound edges were not adherent to the wound base. CNP #900 debrided the area with a scalpel. Post-debridement of her coccyx measured a depth of 4.2 cm with exposure to the bone. Review of the skin wound nursing note, dated 04/02/19, revealed there was a new open area to Resident #10's left gluteal fold, which was found when the dressing change to the coccyx was being done. Observation of the dressing change on 04/03/19 at 7:59 A.M. completed by Registered Nurse (RN) Wound Nurse #607 and RN Supervisor #608 revealed Resident #10 had a wound to her coccyx that was a Stage IV pressure ulcer, as the bone was exposed. RN #607 revealed the wound to her left gluteal fold was unstageable and measured 2.5 cm in length by 2.5 cm in width with 100 percent yellow slough. Interview on 04/03/19 at 8:21 A.M. with RN #607 revealed Resident #10 was not getting turned every two hours as she needed. She indicated she worked 2:00 A.M. to 10:00 A.M., and third shift had not had enough staff to ensure Resident #10 was turned as needed. RN #607 indicated that it could be why Resident #10's coccyx area declined and the resident developed a new area on the left gluteal fold. Interview on 04/03/19 at 8:23 A.M. with RN #608 revealed she had picked up several night shifts, and that third shift had been staffing challenged recently. RN #608 revealed sometimes staff were unable to keep Resident #10 turned every two hours as needed. Interview on 04/03/19 at 9:08 A.M. with State tested Nursing Assistant (STNA) #610 revealed there were times when there was only one aide on the hall, and she indicated she had not been able to turn and reposition residents every two hours. She indicated that sometimes it had been as long as four hours before she was able to turn residents. Interview on 04/03/19 at 12:35 P.M. with Human Resource #614 revealed they had several resignations on night shift in (MONTH) 2019 that they have not been able to replace. She stated they currently were down four nurse's and five STNA's on night shift. This deficiency substantiates Complaint Number OH 356.

Based on interview and record review, the facility failed to ensure an accurate Fall Risk Assessment was completed for Resident #90, and failed to ensure a chair alarm device was functional for Resident #90. This resulted in Resident #90 falling to the floor and sustaining a laceration to the left foot that required sutures. This affected one of three residents reviewed for falls. Findings include: Resident #90 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital transfer form, dated 01/03/13, revealed revealed Resident #90 was being admitted to the nursing home for rehabilitation to improve his current level of function. The same form revealed Resident #90 was incontinent, and required assistance with all activities of daily living including transferring, walking and toilet use. Review of admission physician orders [REDACTED]. Review of a Fall Risk Assessment, dated 01/03/13, revealed Resident #90 was at a low risk for falls, and their risk assessment score was a five. However, the same Fall Risk Assessment did not account for the [DIAGNOSES REDACTED]. The same Fall Risk Assessment did not identify incontinence, the need for assistance in all activities of daily living, an unsteady gait, and anti-anxiety, anti-depressant and anti-hypertensive medications. During an interview with the director of nursing (DON) on 04/15/13 at 1:12 P.M., the DON verified the Fall Risk Assessment was not accurate and increased the score from five to 14. The DON verified this could change the Resident's risk. However, the DON said the risk score was computer generated and she could not verify if the increased score would determine a moderate or high risk. Review of a Fall Investigation and nurse's note dated 01/05/13 at 9:30 A.M., revealed Resident #90 was found on the floor of his room. Resident #90 was attempting to walk unassisted to the bathroom. Interventions to prevent further falls included an alarm when Resident #90 was in a chair or in bed. Review of a Fall Investigation and nurse's note dated 01/06/13 at 10:25 A.M., revealed Resident #90 was found on the floor of his room. The alarm remained attached to the resident and was not sounding. Resident #90 sustained a tear below the fourth and fifth toe. The note described the tear as a "wide gap with bleeding." Resident #90 was sent to the emergency room for sutures. Resident #90 did not return to the facility. During an interview with the DON on 04/15/13 at 1:12 P.M., the DON revealed the alarm used was a personal tab alarm. A tab alarm is a magnetized disc attached to an alarm control unit. A string is attached to the magnetic disc and clipped to the resident's clothing. When the resident attempts to get out of a bed or chair, the alarm magnet releases and the alarm sounds. If the string is to short, the alarm will sound with minimal resident movements that may not include attempts to get out of the bed or chair. If the string is too long, the alarm may not sound because resistance is not put on the string until the resident falls. Each alarm must be adjusted to the resident need. Review of the Falls Investigation, dated 01/06/13, revealed "chair alarm in place and did not alarm due to string did not detach from the alarm, resident did not use call light." During an interview with the DON on 04/15/13 at 1:12 P.M., the DON verified there was no evidence an investigation was completed to determine why the device did not work. Review of the facility Fall Prevention Protocol dated 05/23/12 revealed "Complete fall risk screening upon admission, quarterly, annually, and as needed to assist to identify residents with a history of falling and risk factors that contribute to subsequent falls." This deficiency substantiates Complaint Number OH 770.