Every finding on record at Canal Winchester Care Center

Based on record review, staff and certified nurse practitioner (CNP) interviews, hospital record review, review of surveillance video footage, review of the emergency medical service (EMS) reports, and policy review, the facility failed to timely identify and seek necessary medical intervention following an acute change in condition for Resident #05. This resulted in Immediate Jeopardy and serious physical harm, injuries, and/or death on [DATE] at 3:49 P.M. when Resident #05 had lethargy (a reduced level of consciousness), was non-responsive to verbal commands, had an elevated blood pressure and was placed in bed. No notification was made to the physician regarding Resident #05's change in condition. Approximately 56 minutes later Unit Manager (UM) #107 and Certified Nurse Aide (CNA) #266 entered Resident #05's room; both staff attempted to wake Resident #05 but were unsuccessful in arousing the resident. No notification was made to the physician, and no additional vital signs were obtained. Approximately 25 minutes later Licensed Practical Nurse #250 entered Resident #05's room and found the resident in a deep sleep. Resident #05 was non-responsive to painful stimuli, and her pupils were non-reactive to light. At 5:24 P.M. Certified Nurse Practitioner (CNP) #500 was notified and ordered to send Resident #05 to the hospital at 5:28 P.M. Resident #05 was hospitalized and diagnosed with bilateral subdural hematomas, cerebral edema, and mass effect. Resident #05's condition was determined to be a non-survivable injury by a neurosurgeon, and no surgical intervention was attempted. Resident #05 died on [DATE]. This affected one (Resident #05) of five residents reviewed for appropriate care and services. The facility census was 118.On [DATE] at 2:14 P.M. the Administrator, Regional Registered Nurse (RRN) #600, and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when Resident #05 was identified with a change in condition and the physician was not notified. Resident #05's condition continued to decline when Resident #05 could not be aroused by staff at 4:45 P.M. and no notification was made to the physician, nor a repeat check of the resident's vital signs. Resident #05's condition further worsened at 5:10 P.M. when her pupils were non-reactive and she was not responding to painful stimuli. The Certified Nurse Practitioner (CNP) #500 was notified of Resident #05's change in condition at 5:24 P.M. and the resident was transferred to the hospital where the resident was diagnosed with bilateral subdural hematomas, cerebral edema, and mass effect that was determined to be non-survivable and Resident #05 died on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: -On [DATE] at 9:00 A.M., education on Change in Condition and Notification was started by LPN #353 for facility nursing staff in person and via phone on Change in Condition Notification Policy and Procedure. Education was provided in person to 14 of 24 LPN's, 28 of 50 CNAs, and five of 11 Registered Nurse (RN)'s. The remaining CNAs, LPN's and RN's received education via the telephone. -Licensed nurses and CNAs who were not educated will be educated prior to the next shift by Director of Nursing, (DON), or designee. Education for 100 percent of nursing staff was completed on [DATE] at 7:00 P.M. -On [DATE] at 9:00 A.M., an ad hoc-quality assurance and performance improvement meeting was held with the Medical Director, the Administrator, the DON and the Regional Registered Nurse #600. Interventions were discussed and developed, and ongoing monitoring was established to ensure timely physician notification of changes in resident condition. -On [DATE] at 11:30 A.M., all 114 residents in house were assessed by the DON, LPN #322, and LPN #353 to ensure there was no current change in conditions that needed notification by reviewing progress notes for the past 24 hours and head to toe assessments completed. There were no issues identified -On [DATE] at 1:00 P.M., review of the last seven days of progress notes was completed by Regional Clinical RN #650 to ensure changes were communicated to provider. There were no findings. -On [DATE] at 3:30 P.M., review of 42 at-risk residents for change in condition was completed by the DON, LPN #322, and LPN #353 on [DATE] with no abnormalities found. -On [DATE], the DON or RN/designee will audit starting [DATE] the progress notes of five random residents three times a week for four weeks and one time a week for four weeks, to identify any changes in condition to ensure notifications were completed. Any changes in condition or abnormalities will be corrected at the time of discovery. -Audits will be reviewed in the monthly quality assurance and performance improvement (QAPI) and changes made as needed. -On [DATE], the medical records of five residents (#25, #28, #29, #32 and #38) were reviewed to ensure a change in condition was recognized and the provider was notified timely. - Interviews on [DATE] and on [DATE] with LPN #176, LPN #162 and LPN #150 verified nurses were educated on [DATE] regarding change in condition and notification. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Record review revealed Resident #05 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis, dysphagia, dementia, metabolic acidosis, chronic kidney disease, anxiety and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had impaired cognition. Resident #05 required extensive staff assistance for toileting, bathing and dressing and moderate assistance with eating and transferring and was dependent on staff for mobility. The resident had a manual wheelchair and would push off the walls to propel herself around the facility. Review of Resident #05's comprehensive care plan updated [DATE] revealed the resident was at risk for falls secondary to hemiplegia, cerebrovascular accident, (CVA), weakness and dementia. Interventions included providing assistance when the resident was transferring andambulating, reinforcing wheelchair safety as needed, such as locking brakes, report development of pain, bruises and changes in mental status, activities of daily living (ADL) function, appetite or neurological after a fall. Review of the activities of daily living (ADL) plan of care included interventions to assistance needed to bathe or shower. The amount of assistance varies based on task and time of day; more assistance may be required. Review of Resident #05's nursing progress note dated [DATE] revealed at approximately 10:00 A.M., the resident was found outside of the facility on the ground following an unwitnessed fall from her wheelchair. The resident had a trickle of blood visible on her forehead. Resident #05 was taken by ambulance to the hospital. Review of the hospital records revealed Resident #05's computerized tomography (CT) scan results dated [DATE] revealed a 1.4 centimeter (cm) parenchymal hemorrhage at the right frontal lobe, a 1.3 cm subdural hemorrhage along the left lateral convexity, a three millimeter (mm) subdural hemorrhage along the right lateral convexity and a two mm subdural hemorrhage along the falx (a large, sickle-shaped fold of the dura mater that sits vertically in the midline of the brain, separating the left and right cerebral hemispheres). She had an emergent left craniotomy and removal of a ventriculoperitoneal (VP) shunt and returned to the facility on [DATE]. Review of Resident #05's After Visit Summary (AVS) dated [DATE] revealed the resident was discharged back to the facility. The AVS instructions included notify your provider if you experience uncontrolled blood pressure. Seek immediate care if you feel confused, an increase in swelling or bruising around the eyes or you feel dizzy or faint while standing, or you notice any problems or new symptoms. The general care instructions to elevate the resident's head at a 30-degree angle when lying down. Review of the nursing progress notes dated [DATE] revealed Resident #05 returned to the facility with vital signs within normal range, alert and responsive, with no complaints of pain. She also had an incision on the left side of her head, closed with sutures. She had bruising on the right side of her face, her right hand and on her left arm and abrasions on her right dorsum and right elbow. Review of the nursing progress notes dated [DATE] at 4:10 P.M., authored by LPN #250, revealed Resident #05 became suddenly sleepy while near the nurses' station, showing decreased responsiveness with closed eyelids and not following commands. She was moved to bed, where she began moving independently but appeared fatigued. At the time of this assessment her vital signs were a blood pressure of 160/81 millimeters of mercury (mmHg), pulse 60 beats per minute, 12 respirations per minute, and an oxygen saturation of 95 percent. Blood glucose was 148 milligrams per deciliter (mg/dl). This occurred on her first day of therapy and fatigue was suspected of being the cause. Resident #05's physician was not contacted at this time regarding the altered mental status or the abnormal blood pressure and blood glucose readings. Review of the nursing progress notes dated [DATE] at 5:00 P.M revealed Resident #05 was observed by LPN #250 in a deep sleep and not responding to physical stimuli. The residents' vitals were a pulse of 55 beats per minute, (Normal range: 60 to 100 beats per minute), a blood pressure of 160/82 mm/Hg, and oxygen saturation of 94 percent on room air. Pupillary response was not observed. At this time Resident #05's physician was contacted. CNP #500 directed the nurse to contact emergency services to have Resident #05 taken to the hospital. Review of the surveillance footage provided by Resident #05's family revealed on [DATE] at 3:50 P.M., the Administrator is sitting in the room with Resident #05. The Administrator asks the resident if she had a long day and if she was tired. The resident does not speak or gesture clearly. The Administrator then asks the resident if she is not okay and she nods. The Administrator leaves the room and returns at 3:57 P.M., with LPN #106 and OTA #375. LPN #160 asks Resident #05 if she was okay. She just looks at her. LPN #160 then asks Resident #05 to follow her finger and moves it in a plane around the resident's face. LPN #160 then states, She's not even following my finger. LPN #160 leaves the room. At 4:00 P.M., LPN #160 returns with LPN #250. LPN #250 asks the resident to follow her finger. Resident #05 isn't even looking directly at LPN #250 as she is speaking to her or moving her finger. At 4:03 P.M. LPN #160 asks the resident to open her eyes. LPN #160 then covers Resident #05 with a blanket. At 4:45 P.M., LPN #160 and CNA #266 entered the resident's room. LPN #160 attempts to wake the resident by tapping on her shoulder, yelling her name and rubbing her chest. Resident #05 did not stir. LPN #160 then tells CNA #266 to come back and try to feed her later. LPN #250 re-enters Resident #05's room at 5:10 P.M. She attempts to wake her, but the resident does not stir. LPN #250 checks Resident #05's pupils and sees they are non-reactive. Review of the emergency medical service (EMS) patient care record dated [DATE] revealed a request for emergency transport of Resident #05 was received on [DATE] at 5:39 P.M. When the responding emergency personnel arrived at 5:49 P.M., Resident #05 was unresponsive with the following vital signs: blood pressure 220/96 mmHg, pulse 60 beats per minute, 18 respirations per minute, oxygen saturation 95 percent, and blood glucose 187 mg/dL. Her Glasgow Coma Score (GCS) was three (a score of three to eight indicates a severe brain injury, often signifying a comatose state). When EMS transferred Resident #05 to the hospital staff at 6:12 P.M., the resident's respirations had decreased to five per minute where normal respirations were 12-20 per minute. Review of the hospitalization record progress note dated [DATE] at 6:11 P.M. documented Resident #05 presented to the emergency department with altered mental status and was unresponsive. Resident #05 withdrew from painful stimuli in her extremities but was not protecting her airway so she was intubated. Her eyes were minimally responsive and dilated. The resident began displaying decorticate posturing (an abnormal involuntary body position where a person flexes their arms inward toward their chest while holding their legs out straight and rigid. This involuntary reflex is a critical sign of severe brain damage or intense pressure within the skull.). Review of Resident #05's CT scan dated [DATE] revealed a significant increase in left extra-axial hemorrhage, in comparison to her CT scan performed on [DATE], following the resident's craniotomy, measuring five cm in thickness. There was a compression of the right lateral ventricle with a midline shift to the left of about 1.5 cm. The craniectomy was displaced by the new hemorrhage. Review the hospital's physician's progress notes dated [DATE] at 12:41 A.M. revealed after assessing Resident #05 at the bedside and reviewing the CT scan results, it was determined Resident #05 would not have a meaningful chance of recovery. Resident #05 died [DATE] at 9:50 A.M, following a terminal ventilator withdrawal. During an interview on [DATE] at 2:45 P.M., LPN #106 confirmed in the afternoon of [DATE], the Administrator notified her Resident #05 appeared drowsy. LPN #106 contacted the nurse assigned to the resident, LPN #250, who assessed the resident. All her vital signs were normal. The resident laid down on her bed to rest. Resident #05 was offered a dinner tray, but she was still asleep. LPN #106 said she left the building since her shift ended. During an interview on [DATE] at 3:59 P.M., LPN #250 confirmed the resident was new to her. Resident #05 was previously resided on another unit prior to her fall on [DATE]. When she returned to the facility on [DATE], she was moved to this unit where LPN #250 worked. She said on [DATE], Resident #05 spent most of the day moving up and down the unit hallway in her wheelchair, using the wall to propel herself forward. Suddenly Resident #05 appeared tired, so the staff laid her down for a nap. She said present in the room were the Administrator,Occupational Therapy Assistant (OTA) #375, herself and LPN #106. LPN #250 said she went back in to check Resident #05 about an hour later and the resident would not wake up, would not respond to painful stimuli and her pupils were not reactive. LPN #250 called Resident #05's family and the physician. She then called 911 per the directive from CNP #500. During an interview on [DATE] at 4:35 P.M., CNA #399 stated she had given Resident #05 a shower on [DATE]. She denied the resident falling or injuring herself during the shower. She said following the shower, which occurred around 8:00 P.M., she checked on the resident every two hours, and the resident had no complaints throughout her shift. During an interview on [DATE] at 4:55 P.M., the Administrator stated on the afternoon of [DATE] she noticed Resident #05 was sitting in the hall common area in her wheelchair and appeared, Really sleepy, like she couldn't keep her eyes open. The Administrator asked Resident #05 if she was okay and if she wanted to lie down. She said she alerted LPN #106 and asked OTA #375 to help her get Resident #05 into her bed. During an interview on [DATE] at 5:06 P.M., OTA #75 stated in the late afternoon of [DATE] he helped the Administrator get Resident #05 back into bed. He said the resident appeared tired. He gave the resident a couple of verbal commands, such as squeeze my fingers and pull my finger, but she did not respond. After that, LPN #250 and LPN #106 arrived to assess the resident. After they were done, OTA #375 and LPN #106 transferred the resident into her bed. OTA #375 said per the resident's therapy evaluations, she was a two person assist for transferring and showering. During an interview on [DATE] at 6:28 A.M., LPN#180, who was Resident #05's assigned nurse overnight on [DATE], stated Resident #05 had been showered by the assigned aide. LPN #180 said she believed the aide showered the resident alone. LPN #180 reported no issues with the shower and no issues with the resident that night. During an interview on [DATE] at 12:05 P.M., LPN #250 stated on [DATE] around 4:00 P.M. she noticed Resident #05 was hanging around the nurse's station and she looked tired. LPN #250 proceeded to take her vital signs. She said she had no concerns about Resident #05's assessment or vital signs. She admitted the resident's blood pressure was a little high, but not emergency high. She said they laid the resident down for a nap. LPN #250 then called the resident's family to report what happened. She explained about an hour later, she went into the resident's room to check on her and noticed the resident was no longer arousable, and her pupils were not reacting to light. She said at this time was when she notified the provider, who told LPN #250 to call emergency services to transport the resident to the hospital. During an interview on [DATE] at 1:16 P.M., CNP #500 stated she had a visit with Resident #05 on the morning of [DATE]. CNP #500 said at this time, the resident appeared fine and expressed no concerns. CNP #500 said she was first contacted by the facility staff regarding Resident #05's lethargy and non-responsiveness in the afternoon of [DATE] at 5:24 P.M. CNP #500 said LPN #250 provided Resident #05's current vital signs, the resident was not responding to painful stimuli, and the resident's pupils were nonreactive. CNP #500 directed them to send her to the hospital at 5:28 P.M. Review of the facility policy titled Change in Condition Notification, issued [DATE] and reviewed [DATE], revealed the nurse will notify the resident's physician/practitioner when there is a significant change in the resident's physical, mental or psychosocial status, such as deterioration which includes life-threatening conditions. This deficiency represents non-compliance investigated under Complaint Number 3105531.

Based on record review, staff interview, review of video footage, and policy review, the facility failed to ensure hand hygiene and glove changes were completed prior to assisting residents with their meals. This affected one (Resident #10) out of three residents reviewed for infection control. The facility census was 118.Findings Include:Review of the record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included cerebral atherosclerosis, dementia, pulmonary hypertension, diabetes, hyperlipidemia, anxiety and muscle weakness. The resident is currently receiving hospice services.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 99. The resident was assessed to be dependent on staff for self-care activities and mobility.Review of Resident #10's care plan dated 04/08/26 revealed the resident yells, screams, and has threatening behaviors at times towards staff. The resident will reject care at times from staff. Interventions included explain all procedures to the resident before starting and allow the resident time to adjust to changes. Intervene as necessary to protect the rights and safety of others. Approach and speak to the resident in a calm manner.Review of the surveillance video footage, provided by the family, of Resident #10's room, revealed on 07/18/26 at 10:10 A.M., the Certified Nursing Assistant (CNA) #398, with gloved hands, picked up a tube of barrier cream from the resident's bedside table, picked up some debris from the floor walked to the resident's bathroom and put away the resident's cream and threw away the debris. CNA #398 does not change her gloves or complete hand hygiene. She then proceeded to open two of the resident's milk cartons, open her cutlery and push the plate of the resident's food towards her.After viewing the video with Regional Nurse #600, the Director of Nursing (DON) and the Administrator on 07/23/26 at 11:05 A.M. all three affirmed the CNA failed to maintain facility handwashing standards.Review of the facility policy titled Hand Hygiene, revised 04/14/23 revealed hand hygiene should be completed before and after handling food. This deficiency represents non-compliance investigated under Complaint Number 3094642.

Based on observations, record review, Food Committee Minute review, interviews, and facility policy review, the facility failed to ensure food temperatures were monitored to prevent food borne illness. This had the potential to affect all residents residing in the facility. The facility census was 110.Findings include: Review of dietary food temperature logs for March 2026 revealed missing meal temps on 03/18/26 and 03/23/26 for breakfast and lunch; 03/19/26 and 03/31/26 for breakfast, lunch and dinner; 03/12/26 for lunch and dinner; and 03/14/26, 03/15/26, 03/17/26, 03/26/26, 03/27/26, 03/28/26, 03/29/26 and 03/30/26 for dinner.Review of dietary food temperature logs for April 2026 revealed missing meal temps on 04/06/26, 04/08/26, 04/11/26, 04/12/26, 04/15/26, 04/17/26 and 04/18/26 for breakfast and lunch; 04/01/26, 04/03/26, 04/16/26, and 04/19/26 for breakfast, lunch and dinner; 04/02/26, 04/05/26 and 04/09/26 for dinner; and 04/14/26 for lunch.Review of the food committee meeting minutes for March 2026 revealed residents stated fries, baked potatoes and tenders were undercooked, pork loin was overcooked and broccoli and other vegetables were overcooked and undercooked at times, baked potatoes undercooked and eggs were served cold.Observation on 04/20/26 from 11:15 A.M. to 11:26 A.M. of lunch meal preparation and meal temperatures with Dietary Manager #46 and Dietary [NAME] #49 revealed the meal temperature log for March 2026 and April 2026 had missing meal temperatures.Interview on 04/20/26 at 11:26 A.M. with Dietary Manager #46 and Dietary [NAME] #49 verified the missing documentation prior to serving meals.Review of facility policy titled Food temperature Monitoring and Recording, dated 01/01/12, revealed It is the Center's policy to adhere to the temperatures for food set forth by the Ohio Uniform Food Safety Code. Temperatures of TCS food will be taken and properly recorded for each meal. This deficiency represents non-compliance investigated under Complaint Number 2961159.

Based on closed record review, interview and policy review the facility failed to ensure residents were free of significant medication errors This affected one resident (Resident #111) of three residents reviewed for medications. Findings include:Review of the medical record for Resident #111 revealed an admission date of 04/03/26 and a discharge date of 04/05/26 with diagnoses including secondary malignant neoplasm of bone, aplastic anemia, multiple myeloma not having achieved remission, need for assistance with personal care and adult failure to thrive. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Brief Interview for Mental Status (BIMS) was not assessed. The resident was assessed to require supervision or touching for eating, dependent on staff for toileting hygiene, shower/bathing, dressing and bed mobility.Review of the physician's order dated 04/06/26 revealed Resident #111 had an order for Pomalyst (anti-cancer medication) 2 milligrams (mg) by mouth in the morning until 04/13/26.Review of the Medication Administration Record (MAR) for April 2026 revealed Resident #111 did not receive the scheduled Pomalyst 2 mg on 04/04/26 and 04/05/26 at 9:00 A.M.Review of the nursing progress notes for Resident #111 revealed on 04/05/26 at 9:01 A.M. the nurse was unable to give Pomalyst due to the medication not being available in the medication cart.Interview on 04/22/26 at 3:48 P.M. with Registered Nurse (RN) #66 revealed she worked the day Resident #111 was admitted . The family brought in his medicine and it was in the top drawer of the medication cart and verified it was there. RN #66 entered the order in the MAR, and it stated the medication was in the top drawer of the medication cart. RN #66 verified Resident #111 did not receive the ordered medication.There was no medication error report despite the medication not being provided, yet available, for Resident #111.Review of the facility policy titled, Medication Administration, reviewed 02/03/26, revealed to safely and accurately prepare and administer medication according to physician order, professional standards of practice, and resident needs. This deficiency represents non-compliance investigated under Complaint Number 2975640.

Based on closed record review, interview, and review of facility policy the facility failed to ensure meal intakes were documented for one resident (#111) of three residents reviewed for nutrition. The facility census was 110. Findings include: Review of the medical record for Resident #111 revealed an admission date of 04/03/26 and a discharge date of 04/05/26 with diagnoses including secondary malignant neoplasm of bone, aplastic anemia, multiple myeloma not having achieved remission, need for assistance with personal care, and adult failure to thrive. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not assessed. The resident was assessed to require supervision or touching for eating.Review of Resident #111's meal intakes from 04/03/26 through 04/05/26 revealed one documented meal for breakfast on 04/05/26. Further review of meal intakes revealed no intakes recorded for breakfast, lunch or dinner on 04/04/26; no documented intake recorded for lunch on 04/05/26.Interview on 04/22/26 at 3:32 P.M. with Regional Director of Nursing #204 verified the missing meal intake documentation for Resident #111.Review of facility policy titled Food and Nutrition Services, dated 09/20/17, revealed It is the Centers policy to provide each resident a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each patient/resident. Residents will be provided with three meals daily at regular times comparable to the normal mealtimes in the community or in accordance with resident needs, preferences, requests and plan of care This deficiency is an incidental finding discovered during the course of the complaint investigation.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure hairnets were worn properly by kitchen staff to protect food from potential contamination. This had the potential to affect all residents except one (Resident #2) who did not receive food from the kitchen due to an active NPO (nothing by mouth) order. The facility census was 112.Findings include:Observation on 02/10/26 at 7:20 A.M. revealed [NAME] #108 was wearing a hairnet that was not adequately covering their hair, leaving the back of their hair exposed to hang at approximately shoulder level while frying eggs and plating breakfast foods.Interview on 02/10/26 at 7:30 A.M. with Regional Dietitian #477 verified [NAME] #108's hairnet was not fully covering their hair while performing food service tasks. Further interview at this time revealed Regional Dietitian #477 stated the hairnet could be lower to cover the cook's hair.Review of the facility policy titled Hair Restraints approved 09/15/10 revealed hair shall be restrained to prevent physical contamination of food. Further review of this policy revealed hair restraints shall be worn by all dietary employees while on duty to cover all hair, and employees with hair that cannot be covered by a single hairnet shall wear two hairnets (one for the front and one for the back) or a scrub cap.

Based on medical record review, observation and staff interview, the facility failed to maintain dignity during meal time. This affected one (Resident #28) of seven residents observed in the dining room. The census was 112. Findings include:Review of Resident #28's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included dementia, anxiety, and major depression. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed his cognition was severely impaired, he required substantial/maximal assistance for eating, was dependent for oral hygiene, toileting, shower/bathing, dressing and personal hygiene. On 02/11/2026 at 8:40 A.M. observation of the dining room revealed Certified Nurses Aide (CNA) #206 standing and feeding Resident #28. CNA #206 was observed to continue to stand and feed Resident #28 until 8:46 A.M. Interview on 02/11/26 at 8:46 A.M. with the Administrator confirmed CNA #206 was standing feeding Resident #28.

Based on staff interview, medical record review, and review of the facility policy on bed hold, the facility failed to notify the resident's representative of the facility's bed hold policy in writing. This affected one resident (Resident #133) of one resident reviewed for hospitalization. The facility census was 112.Findings include:1. Review of the medical record for Resident #133 revealed an admission date of 12/03/25 and a discharge date of 01/12/26. Further review of the medical record revealed Resident #133 had diagnoses that included unspecified protein-calorie malnutrition, Type II Diabetes Mellitus, heart failure, cutaneous abscess of abdominal wall, colostomy status, and depression. Review of the five-day PPS Minimum Data Set (MDS) dated [DATE] revealed Resident #133 had moderate cognitive impairment and demonstrated physical, verbal, and other behavioral symptoms.Review of the progress note dated 01/12/26 at 05:17 P.M. revealed the facility nurse practitioner ordered Resident #133 to be evaluated in the emergency department. Further review of the progress note revealed Resident #133 and the resident representative were notified of the transfer.Review of the bed hold notice titled Canal [NAME] Rehabilitation Center, Skilled Nursing & Assisted Living Notice of Bed Hold When Leaving the Facility for Resident #133 revealed the notice of bed hold was dated 01/12/26 and prepared by Business Office Manager (BOM) #316. BOM #316 documented on the back of the bed hold notice that she spoke with Resident #133's representative on 01/12/26.Interview with Unit Manager #130 on 02/11/26 at 10:50 A.M. revealed Resident #133 had a drain for an enterocutaneous fistula. Unit Manager #130 stated that, during wound rounds, the drain was found dislodged and lying on the bed next to Resident #133. Resident #133 could not report how the drain came out.Interview with BOM #316 on 02/12/26 at 8:50 A.M. revealed the facility did not have an address for Resident #133's representative. BOM #316 stated Resident #133's representative was contacted on 01/12/26 to obtain the representative's address. BOM #316 stated the representative of Resident #133 requested a bed hold during that conversation. BOM # 133 verified the bed hold notice was not mailed to Resident #133's representative. Review of the policy titled Bed Hold Agreement effective 01/01/12 and reviewed 03/21 stated, upon discharge, the Center will attempt to review the Notice of Bed Hold with the patient/resident and/or his or her Legal Representative within 24 hours and/or next business day. The policy further stated the Center will also attempt to provide/send written notice within 24 hours and/or the next business day via mail and/or email.

Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to develop a comprehensive, person-centered care plan that included Continuous Positive Airway Pressure (CPAP) therapy (a device that delivers air pressure using a mask to keep the airway open while sleeping). This affected one (Resident #91) of two residents reviewed for CPAP therapy. The census was 112.Findings include:1. Review of Resident #91's medical record revealed the resident was admitted on [DATE] with diagnoses that included acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, pulmonary hypertension, iron deficiency anemia, chronic venous hypertension with ulcer of bilateral lower extremity, obstructive sleep apnea, restless leg syndrome, anemia, pain, shortness of breath, and localized edema.Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #91 was cognitively intact and required partial or moderate assistance for toileting, shower/bathing, and dressing. Resident #91 required substantial and maximal assistance with putting on and taking off footwear. Resident #91 required setup or clean-up assistance with personal hygiene, eating, and oral hygiene. Resident #91 used a non-invasive mechanical ventilator (a method of delivering oxygen using a face mask).Review of physician order's revealed an order dated 01/07/26 at 7:00 P.M. for CPAP to be applied every night shift. Observation of Resident #91 on 02/09/26 at 7:39 P.M. revealed the resident was sleeping in bed. Resident #91 was not wearing the CPAP.Observation of Resident #91 on 02/10/26 at 6:55 A.M. revealed Resident #91 was asleep in bed and did not respond to knock on the door. Resident was observed to not be wearing the CPAP.Observation of Resident #91 on 02/11/26 at 6:55 A.M. revealed Resident #91 was in bed with the lights out did respond to a knock on door. The resident was observed to not be wearing the CPAP.Interview with Certified Nursing Assistant (CNA) #479 on 02/11/26 at 6:55 A.M. verified Resident #91 not wearing the CPAP. CNA #479 stated she did not think Resident #91 used his CPAP anymore because he was also not wearing it the last time she worked.Review of Resident #91's care plan initiated on 01/06/26 revealed no care plan for Resident #91's CPAP.Interview with MDS Coordinator Registered Nurse (RN) #126 on 02/12/26 at 10:35 A.M. verified the CPAP was not care planned for Resident #91 but should have been included in the plan of care.Review of the policy titled Care Plan Comprehensive and Revision issued 08/08/22 and reviewed 02/02/26 revealed the comprehensive, person-centered care plan should describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observations, medical record review, resident interview, staff interview, and review of facility activity calendar, the facility failed to provide meaningful activities to all residents. This affected two (Residents #44 and #101) of six residents reviewed for activities. The census was 112.Findings Include:1. Resident #44 was admitted to the facility on [DATE]. Her diagnoses were chronic kidney disease, congestive heart failure, vitamin D deficiency, disorder of muscle, hypertensive heart and chronic kidney disease, end stage renal disease, Type II Diabetes, acute respiratory failure with hypoxia, rhabdomyolysis, hypoosmolality and hyponatremia, acute kidney failure, hypothyroidism, atherosclerotic heart disease, hypotension, muscle weakness, dyspnea, hypertension, insomnia, edema, osteoarthritis, and constipation. Review of her minimum data set (MDS) assessment, dated 12/12/25, revealed she was cognitively intact. Review of Resident #44's recreational therapy assessment, dated 11/20/25, revealed her interests included: arts and crafts, cards/bingo/puzzles, community outings, computer, exercise/sports, listen to music, outside/gardening, pet therapy, reading/writing, and watching TV/movies/news. It also documented that she was interested in participating in activities. Review of Resident #44's current care plan revealed a care description of resident can make their own decisions as to which programs they would like to attend., Resident is alert and completed their own assessment. Interventions for this care plan area included: reminding resident of ongoing activities and specific locations, and remind her to check the back of the daily chronicle for activities of the day. Review of Resident #44's activity logs, dated November 2025 to January 2026, revealed no documented arts and craft activities documented as being offered, completed, or refused. Interview with Resident #44 on 02/10/2026 at 10:00 A.M. the resident stated activities on the second floor of the facility are pretty good, but not on the first floor. She stated she has to make the effort to go to the second floor if she wants activities. She confirmed there are no activities past 4:15 P.M., and even then, it's only one on one activities. She stated there was very little variety with the activities. She confirmed they do not do many arts and crafts activities and the ones they do, the residents have to provide their own supplies. She confirmed she would like more arts and crafts. Interview with Activities Director #182 on 02/17/2026 at 12:37 P.M. stated the residents must ask the activities staff to get arts and crafts supplies out if it's not on the activity schedule. She stated she would have to look at the activities calendars to see how many arts and crafts activities are scheduled each month, but they perform knitting each Sunday. She did confirm the residents would have to supply their own supplies to participate in that. She also confirmed there are changes to the activity calendar on a daily basis if needed; those are reflected on the daily chronicle/newsletter that is given to each resident, each day. She stated the residents should look at the back of that chronicle to see if there are any changes or what activities are provided for that day. She confirmed they have a limited budget, so they don't buy arts and crafts supplies if it's not in the budget. She confirmed Resident #44 would complete arts and crafts [NAME] days a week if she could. Review of facility activity calendars, dated 11/01/25 to 02/17/16, revealed the following number of arts and crafts activities offered: one for November, three for December, one for January, and one for February. There was an activity named Knotting Knitters that was offered every Sunday. But, it was documented that residents were to bring their own supplies for this activity each week. 2. Review of the medical record for Resident #101 revealed an admission date of 03/24/2023 and a re-entry date of 01/28/2025. Diagnosis included chronic obstructive sleep apnea, depression, and heart failure. Review of Resident #101's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. Review of the plan of care date 01/29/2025 revealed Resident #101 declined group activity frequently, resident declines most group activity attendance and often has prepared reason, wants to do crafts in her room, talk on the phone, and watch television. Interview on 02/10/2026 at 11:00 A.M. with Resident #101 revealed she use to be a teacher and really enjoys working on all different kinds of crafts. Resident #101 stated she refused to attend a lot of the activities due to the facility not really having crafts to do. If they would have more crafts she would attend more of the facility actives. Interview on 02/17/2026 at 10:05 A.M. with Activity Director #182 revealed the facility does not have multiple craft activities, but this is also something that is determined by what the residents vote on and the activities department budget. There are multiple residents who like to make crafts and a couple residents will get together a few times a year and set up a little table outside the facility for visitors to buy their crafts and they get to keep all the money.

Based on medical record review, staff interview, and observations this facility failed to ensure post appointment instructions were followed this affected one (Resident #101) of one resident reviewed for follow up care. The facility also failed to ensure Thrombo-Embolism Deterrent (TED) hose were in place as ordered. This affected two (Resident #80 and #91) of the two residents reviewed for TED hose placement. The facility census was 112. Findings include:1. Review of the medical record for Resident #101 revealed an admission date of 03/24/2023 and a re-entry date of 01/28/2025. Diagnosis included chronic obstructive sleep apnea, need for assistance with personal care, and heart failure. Review of Resident #101's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. Resident #101 was noted to require set up or clean up assistance for oral hygiene and was noted to receive anticoagulants on a daily basis. Review of the plan of care dated 01/28/25 revealed Resident #101 received ancillary services as needed such as dental and podiatry services. Interventions included to coordinate with social services for scheduling of resident need to see in house specialty physicians, coordinate with specialty care physician any medications or treatment changes pre or post operations and to educate resident to communicate need of appointment with nursing and social services to be set up as needed. Review of the plan of care dated 02/10/25 revealed Resident #101 was at risk for oral dental health problems due to resident having her own teeth with some missing on the top and on the bottom with no partials. Interventions include to administer medications as ordered, assist/setup/task segmentation/supervision and cueing for mouth care and hygiene, coordinate arrangements for dental care, transportation as needed/as ordered, dental consult as needed, diet as ordered, provide mouth care as per activities of daily living. Review of Resident #101's medical record revealed no evidence of this resident having a dental appointment on 11/07/2025 nor was there any evidence or pre or post orders to follow for a dental surgery that was scheduled on 12/12/2025. Interview 02/17/2026 12:05 P.M. with Front Desk Coordinator #555 at the dental office claimed that Resident #101 came to the dentist office for an appointment on 07/21/2025, then another appointment on 08/11/2025 then a consult on 11/07/2025 where preoperation (preop) instructions were provided to Resident #101's daughter. When this resident returned to the dental office on 12/12/2025 for surgery, she had informed the office staff that she did eat and did take her medication that morning even though she was not supposed to. The surgery had to be canceled due to the facility not following the preop instructions. Another appointment was scheduled on 12/23/2025 where it was noted the facility reached out to the dental office to have the instructions faxed to them. No issues were noted due to the surgery being pushed off. Interview on 02/17/2026 at 10:30 A.M. with the Director of Nursing (DON) confirmed Resident #101 had a dental procedure completed on 12/23/2025. The DON was not able to provide information about the dental appointment that was on 11/07/2025 or any knowledge of Resident #101 having dental surgery scheduled for 12/12/2025. The DON claimed when a resident has an appointment, this information is added to the resident's Treatment Administration Record (TAR) but this information was not noted in Resident #101's record. The DON also verified when a resident returns to the facility after an appointment, the nurse should have after visit information in case there are any new orders and if the resident does not have this information, then the nurse should contact the office to follow up on this. 2. Review of Resident #91's medical record revealed the resident was admitted on [DATE] and had diagnoses that included acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, pulmonary hypertension, iron deficiency anemia, chronic venous hypertension with ulcer of bilateral lower extremity, obstructive sleep apnea, restless leg syndrome, anemia, pain, shortness of breath, and localized edema. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #91 was cognitively intact and required partial or moderate assistance for toileting, shower/bathing, and dressing. Resident #91 required substantial and maximal assistance with putting on and taking off footwear. Resident #91 required setup or clean-up assistance with personal hygiene, eating, and oral hygiene. Review of the physician order dated 01/07/26 at 7:00 A.M. revealed an order to apply thrombo-embolism deterrent (TED) hose (compression stockings used to prevent blood clots) to both legs every day shift for swelling/circulation. Observation of Resident #91 on 02/10/26 at 8:49 A.M. revealed the resident was sitting up in bed. Resident #91 did not have TED hose on either leg. Observation of Resident #91 on 02/11/26 at 11:30 A.M. revealed the resident was sitting in a wheelchair. Resident #91 did not have TED hose on either leg. Observation of wound care by Licensed Practical Nurse (LPN) #326 on 02/11/26 at 11:52 A.M. for Resident #91 revealed after LPN #326 completed wound care to Resident #91's left great toe and left shin. LPN #326 was observed to apply ace wrap to the resident's left shin after wound care was completed. Interview with LPN #326 on 02/11/26 at 4:15 P.M. verified Ace wraps were placed on Resident #91's legs, not TED hose as ordered by the physician. LPN #326 stated Resident #91 had never worn TED hose and plans to obtain an order for an Ace wrap to be applied to both legs from the physician. Review of the treatment administration record (TAR) for February 2026 revealed on 02/11/26 TED hose were signed off as applied by LPN #326. 3. Review of Resident #80 revealed she was admitted to the facility on [DATE]. Diagnoses included localized edema, major depression, hypertension and acute respiratory failure. Review of the quarterly minimum data set assessment dated [DATE] revealed her cognition was intact. She was independent with eating, she required set up/clean up assistance for oral hygiene, partial/moderate assistance for toileting, personal hygiene, turning and repositioning, and substantial/maximal assistance for shower/bathing and dressing. Review of the physicians orders revealed an order on 10/08/2025 for [NAME] hose to bilateral lower extremities on in morning and off in the evening every day shift for edema. Observations on 02/10/2026 at 9:30 A.M., 1:30 P.M., and 3:30 P.M. revealed no [NAME] hose observed on. Observation on 02/11/2026 at 10:20 A.M. and 2:00 P.M. revealed no [NAME] hose observed on. Observation on 02/11/2026 at 3:46 P.M. revealed no TED hose observed on. Concurrent interview LPN #284 verified the [NAME] hose were not on as ordered. Review of the treatment record for February 2026 revealed on 02/10/2026 they were signed off as applied. Review of the policy titled Physician and Practitioner Orders issued 07/01/22 and reviewed on 02/03/26 revealed a licensed nurse is responsible for completing cares per physician orders. This deficiency represents non compliance investigated under Complaint Number #2695034.

Based on medical record review, observation and staff interview, the facility failed to implement and/or follow physician orders to treat pressure injuries. This affected two residents, (Resident #126 and Resident #91), of four residents reviewed for pressure injury management. The facility census was 112. Findings include:1.Record review for Resident #126 revealed this resident was admitted to the facility on [DATE] with diagnoses including: diabetes mellitus, hemiplegia, hemiparesis, chronic congestive heart failure. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of six. This resident was assessed to require self-care assistance. Resident #126 was coded with a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister.)pressure ulcer and a Stage III (full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) pressure ulcer, both on the sacrum. Review of the care plan dated 01/26/26 revealed Resident #126 was at risk for skin integrity impairment due to hemiplegia and weakness. Interventions included administering treatments per physician orders. Review of Resident #126's physician orders revealed no treatment orders for the resident's pressure ulcers. Review of Resident #126's January and February 2026 treatment administration record, (TAR), revealed no orders to treat the resident's pressure ulcers. The TAR did indicate the resident had a weekly skin check completed on 01/28/26, 02/04/26 and 02/11/26. which were initialed as completed by the nurse. Review of progress note dated 01/27/26 at 11:57 A.M. revealed Resident #126 had pressure injury documented as a Stage I ( Observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence; may include changes in skin temperature, tissue consistency and/or sensation. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues) to the right gluteus. The injury was described as non blanchable erythema of intact skin. Wound was present on admission and unknown how long the wound had been present. Staged by in house nursing wound measured 1.72 centimeters (cm) by 0.91 cm by 0.0 cm with 100% eschar (a layer of thick, dry, black or brown necrotic (dead) tissue that forms over severe wounds, burns, or pressure ulcers ). The wound had no exudate and peri wound was attached. Cleanse with normal saline, apply triad paste and leave open to air. There was a second wound to the left gluteal fold that was documented as a pressure ulcer which was present on admission and measured 1.24 cm by 1.38 cm by 0.0 cm with 100% eschar. No drainage was noted, the treatment was documented as cleanse with normal saline, apply triad paste and leave open to air. There was no wound stage indicated for the wound to the left gluteal fold. Review of progress note dated 01/29/26 at 11:27 A.M. revealed the resident has a stage II pressure ulcer to the left gluteal fold that measured 0.42 cm by 0.34 cm by 0.0 cm with 100% eschar and peri wound attached. Treatment was documented as cleanse with normal saline apply triad paste and leave open to air. The resident also had a stage III pressure ulcer to the right gluteus that measured 0.66 cm by 0.54 cm by 0.0 cm that was 60% epithelial tissue, 10% slough and 30% eschar. Peri wound was documented as attached,and treatment was documented as cleanse with normal saline apply triad paste and leave open to air. Review of progress note dated 02/05/26 at 9:52 A.M revealed the resident had a stage II pressure ulcer to the left gluteal fold that measured 0.49 cm by 0.56 cm by 0.0 cm with 100% eschar and peri wound attached. Treatment was documented as cleanse with normal saline, apply triad paste and leave open to air. The resident had a stage III pressure ulcer to the right gluteus that measured 3.76 cm by 2.75 cm by 0.1cm that was 20% epithelial tissue and 80% granulation tissue and the peri wound was attached. The treatment was documented as cleanse with normal saline, apply triad paste and leave open to air. Review of the physician's Wound Assessment and Plan dated 02/05/26 revealed a stage II pressure injury, measuring 0.49 centimeter (cm) by 0.56 cm. by 0 cm, with a wound onset date of 01/26/26. Wound treatment orders read: clean the wounds with normal saline, pat dry, apply triad cream and leave open to air. The assessment also revealed a stage III pressure ulcer located in the right gluteal fold, measuring 3.76 cm. by 2.75 cm. by 0.1 cm. The wound treatment order read: cleanse with normal saline, pat dry, apply collagen sheet and cover with dry dressing every one day and as needed. Review of physician orders revealed the orders for Resident #126's wounds listed in the Wound Assessment and Plan note dated 02/05/26 were not transcribed as orders into the resident's medical record. Review of progress note dated 02/12/26 at 10:40 A.M. revealed the pressure ulcers were resolved. Interview on 02/12/2026 at 11:05 A.M. an interview with Licensed Practical Nurse, (LPN) #482 confirmed Resident #126 did not have wound care orders for the stage II and stage III pressure ulcers the resident had at admission to the facility. On 02/12/2026 at 11:13 A.M. Regional Director #451 also confirmed that Resident #126 did not have wound care orders for either pressure ulcer. Review of the facility's policy Physician and Practitioner Orders, revised 11/09/23, revealed the licensed nurse is responsible for applying and completing treatments per physician orders. 2. Review of Resident #91's medical record revealed the resident was admitted on [DATE] and had diagnoses that included acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, pulmonary hypertension, iron deficiency anemia, chronic venous hypertension with ulcer of bilateral lower extremity, obstructive sleep apnea, restless leg syndrome, anemia, pain, shortness of breath, and localized edema. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #91 was cognitively intact and required partial or moderate assistance for toileting, shower/bathing, and dressing. Resident #91 required substantial and maximal assistance with putting on and taking off footwear. Resident #91 required setup or clean-up assistance with personal hygiene, eating, and oral hygiene. Review of Resident #91's physician orders revealed an order for right dorsum first digit specified to cleanse with normal saline, pat dry, then apply Betadine and cover with a bordered gauze dressing every night shift until resolved dated 02/05/26, and an order for left dorsum first digit specified to cleanse with normal saline, pat dry, apply wound gel then kerlix wrap every shift until resolved dated 02/05/26. Review of the Skin Issues dated 02/05/26 at 8:23 A.M. revealed Resident #91 had a stage III pressure ulcer (full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present) on the left hallux (great toe) and an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) on the right hallux (great toe). Observation of Resident #91 on 02/09/26 at 7:39 P.M. revealed resident sleeping in bed. Resident #91 did not have dressings on either great toe. Blood was observed on the bottom of Resident #91's left foot. Observation of Resident #91 on 02/10/26 at 8:49 A.M. revealed resident sitting up in bed. Resident #91 did not have dressings on either great toe. Interview with Resident #91 on 02/10/26 at 8:49 A.M. revealed facility staff are applying dressings to the shin area only. Interview with Certified Nursing Assistant (CNA) #70 on 02/11/26 at 11:24 A.M. revealed CNA #70 has only seen dressings on Resident #91's shins. Observation of Resident #91 on 02/11/26 at 11:30 A.M. revealed resident sitting in a wheelchair. Resident #91 did not have dressings on either great toe. Interview with Resident #91 on 02/09/26 at 11:30 A.M. revealed the resident requested a Band Aid for his left toe but the staff did not return to the room to apply the dressing. Resident #91 stated he was unable to finish dressing until the Band Aid was applied. Interview with Licensed Practical Nurse (LPN) #326 on 02/11/26 at 11:52 A.M. verified Resident #91 did not have dressings on either great toe. LPN #326 stated treatment orders must have recently changed for Resident #91 because dressings were not previously ordered for the great toes. Review of Resident #91's orders with LPN #326 confirmed the resident had new orders for the left and right great toes dated 02/05/26. Review of physician orders revealed treatment orders for the right great toe beginning 01/07/26 and modified on 01/15/26, 01/22/26, 01/29/26, and 02/05/26. Review of physician orders revealed treatment orders for the left great toe beginning 01/07/26 and modified on 01/15/26, 01/22/26, and 02/05/26. Review of the Treatment Administration Record (TAR) for February 2026 revealed on 02/09/26, 02/10/26, and 02/11/26 treatments to the right and left great toe were documented as performed. Review of the care plan initiated on 01/06/26 revealed Resident #91 was at risk for skin alteration due to the presence of skin alterations. Interventions to decrease and minimize skin breakdown risk for Resident #91 included administering treatments per physician orders. This intervention was initiated on 01/09/26 for Resident #91.

Based on observation, staff interview, and review of facility nutrition policies, the facility failed to ensure one ( Resident #66) did not experience a significant weight loss and failed to ensure one ( Resident #92's) fluid restriction was followed. This affected two of seven residents (#14, #36, #44, #66, #92, #10, and #10) reviewed for nutrition. The facility census was 112.Findings include: 1. Review of Resident #66's electronic medical record revealed the resident was initially admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), schizoaffective disorder, anxiety disorder, stage three chronic kidney disease, type two diabetes mellitus, muscle weakness, personal history of neoplasm of the large intestine, and acquired absence of other specified of the digestive tract amongst other diagnoses. Further review of Resident #66's electronic medical record revealed a Brief Interview for Mental Status (BIMS) score of eight (dated 11/08/25), suggesting moderate cognitive impairment. Review of weight measurements and physician orders contained in Resident #66's electronic medical record revealed the resident lost over 13% of their weight in a time period of less than three months between 11/10/25 (169 pounds) and 02/02/26 (146 pounds) while the resident was not on a prescribed weight loss program. Review of Resident #66's most recent care plan dated 11/28/25 revealed the resident was identified as at nutritional risk related to COPD, perianal thrombosis, chronic kidney disease, schizoaffective disorder, anxiety disorder, bipolar disorder, depression, dementia, atrial fibrillation, congestive heart failure, constipation, history of nausea and vomiting, history of bowel cancer, diet restrictions, and significant weight loss. Further review of the care plan revealed interventions for mitigating nutritional risk included document food acceptance, monitor weights per order and as needed, provide and serve diet as ordered, Registered Dietitian to evaluate and make diet change recommendations as needed, and provide nutritional supplements as ordered. Review of physician orders as of 02/11/26 in Resident #66's medical record revealed a dietary order for no added salt, regular texture with thin consistency. Further review of dietary orders for Resident #66 revealed no evidence of active orders for any dietary supplement. Observation during lunch service on 02/10/26 at 11:30 A.M. revealed Resident #66 appeared thin or underweight. Further observation at this time revealed there was no nutritional supplement on or near Resident #66's lunch tray. Observation in the kitchen on 02/11/26 at 6:09 P.M. of Resident #66's meal ticket for dinner revealed no marking to indicate that a nutritional supplement should be provided with the meal. Interview on 02/11/26 at 6:10 P.M. with Dietary Manager #266 revealed residents that are intended to receive nutritional supplements with their meal will have the supplement order printed on their meal ticket to notify kitchen staff when preparing meal trays. Further interview at this time verified there was no marking to designate the need for a nutritional supplement on Resident #66's meal ticket. Interview on 02/12/26 at 2:28 P.M. with Regional Dietitian #477 revealed Resident #66 had triggered recently for weight loss within the past 30 days. Further interview at this time revealed Resident #66 should have been receiving nutrition interventions including supplements such as med pass 120 milliliters (ml) twice daily and magic cup twice daily with lunch and dinner. Regional Dietitian also identified other nutritional interventions for Resident #66 included monitoring food intakes and keeping the resident on an appetite stimulating medication that had been started while the resident was previously in the hospital. Interview on 02/12/26 at 2:42 P.M. with Regional Dietitian #477 revealed they were not able to find any active orders for nutritional supplements in Resident #66's medical record. Further interview at this time revealed Resident #66 should have had active orders for nutritional supplements as had previously been discussed, and the resident used to have orders for these supplements prior to a brief hospital stay from which the resident returned to the facility on [DATE]. Regional Dietitian #477 stated there must have been a mix up, because orders for nutritional supplements were not reinstated following the resident's return to the facility on [DATE]. Regional Dietitian #477 stated we will have to get this sorted out and reactivate nutritional orders as indicated. Review of the facility policy titled Dietary Supplements approved 01/01/12 and reviewed 10/19/21 revealed it is the center's policy that patients/residents identified as nutritionally at risk will be provided a dietary supplement during medication passes, meals, or at other times as directed per a physician's order. Further review of the policy revealed the intent of the policy is to assure optimal nutrition for all residents at all times, and dietary supplements are provided to residents who are nutritionally at risk. Additional review of the policy revealed it is the responsibility of nutrition staff to initiate or verify the appropriateness of all dietary supplements for residents, and it is the responsibility of nursing staff for obtaining and discontinuing the physician's order for dietary supplements. 2. Record review for Resident #92 revealed this resident was admitted to the facility on [DATE] with diagnoses including: hypotension, cardiomegaly, end-stage renal disease, Diabetes Mellitus Type II, major depressive disorder, muscle weakness, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require activity of daily living (ADL) assistance Review of the care plan dated 05/15/25 revealed Resident #92 received peritoneal dialysis due to end-stage renal failure. Interventions included a fluid restriction of 950 ml, consisting of 250 mL from the nursing team during day shift, and 100 mL during the night shift. Observation on 02/12/26 at 10:17 A.M. revealed Resident #92 sipping from a 500 mL water bottle and setting it on a table adjacent to her. The table also held a small glass full of water. When asked if both the water bottle and water glass on the table were hers, Resident #92 affirmed that they were. She denied the nursing staff at the facility were monitoring her fluid intake. Interview with Regional Dietician #477 on 02/12/26 at 11:17 A.M. confirmed Resident #92's current diet orders included a fluid restriction of 950 mL per day, including 600 mL allocated for meal times. Interview with Licensed Practical Nurse, (LPN) #482 on 02/12/26 at 11:25 A.M. confirmed she did not receive any information in report about any of the residents currently having a fluid restriction. She reviewed the residents' orders and she could not find any active fluid restriction orders for any residents. At 12:17 P.M. LPN #482 verified Resident #92 had water bottle and a glass of water on her table. Interview with Certified Nursing Assistant, (CNA), #268 on 02/12/26 confirmed she had no knowledge of Resident #482 having a fluid restriction. She admitted the facility nursing staff was not following it. Review of the facility's policy Fluid Restriction Guidelines revealed the nursing staff is responsible for ensuring that the fluid restriction is maintained and that the fluid limits are not exceeded.

Based on observation, interview and record review, the facility failed to follow physician orders for oxygenation therapy for Resident #06 and continuous positive airway pressure, (CPAP) use for Resident #36. This affected two residents, (Residents #06 and #36) of four residents reviewed for respiratory care. The facility census was 112.Findings Include:1.Record review for Resident #06 revealed this resident was admitted to the facility on [DATE] with diagnoses including: cerebral infarction, diabetes mellitus, chronic respiratory failure with hypoxia, anxiety, depression, congestive heart failure and choric obstructive pulmonary disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require mobility and self-care assistance. Review of the care plan dated 01/02/26 revealed Resident #06 has altered respiratory status and breathing difficulty. Interventions included providing oxygen via nasal cannula at three liters per minute (LPM). Review of the physician's orders of Resident #6 revealed oxygen delivery via nasal cannula continuously at three liters per minute. Observation on 02/10/26 at 3:40 P.M. revealed Resident #6 was not wearing her oxygen at time of visit. Observation on 02/12/26 at 4:54 P.M. revealed Resident #6 was not wearing her oxygen. On 02/12/2026 at 5:36 P.M. Licensed Practical Nurse, (LPN) #482 verified that Resident #06 was not wearing her oxygen as ordered. She confirmed the oxygen should be worn by the resident at all times. 2. Review of Resident #36's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included displaced intertrochanter fracture of left femur, mild protein calorie malnutrition, congestive heart failure, atrial fibrillation, and diabetes. Review of the quarterly minimum data set assessment dated [DATE] revealed her cognition was intact. She was independent with eating, oral hygiene and personal hygiene, required partial/moderate assistance with toileting, shower/bathing, and dressing. Requires supervision/touching assistance for sit to stand, and all transfers. Frequently incontinent of urine and occasionally incontinent of bowel. Review of the physicians orders revealed an inactive order dated 09/22/25 for CPAP:during night every night shift for Bipap support (used for sleep apnea). Resident #36 was out of the facility and in the hospital on [DATE] and returned on 02/05/2026. There was no active order for the CPAP upon readmission to the facility. Interview with Regional Director #451on 02/12/26 at 3:02 P.M. verified there was not a current order for the CPAP, but did state Resident #36 had been wearing the CPAP at the facility.

Based on medical record review and staff interview, the facility failed to timely and thoroughly address all pharmacy recommendations. This affected two (Residents #7 and #3) of five residents reviewed for pharmacy recommendations. The census was 112.Findings Include:1. Resident #7 was admitted to the facility on [DATE]. His diagnoses were acute respiratory failure, non-displaced intertrochanteric fracture of left femur, disorder of muscle, acute pulmonary edema, other acute osteomyelitis, cardiomyopathy, hypokalemia, peripheral vascular disease, congestive heart failure, atrial fibrillation, chronic kidney disease (stage IV), atherosclerotic heart disease, hypo-osmolality and hyponatremia, Type II Diabetes, ischemic cardiomyopathy, anxiety disorder, shortness of breath, depression, obesity, insomnia, muscle weakness, hypertension, edema, and umbilical hernia. Review of his minimum data set (MDS) assessment, dated 01/19/26, revealed he was cognitively intact. Review of Resident #7 pharmacy recommendation, dated 04/19/25, had a recommendation to review the use of Insulin Glargine (long acting insulin) 12 units and Insulin Lispro(rapid acting) (sliding scale for the need of both of medications. The recommendation was to stop Insulin Aspart (fast acting) and continue the other medications as ordered. The recommendation form was marked for disagree with the recommendation, but the justification stated, duplicate; there was no actual justification for the response. Also, there was no provider signature or date as to if/when the recommendation was reviewed. Review of Resident #7's pharmacy recommendation, dated 05/24/25, revealed the same pharmacy recommendation as 04/19/25. There was a hand written note that the facility will repeat the A1C laboratory/blood draw in July 2025. It was signed by the provider on 06/09/25. Review of Resident #7's laboratory results, dated 08/06/25, revealed there were no A1C laboratory test obtained in July 2025 as indicated on the pharmacy recommendation. Review of Resident #7 pharmacy recommendation, dated 06/27/25, revealed the same recommendations as 04/19/25 and 05/24/25. This recommendation was agreed upon by the provider and signed on 06/30/25. Review of Resident #7 pharmacy recommendation, dated 09/30/25, revealed the same recommendations as 04/19/25, 05/24/25, and 06/27/25, revealed the pharmacy recommendation form was marked with disagree and other and the typed justification of blood glucose (BG)/A1C at goal for age (79), repeat A1C in three months. It was signed by the provider on 10/02/25. Review of Resident #7 pharmacy recommendation, dated 12/31/25, revealed the same recommendation as 04/19/25, 05/24/25, 06/27/25, and 09/30/25. The pharmacy recommendation was not addressed on this form. But, on a provider progress note, dated 01/29/26, the nurse practitioner agreed to discontinue the Insulin Aspart. Review of Resident #7 physician orders, dated October 2024 to January 2026, revealed he was never ordered to take Insulin Aspart sliding scale dose. He was ordered Insulin Lispro sliding scale from 10/17/24 to 01/08/26, which was when he was discharged to the hospital. Insulin lispro sliding scale was reinstated on 01/12/26, but then discontinued again on 01/29/26, which would align with the pharmacy recommendation and provider order to discontinue it on 01/29/26. There was no order to stop Insulin Lispro sliding scale on 06/27/25, when the provider agreed with the pharmacy recommendation to stop Insulin Aspart sliding scale. Interview with Director of Nursing (DON) on 02/17/26 at 3:10 P.M. confirmed there was no provider signature or date on the 04/19/25 pharmacy recommendation as required. Also, he confirmed Resident #7's A1C was not drawn and run until 08/06/25 instead of July 2025 as ordered/expected from the pharmacy recommendation on 05/24/25. He confirmed Resident #7 never had an order for Insulin Aspart and that the facility never clarified with the pharmacy or provider if that was a clerical error, or if the recommendation should have been for the discontinuation of the insulin lispro sliding scale. He confirmed the pharmacy recommendation on 06/27/25 was not addressed to clarify which portion of the recommendation the provider agreed with. He agreed the nurse practitioner wrote in her note on 01/29/26, that she wanted the Insulin Aspart to be discontinued, even though he was not ordered Insulin Aspart. He agreed the recommendation to discontinue Insulin Aspart on all four pharmacy recommendations were probably a clerical error and should have been Insulin Lispro since they both were sliding scale. 2. Review of Resident #3's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included dementia, depression, anxiety, insomnia, high blood pressure and pain. Review of the admission minimum data set assessment dated [DATE] revealed her cognition was not intact, she was dependent for eating, oral hygiene, toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. Frequently incontinent of bowel and bladder. Received antipsychotics, antianxiety, antidepressants and anticoagulants. Review of Pharmacy Recommendation on 11/07/25 revealed the resident has an order for Morphine (opioid) 20 milligrams (mg) per milliliter (ml) oral solution. Give 0.25 mg every three hours as needed, however hospital record indicate resident was receiving 0.3 ml every two hours as needed for moderate to severe pain. Please clarify this order with prescriber and update accordingly. On 12/04/2025 this was addressed by the physician and was deferred to hospice. Further review revealed no documented evidence it was addressed. On 02/12/2026 at 3:02 P.M. interview with Regional Director #451 verified no follow up by hospice on the pharmacy recommendation after the physician referral by the physician.

Based on observations, medical record review, staff interview, and facility policy review, the facility failed to ensure transmission based precautions and personal protective equipment usage were followed as required. This had the potential to affect 21 (Residents #44, #15, #22, #27, #122, #137, #61, #138, #89, #13, #24, #114, #62, #58, #23, #115, #56, #38, #126, #90, and #66) of 112 residents in the facility. Also, the facility failed to use proper hand hygiene after administering medications and performing wound care treatment. This affected two (Residents #73 and #91) of six residents reviewed for infection control practices. The census was 112.Findings Include:1. Observations on 02/09/26 at 7:05 P.M. revealed Certified Nursing Assistant (CNA) #116 was in Resident #61's room with a mask around their chin. CNA #116 did not have any other personal protective equipment (PPE) on while in the resident's room. Resident #61's room door was observed and had two signs on her door; one for droplet isolation precautions and one for contact isolation precautions. Also, she had a cart outside of her door that was properly stocked with PPE. Resident #61 was admitted to the facility on [DATE]. Her diagnoses were chronic obstructive pulmonary disease, encounter for palliative care, mild protein calorie nutrition, anxiety disorder, Parkinson's disease, conversion disorder, anemia, epilepsy, encephalopathy, dysphagia, diverticulitis of large intestine, cardiomegaly, hepatic failure, acute and chronic respiratory failure, asthma, atrial fibrillation, Type II Diabetes, hypoglycemia, hyperlipidemia, hypothyroidism, morbid obesity, major depressive disorder, lymphedema, venous insufficiency, hypertension, osteoarthritis, and cognitive communication deficit. Review of her minimum data set (MDS) assessment, dated 11/14/25, revealed she was cognitively intact. Review of Resident #61 physician orders, dated 02/10/26, revealed she was on contact and droplet isolation precautions due to a positive SARS CoV-2 (COVID-19) test. Interview with CNA #116 on 02/09/26 at 7:05 P.M. stated they did not think Resident #61 was on isolation precautions. While in the room, CNA #116 asked Resident #61 if she was on contact isolation precautions; Resident #61 stated she did not know. Interview with Registered Nurse (RN) #228 on 02/09/26 at 8:15 P.M. confirmed Resident #61 was on contact and droplet isolation precautions due to a newly identified positive COVID-19 test. She confirmed staff should be wearing PPE when going into her room. 2. Observation on 02/11/26 at 12:08 P.M. revealed Housekeeping and Laundry Manager #339 donned a gown but no gloves to enter Resident #126 room to deliver his meal tray. Resident #126 had a sign on his door to reflect he was on enhanced barrier precautions. While in his room, she touched his bedside table to move items so she could place his dinner meal tray on the table. She then walked out of the room. While outside of the room, she doffed the gown and took the doffed gown across the hallway to the nurse's station to throw it away in a regular trash can. She used hand sanitizer after doffing her gown and prior to assisting with other meal trays. Interview with Dietary Manager #266 on 02/11/26 at 12:10 P.M. confirmed she saw the enhanced barrier precautions sign on Resident #126 door and confirmed that Housekeeping and Laundry Manager #339 walked into his room with only a gown and no gloves on. Interview with Housekeeping and Laundry Manager #339 on 02/11/26 at 12:15 P.M. confirmed she walked into Resident #126 room with a gown but no gloves or other PPE on. When asked why she donned the gown but not gloves, she said, the rules are always changing and I wasn't sure. I probably should have, but I didn't know. She confirmed she walked across the hallway after walking out of Resident #126 room with her gown on, and doffed the gown at the nurse's station where she placed the gown in the regular trash can. Review of facility Standard and Transmission Based Precautions policy, dated 02/04/26, revealed contact transmission is the most frequent mode of transmission of healthcare associated infections. Contact precautions include hand hygiene, personal protective equipment, gloves, and gown. Droplet transmission involves droplets generated by the resident during coughing, sneezing, and talking or during the performance of certain procedures such as suctioning or aerosol generating procedures. Droplet precautions include gloves, gown, mask, and eye protection. 3. Review of the medical record for Resident #73 revealed an admission date of 02/10/26 and diagnoses that included pulmonary embolism, COVID-19, cardiomegaly, acute respiratory failure, acute diastolic (congestive) heart failure, sepsis due to methicillin sensitive staph aureus, staphylococcal arthritis right shoulder, and edema unspecified. Observation of medication administration by Licensed Practical Nurse (LPN) #326 on 02/11/26 at 8:20 A.M. for Resident #73 revealed LPN #326 performed hand hygiene and donned personal protective equipment prior to entering Resident #73's room. LPN #326 touched Resident #73's bilateral lower extremities with weeping edema and soiled bed linens with gloved hands. LPN #326 touched a blood pressure cuff on Resident #73's left arm. LPN #326 administered Resident #73's medications. LPN #326 removed personal protective equipment and performed hand hygiene. Interview with LPN #326 on 02/11/26 at 09:00 A.M. verified soiled gloves were not removed and hand hygiene was not performed before touching the blood pressure cuff and administering the medications. Interview with Unit Manager #130 on 02/17/26 at 9:30 A.M. confirmed hand hygiene should have been performed before moving from a contaminated body site to a clean body site and after handling soiled linens. Review of the policy titled Hand Hygiene issued 08/01/22 and revised 04/14/23 revealed hand hygiene with soap and water or alcohol-based hand rub is indicated before moving from a contaminated body site to a clean body site during resident care, after handling contaminated objects or equipment, before and after handling clean or soiled dressings or linens, and before handling medications. 4. Review of the medical record for Resident #91 revealed the resident was admitted [DATE] and had diagnoses that included acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, pulmonary hypertension, iron deficiency anemia, chronic venous hypertension with ulcer of bilateral lower extremity, obstructive sleep apnea, restless leg syndrome, anemia, pain, shortness of breath, and localized edema. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #91 was cognitively intact and required partial or moderate assistance for toileting, shower/bathing, and dressing. Resident #91 required substantial and maximal assistance with putting on and taking off footwear. Resident #91 required setup or clean-up assistance with personal hygiene, eating, and oral hygiene. Observation of wound care by Licensed Practical Nurse (LPN) #326 on 02/11/26 at 11:52 A.M. for Resident #91 revealed LPN #326 performed hand hygiene and donned gloves and a gown. LPN #326 removed the rolled kerlix dressing on the right shin then LPN #326 cleaned the wound bed on the right great toe with normal saline. LPN #326 applied Betadine to the wound bed on the right great toe. LPN #326 performed hand hygiene and donned gloves. LPN #326 removed the border dressing on the right shin. LPN #326 cleaned the wound beds on the right shin with normal saline. LPN #326 applied Xeroform gauze (petrolatum-impregnated mesh) to the wound beds on the right shin and then applied a border dressing on the right shin and then wrapped the right shin with an ACE wrap. LPN #326 performed hand hygiene and donned gloves. LPN #326 removed the border dressing on the left shin. LPN #326 cleaned the wound bed on the left great toe with normal saline. LPN #326 applied wound gel to a gloved finger. LPN #326 applied the wound gel to the wound bed on the left great toe. LPN #326 applied rolled gauze and tape to the left great toe. LPN #326 touched the back pocket of her scrubs with her gloved right hand to turn off her ringing cell phone. LPN #326 cleaned the wound bed on the left shin with Vashe (a type of wound cleanser). LPN #326 applied Xeroform gauze to the wound bed on the left shin. LPN #326 applied a border dressing on the left shin. LPN #326 touched her cell phone with her gloved right hand to turn off her ringing cell phone. LPN #326 performed hand hygiene and donned gloves. LPN #326 applied a border dressing to the right great toe. LPN #326 applied an Ace wrap to the left shin. LPN #326 wiped the floor with a towel. LPN #326 moved Resident #91's wheelchair. LPN #326 removed gown and gloves. LPN #326 performed hand hygiene. Interview with LPN # 326 on 02/11/26 at 12:20 P.M. verified hand hygiene was not consistently performed after touching soiled dressings and linens and before moving from a contaminated body site to a clean body site. LPN #326 stated she thought hand hygiene only needed to be performed between legs. Interview with Unit Manager #130 on 02/17/26 at 09:30 A.M. confirmed hand hygiene should have been performed before moving from a contaminated body site to a clean body site and after handling soiled dressings and linens. Review of the policy titled Hand Hygiene issued 08/01/22 and revised 04/14/23 revealed hand hygiene with soap and water or alcohol-based hand rub is indicated before moving from a contaminated body site to a clean body site during resident care, after handling contaminated objects or equipment, and before and after handling clean or soiled dressings or linens. 3. Review of Resident #66's electronic medical record revealed the resident was initially admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), schizoaffective disorder, anxiety disorder, stage three chronic kidney disease, type two diabetes mellitus, muscle weakness, personal history of neoplasm of the large intestine, and acquired absence of other specified of the digestive tract. Further review of Resident #66's electronic medical record revealed a Brief Interview for Mental Status (BIMS) score of eight (dated 11/08/25), suggesting moderate cognitive impairment. Review of physician orders contained in Resident #66's electronic medical record revealed an order for enhanced barrier precautions active as of 01/30/26 in the setting of a peripherally inserted central catheter (PICC) intravenous line and Jackson Pratt (JP) drain inserted in the resident's body. Observation on 02/12/26 at 8:42 A.M. revealed Laboratory Technician #452 entered Resident #66's room and announced to the resident that she was there to draw blood to check the resident's potassium level. Further observation at this time revealed Laboratory Technician #452 was observed drawing a blood sample from Resident #66's arm while not wearing a gown as indicated on the enhanced barrier precautions signage posted on the door to Resident #66's room. Interview on 02/12/26 at 8:45 A.M. with Laboratory Technician #452 revealed she did not see the signage posted on the door to Resident #66's room, nor did she see the personal protective equipment (PPE) that was hanging on the back of the door. Further interview at this time revealed Laboratory Technician #452 would normally wear a gown and gloves upon entry into a resident's room for a blood draw if the resident was on enhanced barrier precautions. Review of the facility policy titled Enhanced Barrier Precautions, revised 02/06/26 revealed enhanced barrier precautions involve gown and glove use during high-contact resident activities for residents known to be colonized with a Centers for Disease Control (CDC) targeted multidrug resistant organism (MDRO), as well as residents at increased risk of MDRO acquisition due to indwelling medical devices, including surgical drains and PICC lines. Further review of the policy revealed PPE will be applied prior to performing high contact resident care activities. This deficiency represents non compliance investigated under Complaint Number #2713145.

Based on observation and staff interview, the facility failed maintain a safe environment free of hazardous chemicals for one (Resident #97) of 17 residents on the 300 hall way. The census was 112. Findings include:Review of Resident #97's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to hypertension, hyperlipidemia and atrial fibrillation. Review of the comprehensive minimum data set (MDS) assessment dated [DATE] revealed Resident #97 was cognitively impaired, used a walker and wheelchair for mobility, and had no behaviors. The facility identified Resident #97 as being cognitively impaired, independent with ambulation and mobility, and residing on the 300 hallway.Observation on 02/11/2026 at 11:03 A.M. of the 300 hallway revealed residents up and about the hallways and a container of microdot minute wipes (clean and disinfectant wipes) on top of both medication carts stored on the 300 hallway.Review of the microdot minute wipe container revealed a label that read keep out of reach of children. Hazards to humans and domestic animals.Interview on 02/11/2026 at 11:27 A.M. with Licensed Practical Nurse (LPN ) #284 confirmed the microdot minute wipes were on top of the medication cart, not secured.

Based on resident record review, staff interviews, and review of facility policy, the facility failed to provide care and services to prevent falls. This affected two residents (Resident #15 and Resident #120) out of five residents reviewed for falls. The facility census was 100 residents.Findings include: 1. Review of the medical record revealed Resident #120 was admitted to the facility on [DATE] and had diagnoses that included pulmonary hypertension, dementia and spondylosis. The resident was discharged home from the facility on 10/10/25. Review of Resident #120's admission assessment on 09/27/25 revealed that she was at risk for falls and she was to have two-person assistance with bed mobility. Review of Resident #120's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #120 had a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. She was assessed as needing touch assistance for mobility and transfers. Review of Resident #120's baseline care plan dated 09/27/25 revealed that she was at risk for falls. An intervention initiated on 09/27/25 to help prevent falls revealed staff were to provide assistance with transfers and two-person assistance for bed mobility. Review of Resident #120's progress notes authored by Unit Manager #160 and dated 10/08/25 revealed that Resident #120 reported to nursing on 10/08/25 that on 10/01/25, she was lifted with a mechanical lift by an aide as she was getting weighed. Resident #120 stated that the mechanical lift strap broke while she was in the lift, which caused her to fall backwards onto the bed, jarring her neck and shoulder. Review of the fall investigation for Resident #120 dated 10/10/25 revealed that Certified Nursing Assistant (CNA) #150 was transferring Resident #120 on 10/01/25 via mechanical lift without additional assistance per the facility's policy. Resident #120 was fully assessed with no negative findings. An interview with CNA #150 on 12/04/25 at 12:47 P.M. confirmed that on 10/01/25, she lifted Former Resident #120 with a mechanical lift without any assistance from other staff members. An interview with the Director of Nursing (DON) on 12/04/25 at 1:05 P.M. revealed that his expectation was to always use two trained staff members when using a mechanical lift for a resident. The DON confirmed that the strap broke when Resident #120 was lifted by the mechanical lift while the resident was less than 6 inches in the air and the resident fell back on to the mattress with no injury. Review of a policy titled, Transferring- Using a Mechanical Lift, dated 09/28/25, revealed that at least two nursing assistants or other licensed and trained staff are needed to safely move a resident with a mechanical lift. This is not limited to transfers, but also may include repositioning. 2. Review of the medical record revealed Resident #15 was admitted on [DATE] with diagnoses that included heart failure, essential (primary) hypertension, cognitive communication deficit, malignant neoplasm of bladder, malignant neoplasm of right kidney renal pelvis, left bundle branch block, muscle weakness, other abnormalities of gait and mobility and ulcerative (chronic) rectosigmoiditis without complications. Review of Resident #15's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #15 had a Brief Interview for Mental Status (BIMS) score of 05, indicative of impaired cognition. Review of Resident #15's care plan dated 10/28/25 revealed Resident #15 had an activities of daily living (ADL) self-care deficit related to malnutrition, adult failure to thrive, cancer history of right breast, kidney, and sigmoid colon, weakness, pain, as well as effects of medications per orders. Interventions included transfer with two-person physical assistance with gait belt, stand pivot transfer, and it noted the resident did not walk at baseline. Review of Resident #15's progress notes revealed on 11/24/25 Resident #15 fell in the weight station while being re-weighed. Resident #15 was eased down to the floor by staff and no major injuries were noted. Vital signs were within normal limits and recorded. Neuro checks were initiated, the primary care physician and family were notified. Safety precautions were in place and the call light was within reach. Review of Resident #15's 11/24/25 fall investigation revealed Licensed Practical Nurse (LPN) #180 was re-weighing Resident #15 at the weight station. Resident #15 was able to stand up from her wheelchair and moved herself to the weight scale with no issues. LPN #180 was standing at Resident #15's back at the time. Resident #15 lost her balance and was dropping to the floor while she was moving to her wheelchair. LPN #180 grabbed onto the residents back and called for assistance. Staff came and eased Resident #15 down to the floor. Resident #15's wheelchair was locked, grip socks were on both feet and no major injury was noted. Review of Resident #15's progress note dated 11/25/25 confirmed the interdisciplinary team (IDT) review of Resident #15's witnessed fall on 11/24/25. After review of the residents chart and interviews, it was noted that Resident #15 was in the weight room being weighed and lost her balance and was lowered to the floor. Resident #15 obtained no injury. Resident #15 complained of right knee pain but also stated she has arthritis pain. The Nurse Practitioner and family were made aware. Orders were placed to continue to monitor. A new intervention was in place to only weigh the resident in a wheelchair. All parties agreed with the plan of care. Interview on 12/04/25 at 3:22 P.M. with LPN #180 confirmed he was assisting Resident #15 with getting her weight when she lost balance. LPN #180 stated he was using a gait belt and was the only staff member assisting Resident #15 at the time. Interview on 12/04/25 at 3:35 P.M. with the Director of Nursing verified after investigating Resident #15's fall on 11/24/25, LPN #180 was the only staff member assisting Resident #15 at the time and two staff were to assist the resident for transfers per her care plan. Review of the facility's policy titled Fall Management Guidelines dated 12/13/23 verifies the interdisciplinary team will review the resident's current care plan and interventions to ensure that the interventions are appropriate and review the resident's current care plan and interventions to ensure that the interventions are appropriate and the resident's post fall intervention(s) correlate to the root cause of the fall in an attempt to prevent future falls. This deficiency represents non-compliance investigated under Complaint Number 2679795.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, review of hospital records, facility policy review and interview, the facility failed to ensure fall risk/safety interventions were in place to prevent falls for one resident (#103) with known history of falls from bed. Actual harm occurred on 04/20/25 when Resident #103 who had a severe cognitive impairment and required extensive assistance from two staff for bed mobility sustained a fall out of bed resulting in hospitalization and surgical repair for a nondisplaced intertrochanteric fracture with of left femur when Certified Nursing Assistant (CNA) #800 left the room with the resident's bed in high position and the fall mat leaned against the wall to retrieve personal care supplies in the facility supply room. This affected one resident (#103) of three residents reviewed for falls. The facility census was 108. Findings Include: Review of the medical record for Resident #103 revealed an initial admission date of 08/15/22 with the latest readmission of 04/26/25 with diagnoses including nondisplaced intertrochanteric fracture of left femur, anemia, mood disorder, contracture of muscle multiple sites, attention-deficit hyperactivity disorder, overactive bladder, cerebrovascular accident (CVA) with left sided hemiplegia, anxiety disorder, insomnia, depression, adult failure to thrive, osteoarthritis, constipation, personal history of traumatic brain injury and hypertension. Review of the plan of care dated 12/07/22 revealed Resident #103 was at risk for falls and had potential for injury related to confusion, deconditioning, gait/balance problems, incontinence, unaware of safety needs, CVA with left sided hemiplegia, cerebral aneurysm, depression, anxiety, overactive bladder, adult failure to thrive, muscle weakness as well as effects of medications as ordered. Interventions included anticipate needs every shift, assure resident placed in middle of bed at all times, bed against the wall, bed to be in low position when in bed, Dycem to seat of Broda chair, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, encourage resident to participate in activities that will promote exercise, physical activity for strengthening and improved mobility, fall evaluation per facility protocol, labs as ordered, monitor for changes in gait and/or ambulation, assist with ambulation as needed, monitor for any medication side effects and recent change in medication, abnormal labs, signs/symptoms infection and pain as an increased risk for falls, report abnormal findings to physician, neuro-checks as ordered, nonskid socks when wearing shoes while out of bed, notify family, physician and Director of Nursing (DON) of any fall type incident as soon as possible, therapy to evaluate and treat as ordered or as needed, remind resident to request assistance for transfers if resident is alert and able to comprehend instructions, resident needs activities that minimize the potential for falls while providing diversion and distraction, review information on past falls and attempt to determine cause of falls, record possible root causes, alter remove any potential causes if possible, educate resident/family/caregivers/interdisciplinary team (IDT) as to causes and vision consult as needed. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident was dependent on staff for bed mobility. Review of the fall investigation dated 03/20/25 revealed the resident had a fall from her bed and was found to have no injuries. Review of the resident's fall risk evaluation dated 03/28/25 revealed the resident was at risk for falls. Review of the progress note dated 04/20/25 at 5:22 P.M., authored by Licensed Practical Nurse (LPN) #407 revealed Resident #103 was found on the floor by her bed lying on her left side. The note indicated the resident had been put back to bed after lunch. The entry documented the bedside mat was not in place at the time of the fall. The resident complained of pain to her left hip at a pain level of three out of 10 with 10 being the worst pain possible. The resident was given as needed pain medication. Certified Nurse Practitioner (CNP) #801 was notified and a new order was obtained for a left hip x-ray. The resident's husband was made aware of the incident and the staff were educated to make sure all fall precautions were always in place. Review of the fall investigation dated 04/20/25 revealed the resident had a fall from her bed when the staff member removed the mat, placed the mat against the wall and left the room to get disposable wipes from the supply room. Review of the Director of Nursing (DON) comment revealed the resident's fall interventions were not in place. Education was completed with staff, like residents identified and assessed for falls and falls were being audited. Review of left hip, unilateral with pelvis x-ray results dated 04/20/25 revealed a comminuted intertrochanteric fracture was identified on the left. Mild inferior lateral displacement of the distal fracture fragment was noted. The fracture does not involve the articular surface. Moderate to severe degenerative changes were noted. The surrounding soft tissues were normal. Orthopedic hardware was noted on the right. Conclusions: Intertrochanteric fracture, as detailed above, age undetermined. Review of the progress note dated 04/21/25 at 9:20 A.M., authored by LPN #530 revealed CNP #801 was notified of the x-ray results, and a new order was obtained to transfer the resident to the emergency room (ER). Review of Resident #103's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not assessed. The assessment indicated the resident was dependent on staff for bed mobility. Review of a hospital Discharge summary dated [DATE] revealed Resident #103 arrived to the emergency department (ED) with the chief complaint of left hip pain following a fall at the skilled nursing facility (SNF). Following imaging the resident was found to have a closed displaced supracondylar fracture of distal end of left femur with intracondylar extension and a closed wedge compression fracture of the thoracic four (T4) vertebra. The hospital course included a [NAME] resection arthroplasty (used to resect the femoral head, to relieve pain and the source of infection.) of the left hip. On 04/25/25 the resident's plan of care was updated to include floor bed next to bed when resident in bed. Review of the progress note dated 04/26/25 at 8:17 P.M., authored by LPN #472 revealed the resident was re-admitted to the facility with a surgical incision to the left hip and a bruise on the front of the left thigh. The entry documented the resident had screamed out in pain when the nurse and aide tried to change her incontinence brief. The on-call physician was notified and a new order for pain medication was obtained. The entry documented the resident's bed was in the lowest position. Review of the physician progress note dated 05/02/25 revealed the resident was being seen for fall with hip fracture and weakness. The resident was hospitalized from [DATE] to 04/26/25 after a fall and found to have a left intertrochanteric and subtrochanteric hip fracture. The hospital course included a repair of the left hip on 04/24/25. The resident was also found to have a wedge compression fracture of the thoracic T4 with no surgical intervention. On 06/09/25 at 10:11 A.M., an interview with LPN #530 revealed she was notified of the residents' fall the day the fall occurred. The LPN revealed she was informed the resident rolled out of bed when CNA #800 failed to ensure the bed was in the lowest position and the fall mat was in place. On 06/09/25 at 10:32 A.M., observation of Resident #103 revealed the resident was lying in bed on her left side in fetal position. The resident had non-skid socks in place. The resident's bed was observed to be in the lowest position and the bed mattress was next to the bed. On 06/09/25 at 12:38 P.M., an interview with LPN #407 revealed he was the nurse on duty when Resident #103 rolled out of bed. The LPN revealed CNA #800 laid the resident down after lunch and was providing incontinence care. The LPN revealed the CNA left the room to retrieve disposable wipes from the supply room and the bed was not in the low position and the floor mat was leaned against the wall. The LPN revealed the resident rolled out of her bed while the CNA left the room and verified the resident's fall interventions were not in place at the time of the incident. The LPN revealed he notified management immediately and educated the staff on making sure fall interventions were in place at all times. Review of the facility policy titled, Fall Management Guidelines, implemented 12/13/23 revealed a fall is defines as unintentionally coming to resident on the ground, floor or other level with or without injury to the resident, but not as a result of an overwhelming external force. The facility staff with the input of the attending physician, will implement a resident centered comprehensive care plan that addresses the fall management program, the goal for fall management, individualized interventions to address the resident's modifiable fall risk factors, interventions to try to minimize the consequences of risk factors that are not modifiable and the plan for reduction of risk and or risk for injury. The deficient practice was corrected on 05/04/25 when the facility implemented the following corrective actions: • On 04/20/25 at approximately 3:30 P.M. Resident #103 sustained a fall incident. An immediate resident assessment was completed by LPN #407. The resident was medicated for complaints of left hip pain with as needed analgesic. The resident's physician and power of attorney (POA) were notified of the incident and a new order for an x-ray of the resident's left hip was obtained. LPN #407 educated Certified Nursing Assistant (CNA) #800 on ensuring fall precautions were in place. • On 04/21/25, the left hip x-ray results were received and communicated to the resident's physician and POA. The DON began the fall investigation and met with the resident. The resident was transferred to the local emergency room (ER) for further evaluation. The DON interviewed LPN #407 related to the fall incident. • On 04/22/25, the DON interviewed CNA #800 and education was provided to CNA #800 on ensuring fall interventions were in place. • From 04/23/25 through 04/28/25, fall risk residents were identified and audits completed for fall evaluations by Unit Manager #456 and #530. Resident Kardex's were modified as needed. The DON educated nursing staff on having fall interventions in place. The facility began audits on fall interventions in place and was ongoing. • On 04/28/25, Quality Assurance Performance and Improvement (QAPI) was signed by the Medical Director and all Department Heads. Fall intervention audits were to be completed on the following schedule: four times a week for four weeks, then three times a week for three weeks, two times a week for two weeks, one time a week for two weeks, and once a week ongoing. • Review of the facility timeline of corrective action and interview with Administrator revealed the facility identified corrective actions were completed as of 05/04/25. • On 06/09/25, interviews conducted from 10:11 A.M. to 2:40 P.M. with the DON, Registered Nurse (RN) #514, LPN #407, #443, #530 and CNA #487 and #552 revealed they had all received education by management staff on or around 04/23/25 through 04/28/25 regarding ensuring resident fall interventions were in place at all times. This deficiency represents non-compliance investigated under Complaint Number OH00166328.

Based on observation, record review and interview, the facility failed to provide timely care for surgical incision staple removal for Resident #103 and Resident #109. The facility also failed to obtain physician ordered daily weights for Resident #83. This affected two residents (#103 and #109) of three residents reviewed for wound/incisional care and one resident (#83) of three residents reviewed for implementation of physician orders. The facility census was 108. Findings include: 1. Review of the medical record for Resident #103 revealed an admission date of 08/15/22 with diagnoses including fractured femur, sick sinus syndrome, attention deficit hyperactivity disorder (ADHD), mood disorder, cerebral infarction with associated hemiplegia and hemiparesis, anxiety disorder, depression, dependence on wheelchair, presence of pace maker, presence of artificial hip joint (left), and presence of cerebrospinal fluid (CSF) draining device. Review of progress notes for Resident #103 revealed Resident #103 had surgery on 04/22/25 and a post-operative (op) follow-up appointment on 05/13/25. Review of the most recent significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of five out of a possible 15 indicating cognitive impairment. The resident had no functional limitation in range of motion of the upper extremities but had impairment on one side of the lower extremities. The resident was assessed to have no difficulties chewing or swallowing. Resident #103 was at risk for pressure ulcers but had none. Resident #103 had a surgical incision. Resident #103 had a pressure reducing device on her bed and received surgical wound care. Review of the progress note dated 05/13/25 at 11:46 A.M. revealed the trauma clinic called to cancel post op appointment for today, refused to see the resident, remove staples or look at X-Ray and suggested following up with the orthopedist, Certified Nurse Practitioner was made aware. Review of progress note dated 05/28/25 at 9:54 A.M. revealed Licensed Practical Nurse (LPN) # 530 call the surgeons office and obtained an order to remove the staples. 22 staples were then removed with no complications. There was no documentation in the medical record between 05/13/25 and 05/28/25 that there were any appointments made, or any plans discussed to remove the staples. Observation on 05/27/25 at 12:30 P.M. revealed Resident #103 sitting in her wheelchair in the common area with her spouse. Resident #103 was rubbing/scratching left hip area. Interview on 05/27/25 at 12:30 P.M. with the spouse of Resident #103 revealed Resident #103 still had the staples in her incision from surgery in April and it appears they itch at times but Resident #103 does not appear to be in pain. Resident #103's spouse has been asking if someone in the facility can remove them but they have not been removed yet. Interview on 05/29/25 at 8:55 A.M. with LPN #530 confirmed Resident #103 had a follow-up appointment to remove staples on 05/13/25 that was canceled by the trauma clinic and facility was told to scheduled follow-up with the surgeon. Staples were not removed until 05/28/25 and they were removed in the facility. LPN stated there were appointments scheduled and the husband, who is the POA, canceled because he wanted follow-up done in the facility. Going out to appointments increases Resident #103's confusion. Interview on 05/29/25 at 12:00 P.M. with the spouse of Resident #103 confirmed Resident #103 was in the van on her way to the follow-up appointment to remove her staples on 05/13/25 when the office called and canceled the appointment. The spouse stated Resident #103 becomes more confused when she leaves the facility so he asked if someone could remove her staples at the facility. The spouse has told the facility he would prefer as much of her care as possible be done in the facility to decrease the number of times Resident #103 needs to be taken outside the facility. The staples were finally removed at the facility on 05/28/25. The spouse had no knowledge of any other follow-up appointments being scheduled. 2. Review of the closed medical record for Resident #109 revealed an admission date of 02/23/25 with a discharge date of 03/12/25. Resident #109 had diagnoses including diverticulitis, influenza, acute respiratory failure, rheumatoid arthritis, anxiety disorder, disorder of psychological development, osteoporosis, pain, presence of urogenital implants, and colostomy. Review of the hospital Clinical Summary Clinical Discharge Instructions dated 02/22/25 revealed the resident had a perforated diverticulum, leukocytosis, anemia due to blood loss, urinary retention, Influenza, acute respiratory failure with hypoxia, Hypertensive urgency and severe malnutrition. Wound Care Follow-up was to be set up with the wound care clinic. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a BIMS score of 12 out of 15 indicating mild cognitive impairment. The resident was assessed to require assistance of a walker for mobility with no impairment of joint mobility in upper or lower extremities. Resident #109 had an indwelling catheter or nephrostomy tube and an ostomy. No difficulty chewing but some complaints of pain when swallowing and resident was noted to recently have significant weight loss. Resident #109 was at risk for pressure ulcers but has none. Resident received antiplatelet medications with indication present. Review of the nurse practitioner progress note dated 02/27/25 revealed at the hospital the resident underwent an urgent sigmoid colectomy with colostomy and a Hartman's pouch. The resident was at the facility to receive skilled services with an abdominal surgical wound incision. Review of admission skin assessment indicated Resident #109 had an ostomy and a surgical incision. Review of Skin assessment dated [DATE] at 10:39 A.M. revealed left lower abdomen incision present for one month with 23 staples in place. Incision approximated (present on admission) 9.1 cm by 0.5 cm. No depth to surgical incision to abdomen with intact staples, current treatment to continue as ordered. Surrounding tissue without redness, warmth or swelling. Educated on importance of keeping dressing clean dry and intact. Notified NP and family. Review of physicians' orders for Resident #109 during the stay at the facility indicated there was no order written to remove staples. Review of the medical record for Resident #109 indicated the staples were intact and the surgical wound was healing. The wound/skin assessment pictures of the incision with staples were included in the assessment documentation. The medical record contained no documentation regarding any discussion about when the staples should be removed during the resident's entire stay at the facility. A telephone interview on 05/30/25 at 9:23 A.M. with Registered Nurse/Wound Clinic Nurse #620 confirmed Resident #109 was a patient but all information needs to be released through the medical records department. (05/30/25 at 9:30 A.M. Medical records secretary stated those records have not come to the medical records department yet). 3. Review of the medical record for Resident #83 revealed an admission date of 03/11/25 with diagnoses including myocardial infarction, acute respiratory failure, metabolic encephalopathy, sepsis due to Escherichia (E.) Coli, acute kidney failure, pain, long term use of aspirin and insulin, and dysphagia. Review of the most recent quarterly MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15 indicating the resident was cognitively intact. The resident was assessed to require a walker for mobility assistance (limited ROM in upper extremities, lower extremities no impairment). Resident has no difficulties chewing or swallowing and was on a mechanically altered diet and therapeutic diet. Resident #83 had one stage four pressure ulcer which was present on admission or re-entry. Resident #83 had a diabetic foot ulcer and a surgical wound. Resident #83 has a pressure reducing device on her bed and was receiving pressure ulcer and surgical wound care. Resident #83 received seven days of insulin during the look back period. Resident #23 received diuretic, opioid, antiplatelet and hypoglycemic medications. Review of physician's orders for Resident #83 revealed on 05/21/25 new orders were added to decrease Spironolactone 25 milligram oral tablets from one tablet every morning to one half tablet every morning for high blood pressure and Torsemide 20 milligrams oral tablet every morning for edema related to congestive heart failure. Review of the cardiology office visit after visit summary dated 05/21/25 at 2:01 P.M. revealed the medications changes to the amount of Spironolactone and Torsemide as listed above as well as an order to weight Resident #83 daily. Observation on 05/27/25 at 12:00 P.M. revealed Resident #83 had some mild swelling in her ankles. Resident #83 was in the process of getting into bed. Interview on 05/27/25 at 12:00 P.M. with Resident #83 revealed Resident #83 had a cardiology appointment last week (05/21/25) and the facility made the ordered medication changes but there was also an order for daily weights. Resident #83 has not been weighted daily. Resident #83 confirmed there was some mild swelling in her ankles but stated that it happens sometimes after she has been up walking around and it goes away when she elevates her feet. Interview on 05/27/25 at 12:30 P.M. with licensed practical nurse (LPN) #497 revealed it is the floor nurse's responsibility to place new orders in the system when a resident returns from the hospital or a doctor's appointment. The floor nurse is also responsible for notifying the resident or the resident's family and the facility physician when there are new orders from and after visit summary. Interview on 05/28/25 at 11:58 A.M. with LPN #530 confirmed when a resident received an after-visit summary with new orders the floor nurse enters the orders into the computer. Then the unit managers double check the orders for accuracy. Interview on 05/28/25 at 4:35 P.M. with cardiology office nurse #640 via telephone confirmed the nurse practitioner placed an order for daily weights. The order is on the office visit note sent to the facility. Interview on 05/29/25 at 9:03 A.M. with LPN #530 confirmed Resident #83 had an after visit summary order from 05/21/25 for daily weight after medication changes. LPN #530 confirmed Resident #83 has no order for daily weights currently and has not been weighed since 05/09/25. This deficiency represents non-compliance investigated under Complaint Number OH00165568.

Based on observation, medical record review, staff interview, hospice staff interview, review of hospice visits notes and review of facility policy, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to timely identify, assess and implement treatment for Resident #51 related to a pressure ulcer to the left lateral foot. Actual harm occurred on 08/09/24 when Resident #51, who was cognitively impaired and dependent on staff for activity of daily living care was first identified by the facility to have an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the left lateral foot. Prior to 08/09/24 hospice staff had identified this pressure ulcer, however the facility failed to identify the unstageable pressure ulcer prior to 08/09/24, failed to ensure on-going assessments and monitoring of the ulcer were completed and failed to ensure the ulcer was properly treated to prevent deterioration. This affected one resident (#51) of three residents reviewed for skin breakdown. The facility census was 72. Findings Include: Review of the medical record for Resident #51 revealed an initial admitted [DATE] with current diagnoses including cerebrovascular accident with left sided hemiplegia, severe protein calorie malnutrition, pressure ulcer left ankle (added on 08/03/24), Parkinson's disease, major depressive disorder, neuropathy, anxiety disorder, gastro-esophageal reflux disease, atrial fibrillation, overactive bladder, aphonia, dry eye syndrome, hyperlipidemia, constipation, pain, bladder-neck obstruction, chronic sinusitis, ataxic gait, asthma, benign prostatic hyperplasia with lower urinary tract symptoms, insomnia, repeated falls, osteoarthritis and dysphagia. Review of the resident's physician orders identified an order dated 03/15/23 for a skin evaluation to be completed weekly. Check skin for open areas, bruises, abrasions, DTI, and incisions. Review of the medical record revealed the resident was admitted to hospice services on 06/01/23 for the terminal diagnosis of Parkinson's disease with a life expectancy of six months or less if the disease runs its normal course. Review of the care plan dated 04/06/23 revealed the resident was at risk for pressure injury formation related to generalized debility and weakness as evidenced by decreased mobility in bed and wheelchair, incontinence of bowel and bladder, the resident needing assistance with incontinence care, turning/repositioning and the presence of a pressure injury to the sacrum. Interventions included treatment per physician orders, barrier cream to buttocks after every incontinent episode, bilateral mobility bars to aide with turning and mobility in bed, Braden scale to be completed per facility policy, consult wound team as needed, encourage and assist as needed to turn/reposition per policy, use assistive devices as needed, encourage intake of 75 to 100% of diet and fluids daily. Dietician to assess dietary needs quarterly and with significant changes, encourage resident to float heels and/or wear heel boots, labs as ordered, report abnormal results to physician, low air loss mattress on bed, monitor skin daily during care for redness, excoriation or breakdown, pressure reduction cushion to broad chair, preventative skin care post incontinence care daily, as needed and skin evaluation weekly and on 08/13/24 the facility implemented the use of a moon boot to the left foot at all times, remove for skin integrity checks every shift. Review of the resident's Braden scale dated 02/05/24 revealed a score of 11 indicating the resident was at high risk for skin breakdown. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive impairment. The assessment indicated the resident was at risk for skin breakdown and had one unstageable pressure ulcer not present on admission. The facility implemented pressure reducing device to bed/chair, pressure ulcer/injury care, application of nonsurgical dressings other than to feet and application of ointments/medications other than to feet. Record review revealed this pressure ulcer was to the resident's sacrum. A second State optional MDS assessment also dated 11/16/23 revealed the resident had a severe cognitive deficit and resident required extensive assistance from two staff for bed mobility, transfers and toileting. Review of a hospice wound note revealed on 02/06/24 the Hospice Registered Nurse (HRN) #295 identified Resident #51 had an unstageable deep tissue injury (DTI) (DTI is defined as a purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) to the left lateral foot measuring 2.5 centimeters (cm) by 2.5 cm by 0.5 cm. There were no additional notes from hospice on this date related to the why the ulcer developed. Review of the resident's medical record revealed no documented evidence the facility had identified or addressed the unstageable DTI development, implemented any interventions to prevent the worsening of the DTI or updated the resident's plan of care to reflect the development of the DTI. Review of a hospice wound note revealed on 02/12/24 the unstageable DTI to the left lateral foot measured 1.0 cm by 0.5 cm. The wound was described as square with less than 25% white necrotic tissue and 75 to 100% granulation tissue. Review of the resident's physician orders revealed no treatment was implemented for the DTI pressure ulcer/injury until 02/12/24 (six days after hospice staff first identified the ulcer) when an order was obtained to cleanse with soap and water or wound cleanser, pat dry and apply Allevyn dressing every shift for wound care. The order indicated the facility floor nurse was to complete wound care as needed if the dressing became heavily soiled. The order was discontinued on 02/14/24. On 02/16/24 a new order was noted to cleanse the left lateral foot with soap and water or wound cleanser, pat dry, apply Allevyn dressing every Monday and Friday for wound care. The order indicated hospice would provide all supplies and wound care and the facility floor nurse may complete (dressing change) as needed if heavily soiled. Review of the hospice wound note revealed on 02/19/24 the DTI to the left lateral foot measured 1.0 cm by 1.0 cm and described as round with 100% epithelialization. Review of the hospice wound note revealed on 02/26/24 the DTI to the left lateral foot measured 1.5 cm by 2.0 cm and remained round with 100% epithelialization. Review of the hospice wound note revealed on 03/04/24 the DTI to the left lateral foot measured 1.0 cm by 1.0 cm and remained round with 100% epithelialization. Review of the hospice wound note revealed the next comprehensive assessment of the DTI to the left lateral foot was completed on 03/22/24 and the ulcer measured 1.0 cm by 0.5 cm and was described as 75 to less than 100% necrotic tissue with distinct edges. Review of the hospice wound record report revealed the next comprehensive assessment was completed on 04/22/24 (a month later). The DTI to the left lateral foot measured 0.5 cm by 0.5 cm. The wound was described as round. The hospice nurse implemented a treatment to cleanse the wound to the left lateral foot with soap and water or normal saline (NS), pat dry and apply a small Allevyn to pad and protect every Monday and Friday per the hospice nurse. Review of physician's orders dated 04/23/24 revealed an order for Enhanced Barrier Precautions every shift related to the resident's pressure ulcer. Review of the hospice wound record report revealed the next assessment for the DTI to the left lateral foot was completed on 05/31/24 (over 30 days later) and the ulcer measured 0.5 cm by 0.5 cm and was described as being round. The same treatment continued, including the facility were to change the dressing as needed for dislodgement or soiled. Review of the resident's physician orders revealed the treatment order that was implemented on 02/16/24 to resident's left lateral foot was discontinued on 06/05/24. Review of the corresponding June 2024 Treatment Medication Record (TAR) also revealed the facility discontinued the treatment to the left lateral foot on 06/05/24. Record review revealed no facility assessments or progress notes from 02/2024 through 06/05/24 related to the resident's left lateral foot pressure ulcer. Review of a hospice wound record report revealed an assessment for the DTI to the left lateral foot was completed on 06/14/24 and the ulcer now measured 1.4 cm by 1.5 cm. The wound was described as round with 75 to 100% yellow slough. Despite the presence of yellow slough tissue, it appeared the treatment order that had been discontinued on 06/05/24 continued to be provided at this time. Review of the hospice wound record report revealed the next assessment for the DTI to the left lateral foot was completed on 06/21/24 and the ulcer measured 0.5 cm by 1.5 cm. The wound was described with 26 to 50% white necrotic tissue. No changes were made to the resident's treatment. Review of physician's orders revealed an order dated 07/25/24 for house liquid protein 30 milliliters (ml) three times a day for wound healing. There was no additional information as to why this nutritional supplement was not added until 07/25/24 when the pressure ulcer was first identified in February 2024. Review of the hospice wound record report revealed the next assessment for the DTI to the left lateral foot was completed on 08/02/24 (over 30 days from the previous assessment completed on 06/21/24). The ulcer was assessed to measure 2.0 cm by 1.5 cm by 0.5 cm. The wound was described as round with 50 to 75% white necrotic tissue with purulent drainage. Review of the hospice wound record report revealed the next assessment of the DTI to the left lateral foot was completed on 08/05/24 with the ulcer measuring 1.0 cm by 0.5 cm by 0.2 cm with 75 to 100% yellow necrotic tissue. Record review revealed no facility assessments or progress notes from 06/06/24 through 08/05/24 related to the resident's left lateral foot pressure ulcer. A facility incident report dated 08/09/24 at 11:47 A.M. revealed Resident #51 was found to have a new pressure ulcer to the left lateral foot during a skin assessment. The facility implemented a treatment to cleanse with NS, apply calcium alginate and cover with boarder dressing. Record review revealed the facility also implemented protective boots at this time. Review of the progress note dated 08/09/24 at 11:55 A.M. revealed during skin assessment a new area was found, the Nurse Practitioner (NP), hospice and family were notified of the new area. The resident was referred to for wound care and a new order to cleanse with normal saline, apply calcium alginate and cover with foam border dressing was implemented. Although this area was consistent with the ulcer being treated by hospice, since February 2024, the first identification of the ulcer by the facility did not occur until 08/09/24 when the facility assessed the resident to have an unstageable pressure ulcer to the left lateral ankle. Review of the medical record revealed no documented evidence the facility comprehensively assessed the unstageable pressure ulcer to the resident's left lateral foot including measurements, description of the wound and exudate when found on 08/09/24 Review of a hospice wound record report revealed the next assessment of the DTI to the left lateral foot was completed on 08/12/24 measuring 1.0 cm by 2.0 cm with 75 to 100% yellow necrotic tissue, although the facility was classifying the DTI as an unstageable pressure ulcer on 08/09/24. Record review revealed the facility first weekly skin and wound evaluation was completed on 08/13/24 (four days after facility staff noted the ulcer) and revealed the resident had an unstageable pressure ulcer to the left lateral foot measuring 1.6 cm by 1.3 cm. The wound was described as having 100% slough with a moderate amount of serous exudate. The edges were described as non-attached. The facility documented the new area was found when doing skin assessment. The facility continued the 08/09/24 treatment to cleanse with normal saline (NS), apply calcium alginate and foam border dressing daily for wound care. Review of a physician order dated 08/13/24 revealed an order for a moon boot to the left foot at all times, remove for skin integrity check every shift. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the mood and behavior revealed the resident displayed physical behaviors directed towards others, however the resident did not reject care. The assessment indicated the resident was always incontinent of both bowel and bladder. The assessment indicated the resident was at risk for skin breakdown and had Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer that was not present on admission (ulcer to the coccyx) and one unstageable pressure ulcer that was not present on admission (to the left lateral foot). The assessment indicated the resident also had an infection to the foot and skin tears. The facility implemented pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressings other than to feet, application of ointments/medications other than to feet and application of dressings to feet. Record review revealed beginning on 08/14/24 facility staff completed wound assessments which included the following: A facility weekly skin and wound evaluation dated 08/14/24 revealed the unstageable pressure ulcer to the left lateral foot measured 1.5 cm by 1.2 cm by 0.2 cm. The wound was described as 100% slough with a moderate amount of serous exudate. The edges were attached and appeared as flush with wound bed or a sloping edge. The wound was new, and the wound physician made the initial visit and implemented the treatment to cleanse with normal saline (NS), pat dry, apply calcium alginate and foam border dressing. A facility weekly skin and wound evaluation dated 08/21/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.3 cm by 0.7 cm by 0.2 cm. The wound was described as having 40% slough and 50% granulation tissue with a moderate amount of serous exudate. The assessment had no documentation of the edges. The facility determined the wound had improved. The facility documented a Curette was used to surgically excise devitalized tissue including slough, biofilm and nonviable muscle level tissues were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 40 percent to zero percent. Hemostasis was achieved and clean dressing was applied. The wound consisted of 40% slough, 50% granulation tissue and 10% other viable tissues. A facility weekly skin and wound evaluation dated 08/28/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.5 cm by 1.2 cm by 0.3 cm. The wound was described as 30% slough and 60% granulation tissue with a moderate amount of serous exudate. The edges were described as non-attached. The facility determined the wound had improved. A facility weekly skin and wound evaluation dated 09/04/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.5 cm by 1.2 cm by 0.3 cm. The wound was described as 30% slough and 60% granulation tissue with a moderate amount of serous exudate. The edges were described as non-attached. The facility determined the wound was stable. Review of a physician order dated 09/05/24 revealed an order for Resident #51 to be seen by wound consultant. A facility weekly skin and wound evaluation dated 09/11/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.4 cm by 1.0 cm by 0.2 cm. The wound was described as 30% slough and 60% granulation tissue with a moderate amount of serous exudate. The edges were described as non-attached. The facility determined the wound had improved. A facility weekly skin and wound evaluation dated 09/18/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 2.6 cm by 1.8 cm. The wound was described as 80% slough and 20% granulation tissue with a moderate amount of serous exudate. The edges were described as non-attached. The facility determined the wound was stable. A facility weekly skin and wound evaluation dated 09/24/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as stage IV pressure ulcer measuring 2.4 cm by 2.2 cm by 0.4. The wound was described as 50% slough and 50% granulation tissue with a heavy amount of serous exudate. The edges were described as curled under. The facility determined the wound was stable, however the facility changed the treatment to cleanse with NS, apply Medi-honey then calcium alginate and cover with foam border dressing daily. Review of physician's orders for September 2024 revealed an order dated 09/24/24 to cleanse left lateral foot wound with normal saline (NS), apply Medi-honey then calcium alginate and foam boarder dressing every night shift, cleanse wound to sacrum with NS, moisten gauze with NS then pack gently into wound and cover with foam dressing. A facility weekly skin and wound evaluation dated 10/01/24 revealed the unstageable pressure ulcer to the left lateral foot was classified as Stage IV pressure ulcer measuring 1.6 cm by 1.6 cm by 0.2. The wound was described as 20% slough and 80% granulation tissue with a light amount of serous exudate. The edges were described as non-attached. The facility determined the wound had improved. On 10/01/24 at 2:20 P.M., Licensed Practical Nurse (LPN) #209 and LPN #241 were observed to provide the physician ordered treatment to Resident #51's pressure ulcer. LPN #209 measured the wound at 1.6 cm by 1.6 cm by 0.2 cm. The wound bed was reddish with white rolled edges. LPN #241 applied Medi-honey to the wound bed, applied calcium alginate and covered with a foam border dressing. On 10/02/24 at 8:17 A.M., interview with Hospice Case Manager (HCM) #294 revealed the resident had multiple pressure ulcers, however the DTI on the left lateral foot was first identified as a DTI in February 2024 and Hospice Registered Nurse (HRN) #295 found the wound. During the interview, HCM #294 revealed it was difficult to communicate with the facility Unit Managers (UM) as well as the Director of Nursing (DON) due to facility having a lot of turnover (in staffing). On 10/02/24 at 9:14 A.M., interview with HRN #295 revealed she found the resident had a left lateral foot pressure ulcer/wound in February 2024. She said it was a deep tissue injury (DTI) and they were using a pad to protect the area due to the resident's contractures. She said then it just got worse. She said she gave the facility orders for the wound of pad and protect. She said the left lateral foot wound was almost healed and then opened again. She said when she was there on 09/30/24 during her routine visit his foot was soaked with drainage and she changed the dressing. She said the facility doesn't always date or initial the dressing, so she did not know how long this dressing was actually on the wound. She said the use of a moon boot as a preventative measure was not implemented until August 2024. She said the wound was just a red spot and then in August 2024 it deteriorated and opened. On 10/03/24 at 10:30 A.M. interview with the Director of Nursing (DON) verified the facility had no documented evidence that facility staff identified the development of the resident's pressure ulcer, assessed or monitored Resident #51's DTI/unstageable pressure ulcer with the onset of 02/06/24 until 08/13/24. Per record review, facility staff first documented the presence of the pressure ulcer on 08/09/24. On 10/03/24 at 2:10 P.M., interview with LPN #209 and #241 revealed a treatment to the DTI was initiated on 02/07/24 to pad and protect twice weekly until 02/12/24 when the treatment was changed to pad and protect daily. The treatment was discontinued on 02/14/24 and the wound did not have treatment until 02/16/24 when the pad and protect twice weekly on Monday and Friday was implemented. The treatment was discontinued on 04/12/24 when the facility implemented the same pad and protect treatment twice weekly on Monday and Friday. The facility then documented the ulcer was healed on 06/05/24 (which was not accurate). LPN #209 and #241 verified they were unaware of hospice continuing the assessment and treatment of the wound following this date. LPN #209 revealed on 08/09/24 facility staff identified the resident had an unstageable pressure ulcer to the left lateral foot in the same area as the DTI. LPN #209 verified the facility had no comprehensive assessments of the DTI prior to the 08/13/24 assessment. Review of the facility policy titled, Skin and Wound Guidelines, last revised on 03/20/24 revealed skin alterations and pressure injuries were evaluated and documented by the licensed nurse. Weekly evaluations of the skin alteration in the resident's medical record by the wound team or licensed nurse per state and federal regulations. This deficiency represents non-compliance investigated under Complaint Number OH00158032 and Complaint Number OH00157831.

Based on medical record review and interview, the facility failed to ensure Resident #45 was free from a significant medication error. Actual Harm occurred when Resident #45's dose of the medication, [MEDICATION(S)] (used to control symptoms of [CONDITION(S)]) was administered at a decreased/lowered dose, without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one resident (#45) of five residents reviewed for medication administration. Findings include: Review of the medical record for Resident #45 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of March 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M The resident also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 10:00 A.M., 2:00 P.M. and 4:30 P.M. Record review revealed on 03/22/22, the Director of Nursing (DON) discontinued the [MEDICATION(S)]-[MEDICATION(S)] ER ,d+[DATE] mg two tablets at 8:00 P.M. and reduced the [MEDICATION(S)]-[MEDICATION(S)] 25-100 mg from two tablets to one tablet and changed the times to 8:00 A.M., 11:00 A.M., 2:00 P.M. and 5:00 P.M. (30 minutes away from meals). A nursing progress note, dated 03/22/22 at 12:25 P.M., and authored by the DON documented orders were received from the neurologist to change the times of the [MEDICATION(S)]-[MEDICATION(S)] to 8:00 A.M., 11:00 A.M., 2:00 P.M. and 5:00 P.M. and to take 30 minutes away from meals. The note did not address the medication had been lowered in dosage. There were no physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did have one prescription (page two of four) that had been faxed from the neurologist on 03/10/22. Page two of four included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 11:00 A.M., 2:00 P.M. and 5:00 P.M. There was no evidence the facility had obtained/reviewed/clarified the content of the three additional pages of the fax. On 07/18/22 at 2:45 P.M., interview with the DON revealed Resident #45 had a tele-visit with the neurologist (the tele-visit occurred at the facility) on 03/10/22. She stated the resident's wife was present for the tele-visit, but no staff. She stated the resident's wife had later mentioned to her the neurologist had made medication changes on 03/10/22. She stated the neurologist normally faxed orders to the facility, but did not normally provide any progress notes of the appointment. She stated on 03/22/22 she asked the neurologist to re-fax the orders from the 03/10/22 visit. The DON revealed she did not remember if she noticed the fax said page two of four. The DON revealed after receiving the fax on 03/22/22 she reduced the [MEDICATION(S)]-[MEDICATION(S)] to 25-100 mg one tablet four times daily. The DON revealed she did not clarify or question the dose reduction for the resident at that time. The DON also confirmed her nurse's progress note, dated 03/22/22 addressed time changes but did not address the reduction in the medication. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. was added by Registered Nurse (RN) #100. There was no additional information related to why this order was written or the circumstances surrounding this order. On 07/18/22 at 3:30 P.M., interview with Licensed Practical Nurse (LPN) #101 revealed she spoke to RN #100 and the RN did not remember who gave the order to add the P.M. dose of medication on 03/24/22. The [MEDICATION(S)]-[MEDICATION(S)] 25-100 mg remained at the lower dose of one tablet four times a day (previously two tablets four times a day) until 06/21/22. The facility had a concern form, dated 06/21/22 which indicated Resident #45's wife stated the facility had not been giving her husband the correct dose of his [MEDICATION(S)]-[MEDICATION(S)] since March (2022). Review of a progress note from the neurologist, dated 06/21/22, revealed instructions for the following medication changes: On 06/21/22 only give [MEDICATION(S)]-[MEDICATION(S)] 25-100 Immediate Release (IR) 1.5 tabs at the 2:00 P.M. and 5:00 P.M. doses. Starting on 06/22/22 give [MEDICATION(S)]-[MEDICATION(S)] 25-100 mg IR one tab at 8:00 A.M., 11:00 A.M., 2:00 P.M., and 5:00 P.M. [MEDICATION(S)]-[MEDICATION(S)] 25-100 mgER on e tablet at 8:00 A.M., 11:00 A.M., 2:00 P.M. and 5:00 P.M. and [MEDICATION(S)]-[MEDICATION(S)] 50-200 mg ER two tablets at bedtime. These medication orders were implemented on 06/21/22 as written. Review of the concern form, dated 06/21/22 revealed the DON documented she called the neurologist's office and there were no medication errors. The facility increased the medication on 06/21/22 due to worsening progression of (the resident's) disease. The resident's wife was updated on what neurologist office said but still blamed the facility for the resident's decline in condition. On 07/18/22, the progress notes from the neurology visit on 03/10/22 were sent to the facility (after the surveyor spoke to the neurology office) for review. The progress note indicated Resident #45 was tired during the day, sense of between [MEDICATION(S)] dose movement wearing off. The plan revealed [MEDICATION(S)]-[MEDICATION(S)] 25-100 mg would be reduced from two tablets down to one tablet four times daily and [MEDICATION(S)]-[MEDICATION(S)] 25-100 mg ER would be started at one tablet four times daily at the same times. [MEDICATION(S)]-[MEDICATION(S)] 50-200 mg would continue at two tablets nightly. On 07/18/22 at 2:00 P.M., interview with Medical Assistant #102 (staff from the neurologist office) confirmed Resident #45 had a tele-visit with the neurologist on 03/10/22. She confirmed the medication should not have been reduced by the facility as it was on 03/22/22 and confirmed the orders as written above on the 03/10/22 neurology progress note. On 07/18/22 at 2:15 P.M. interview with Occupational Therapist (OT) #103 (who was also acting therapy director) revealed Resident #45 had received occupational and physical therapy prior to the medication error in March 2022 (ending in February 2022). She stated the resident had experienced a decline in his mobility between when last seen in February 2022 and when he was started on therapy again in April 2022. She stated when the resident's physical therapy was discontinued on 02/23/22, he was able to stand up and sit down with only stand by assistance (no hands on). She stated he was able to walk 30 feet with a wheeled walker. When physical therapy was started again on 04/11/22 (three weeks after his medication had been reduced) he had declined and was not able to walk. Review of physical therapy notes revealed a discharge summary on 02/23/22 indicated the resident had met goals of spontaneously righting self when needed in order to prepare for transfers, increased ability to stand supported for 1-3 minutes, functional bed to/from wheelchair transfer both with and without front wheeled walker and short distance ambulation from bed to/from toilet. A physical therapy evaluation, on 04/11/22 revealed Resident #45 now required maximum assistance from staff with transfers, was able to stand less than 30 seconds, was not able to walk or propel himself in a wheelchair and was totally dependent (on staff) for these tasks. The notes assessed the resident had a decline in functional mobility. On 07/18/22 at 2:40 P.M. interview with RN #104 revealed she was Resident #45's nurse. She stated the resident had a period of decline after his [CONDITION(S)] medications were changed in March 2022 until they were changed again in June 2022. She stated the decline included the resident not being able to stand, pivot or take steps as he previously had been able to do. On 07/18/22 at 2:45 P.M., interview with the DON revealed she was not aware of the medication error (related to the administration of the resident's [MEDICATION(S)]) until this date when the 03/10/22 progress notes were received and reviewed from the neurology office. The initial information received on 03/10/22 was incomplete (as it only contained one of four pages) and did not reflect the entire orders for the medication. The facility failed to identify the lack of complete orders or follow-up with the neurologist to ensure the correct dose of medication was being administered as ordered to prevent the resident's decline in physical condition. This deficiency substantiates Complaint Number OH 103.

Based on observations, staff interview, family interview, medical record review, and review of the facility policy on skin care program, the facility failed to provide care, treatment and interventions to prevent the development of unstageable pressure ulcers on the heels for two residents (Residents #13 and #56) and unstageable pressure ulcers on the heel and top of foot for Resident #16. This resulted in actual harm for Residents #13, #16, and #56, who developed avoidable, unstageable pressure ulcers to the heels, that were not identified until they were unstageable areas. In addition the facility failed to provide adequate repositioning for one resident (Resident #21) admitted with a pressure ulcer. This affected four of six residents reviewed for pressure ulcers. The facility identified 13 residents with pressure ulcers, including six in-house developed pressure ulcers. The facility census was 68. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set 3.0 (MDS) assessment completed 06/14/18 indicated the resident had short and long term memory problems, required extensive assistance from staff with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #13 was at risk for pressure ulcers but had no current pressure ulcers. Review of a pressure ulcer risk assessment completed 06/07/18 revealed the resident was at low risk for the development of pressure ulcers. A pressure ulcer risk assessment completed 09/13/18 indicated the resident was at high risk for the development of pressure ulcers and a pressure ulcer risk assessment completed 11/29/18 indicated the resident was at moderate risk for the development of pressure ulcers. Review of physician's orders dated 12/13/18 revealed to reposition Resident #13 frequently and float heels in bed. Review of a nursing assistant skin tool revealed on 01/09/19 Resident #13 had a blister on the right heel. However, review of nurses progress notes and skin condition reports revealed no evidence of an assessment of the area or any evidence treatment was provided until 01/16/19. Review of a skin condition report dated 01/16/19 revealed Resident #13 developed a new pressure area on the right heel. The notes indicated unable to accurately stage. Suspected deep tissue injury measuring 2.8 centimeters (cm) long by 3.1 cm wide. Skin is not blanchable, minimal red tinged drainage. The note stated the area was not present on admission. A new treatment was ordered. The note indicated that a splint applied by the resident's wife had caused the area on the heel. Review of the quarterly MDS assessment completed 01/17/19 revealed Resident #13 had two unstageable pressure ulcers (an unstageable pressure ulcer is defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture). Review of wound evaluation notes dated 01/22/19 by the wound care physician revealed Resident #13 had an unstageable (due to necrosis) pressure wound of the right medial heel measuring 1.5 cm by 1.5 cm. The wound was described as 80% necrotic tissue, 10% slough, and 10% granulated tissue. Debridement of the wound was completed at that time. The physician recommended to elevate legs and float heels in bed. Review of pressure ulcer risk assessments completed on 02/02/19 and 02/16/19 indicated the resident was at moderate risk for the development of pressure ulcers. At that time resident #13 had an unstageable pressure ulcer on the right heel. Observations on 03/25/19 at 4:31 P.M. and 03/27/19 at 3:30 P.M. revealed Resident #13 up in a wheelchair with hard soled tennis shoes on both feet with his right foot strapped to the wheelchair pedal. Observations on 03/28/19 at 7:52 A.M. revealed Resident #13 in bed on his back. His right foot was elevated with a pillow. However, the back of his right heel was touching the pillow. The left foot was resting on the mattress. On 03/28/19 at 9:50 A.M. the resident was up in a wheelchair in his room with hard soled tennis shoes on both feet with his right foot strapped to the wheelchair pedal. Review of a wound evaluation by the wound physician dated 03/26/19 revealed Resident #13 was noted to have a stage three pressure ulcer of the right medial heel measuring 0.6 cm long by 0.7 cm wide by 0.1 cm deep. Recommendations again stated to elevate legs and float heels in bed. Interview with Resident #13's personal assistant (a private duty assistant hired by the family) on 03/28/19 at 9:50 A.M. revealed she worked from 9:30 A.M. to 6:00 P.M. She stated the resident is usually up in his wheelchair when she arrives for the day and he lays down for a nap between 1:00 P.M. to 2:00 P.M., otherwise up in the wheelchair until 7:00 P.M. She confirmed he always wears the tennis shoes when up and has a strap to hold his right foot in place on the wheelchair pedal. Interview with State tested Nursing Assistant (STNA) #352 on 03/28/19 at 10:35 A.M. revealed Resident #13 gets up around 9:00 A.M. She confirmed he wears tennis shoes all the time when up in the wheelchair. STNA #352 confirmed Resident #13 is transferred with a sit to stand lift. He stated he has the strap on his foot to keep him from moving his foot when up. STNA #352 stated Resident #13 lays down for a nap at 1:00 P.M. and is then up until the next shift puts him to bed around 7:00 P.M. STNA #352 stated when he is in bed they use a pillow to try to keep his heels off the bed but no heel boots are used. Observations on 03/28/19 at 2:00 P.M. revealed Resident #13 had a 1.0 cm long by 1.5 cm wide by 0.1 cm deep open area on the right heel with necrotic tissue around the edges of the open wound. The resident's right heel was touching a pillow placed under his right leg. Interview with LPN #413 on 03/28/19 at 3:00 P.M. verified wearing tennis shoes would probably put pressure on Resident #13's heel. Observations on 03/29/19 at 7:46 A.M. revealed Resident #13 in bed on his back. He had a pillow under his legs but his right heel was resting on the mattress. This was confirmed by the Director of Nursing (DON) at the time of the observation. The DON stated Resident #13's heels should be floated so they do not touch the mattress. The DON stated Resident #13's wife insisted on him wearing shoes when he is up. Review of the plan of care revealed it did not address the wife wanting the resident to wear shoes when up. The plan of care stated to float heels when in bed and encourage to change position frequently. The plan of care did not address pressure relief for the heel when up in the wheelchair. Interview with the Director of Nursing (DON) on 03/29/19 at 7:46 A.M. confirmed that the entry Spouse declines to leave shoe off until pressure area heals was added to the plan of care after the surveyor asked about the resident wearing shoes at all times while up in the wheelchair with the pressure ulcer on his heel. Interview with the DON on 03/29/19 at 8:28 A.M. confirmed the nursing assistant skin tool identified a blister to the right heel on 01/09/19 but no assessment or treatment was done until 01/16/19. The DON confirmed the area should have been assessed and treatment started on 01/09/19. The DON confirmed the area developed in the facility. Interview with the DON on 03/29/19 at 9:30 A.M. confirmed the pressure ulcer risk assessments for Resident #13 ranged from low risk to high risk even though the level of staff assistance remained the same. The DON stated the risk assessments are completed by different nurses and are completed based on how that nurse feels when doing the assessment. Interview with Resident #13's wife on 03/29/19 at 2:00 P.M. confirmed the area on the heel was caused from the splint she applied. However, she stated she had not requested the resident's shoes be left on while up in the wheelchair. 2. Review of the medical record for Resident #16 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of an admission MDS assessment 01/11/19 revealed Resident #16 required extensive assistance from staff with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. The MDS indicated the resident had one stage two pressure ulcer upon admission. However, review of an admission nursing assessment completed on 01/04/19 did not indicate any pressure ulcers present upon admission. Review of a pressure ulcer risk assessment completed 01/04/19 revealed the resident was at low risk for the development of pressure ulcers. Review of skin condition reports revealed on 01/10/19 Resident #16 was noted to have a blister on the left heel measuring 6.0 cm long by 3.5 cm wide. Skin was not blanchable. A new treatment was ordered. The notes stated this wound was not present upon admission and was an intact fluid filled blister. Staging of the area was not identified. On 01/15/19 skin condition notes stated the area on the left heel was now open with minimal red tinged drainage present. A physician's order was obtained on 01/15/19 to encourage resident to float heels off bed. On 01/22/19 the area was noted to be a stage two area measuring 2.4 cm long by 0.6 cm wide with red tinged drainage. On 01/25/19 a pressure ulcer risk assessment was completed indicating the resident was at high risk for pressure ulcers. On 01/29/19 the area on the left heel was noted as unstageable measuring 2.0 cm long by 4.0 cm wide. Skin was not blanchable. An order was obtained for heel protectors on while in bed. Review of the plan of care revealed an intervention for heel protectors while in bed. On 02/04/19 a pressure ulcer risk assessment was completed indicating the resident was low risk for pressure ulcers, however Resident #16 had an unstageable pressure ulcer. There was no evidence the resident was seen by the wound care physician until 02/12/19. On 02/12/19 the wound care physician documented Resident #16 was noted to have an unstageable (due to necrosis) pressure ulcer of the left heel with moderate serous exudate measuring 2.0 cm long by 3.0 cm wide. The area was debrided at that time. Review of skin condition reports revealed on 02/19/19 the resident was noted with a new pressure ulcer on the top of the right foot measuring 2.0 cm long by 2.0 cm wide with the wound base not visible. Skin was not blanchable. The report indicated the wound was not present upon admission. Wound evaluation notes by the wound physician on 02/19/19 indicated Resident #16 in addition to the unstageable pressure ulcer on the left heel, had an unstageable pressure ulcer on the left dorsal foot measuring 2 cm long by 2 cm wide. A physician's order was obtained on 02/19/19 to only have the foot rests on wheelchair when being pushed down hallway. Review of wound evaluation notes by the wound physician on 03/05/19 revealed an unstageable (due to necrosis) pressure ulcer on the left heel measuring 2.2 cm long by 2.3 cm wide. The area was surgically debrided at that time. The resident was also noted with an unstageable (due to necrosis) pressure ulcer of the left dorsal foot measuring 6.0 cm long by 6.0 cm wide. This area was also surgically debrided at that time. Recommendations were made to elevate legs, float heels in bed, off load wound, and reposition per facility protocol. Review of wound evaluation notes by the wound physician on 03/26/19 revealed Resident #16 currently had an unstageable pressure ulcer of the left heel measuring 1.7 cm long by 1.9 cm wide with 15% slough and 85% granulation tissue. The resident also had an unstageable pressure ulcer of the left dorsal foot measuring 6.0 cm long by 5.0 cm wide with 10% necrotic tissue, 20% slough and 70% granulation tissue. Recommendations were to elevate legs, float heels in bed, off load wound, and reposition per facility protocol. Review of dietary progress notes revealed no evidence the pressure ulcers were identified by the dietician until 03/27/19 (developed area on left heel on 01/10/19 and top of left foot on 02/19/19). On 03/27/19 the dietician indicated Resident #16 had unstageable skin impairment. and the resident's protein intake was not adequate to meet needs. A house supplement of 120 milliliters three times per day was recommended to provide an additional 600 calories and 30 grams of protein per day. Observations on 03/27/19 at 3:14 P.M. revealed Resident #16 in bed on her right side. The resident had on gripper socks and her feet were laying directly on the mattress. There was one heel boot laying on the counter across the room. The resident was confused, yelling out a man's name and stating she was getting married tomorrow night. On 03/28/19 at 8:04 A.M. Resident #16 was observed in bed on her left side. The resident had a heel boot on the left foot only. On 03/28/19 at 8:20 A.M. the resident was noted up in a wheelchair in the dining room for breakfast. The resident was seated at a table with her feet under the table. The resident had on gripper socks with her heels resting on the pedals of the wheelchair. On 03/28/19 at 9:29 A.M. Resident #16 was observed in bed on her right side with gripper socks on. Both heels were resting on the mattress. There were no pillows or heel boots near the resident. On 03/28/19 at 11:00 A.M. Resident #16 was observed in bed on her right side with gripper socks on. Her heels were resting on the bed. No pillow or heel boots were near the resident. On 03/28/19 at 2:41 P.M. heel protectors while in bed were documented as provided on the nursing assistant tasks completed sheet. There was no evidence of refusal. On 03/28/19 at 12:49 P.M. the resident was up in a wheelchair in the lounge with gripper socks on. The resident's feet were resting on the the foot pedals of the wheelchair. On 03/29/19 at 7:53 A.M. the resident was up in a wheelchair in the dining room with her feet under the table drinking coffee. The resident had gripper socks on her feet and her feet were resting on the wheelchair foot pedals under the table. On 03/29/19 at 10:15 A.M. the resident was in bed on her back. The resident did not have heel boots on and her left heel was resting on the mattress. Interview with DON #422 from a sister facility on 3/28/19 at 2:48 P.M. confirmed Resident #16's admission nursing assessment did not identify any pressure ulcers upon admission. Interview with the DON on 03/29/19 at 9:30 A.M. confirmed the area on the top of the left foot developed from putting her foot under the wheelchair pedal. The DON confirmed the pressure ulcer risk assessments for Resident #16 ranged from low risk to high risk even though her level of assistance remained the same. She stated the risk assessments are completed by different nurses and are completed based on how that nurse feels when doing the assessment. Interview with the Dietician on 03/29/19 at 11:00 A.M. revealed she did not know why the resident's pressure ulcers were not addressed in the nutrition progress notes until 03/27/19. She stated if a resident developed pressure ulcers, the resident is assessed to determine if any additional nutritional interventions are needed to assist in wound healing. She stated normally additional protein is added to assist in wound healing and that was done for Resident #16 on 03/27/19. Interview with the DON on 03/29/19 at 10:15 A.M. confirmed Resident #16 did not have heel boots on as ordered and confirmed her heel was not floated. The DON further confirmed the nursing assistants were documenting that heel protectors were being provided with no evidence of refusal. On 03/29/19 at 9:30 A.M. the DON confirmed the resident was not to have the foot pedals on the wheelchair except for when being pushed down the hallway. Observations on 04/01/19 at 7:20 A.M. revealed Resident #16 had a 1.8 cm long by 1.3 cm wide open area on the left heel. Red granulation tissue was noted in the wound. The resident also had a 5.8 cm long by 5.5 cm wide open area on the top of the left foot. The wound bed contained slough and pink tissue. 3. Review of the medical record for Resident #56 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of an admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 9 indicating moderately impaired decision making skills. The MDS revealed Resident #56 had no pressure ulcers. Review of a pressure ulcer risk assessment dated [DATE] revealed the resident was not at risk for the development of pressure ulcers. Review of a physician's order dated 02/11/19 indicated to encourage to float heels in bed. Review of the plan of care revealed an intervention was added on 02/11/19 to encourage to turn and reposition frequently and on 02/15/19 float heels as ordered was added. Review of skin condition reports revealed on 02/12/19 the resident was noted to have a blister on the left heel that was a suspected deep tissue injury measuring 4.0 cm long by 4.0 cm wide. Skin was not blanchable. The notes indicated the wound was not present upon admission. Review of a wound evaluation report by the wound physician on 02/12/19 revealed an unstageable deep tissue injury of the left heel measuring 4.0 cm long by 4.0 cm wide. Recommendations were to elevate legs and float heels in bed. A MDS assessment completed 02/14/19 indicated the resident required extensive assistance from staff with bed mobility, transfers, and locomotion. Review of wound evaluation notes from the wound physician on 03/26/19 revealed an unstageable deep tissue injury on the left heel measuring 2.0 cm long by 0.7 cm wide. Recommendations remained to elevate legs and float heels in bed. Observations on 03/27/19 at 3:34 P.M. revealed Resident #56 in bed on her back with compression stockings on. The resident's heels were resting on the mattress. On 03/28/19 at 7:57 A.M. the resident was in bed on her back with both heels resting on the mattress. Her feet were bare. On 03/28/19 at 8:30 A.M. the resident was observed up in a wheelchair in the lounge. The resident had on the compression stockings and clog (open back) shoes on both feet. He feet were resting flat on the foot rest of the wheelchair. On 03/28/19 at 10:57 A.M. and 12:54 P.M. the resident was observed in bed on her back. Her feet were resting on a bed pillow with her heels laying on the pillow,(not floated). Observations on 03/29/19 at 10:20 A.M. revealed Resident #56 had a 2.0 cm long by 0.6 cm wide light brown scabbed area on the left heel. Review of the facility policy on Skin Care Program dated 09/26/13 revealed nursing assistants were to assess skin during bathing and notify the nurse of any new areas. The policy also stated nutrition staff would be notified when a new area developed. 4. Review of Resident #21's medical record revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. On admission Resident #21 had an unstageable pressure injury on her coccyx. The measurements were 4 cm in length by 1.5 cm in width and no depth noted as the wound base was covered with eschar. Review of Resident #21's quarterly MDS dated [DATE] revealed cognition was severely impaired. Resident #21 had no behaviors and did not reject care. Resident #21 required extensive assistance of two staff for bed mobility, and to transfer. Resident #21 had one unstageable pressure injury. Review of Resident #21's Braden scale for pressure sore development risk dated 1/25/19 revealed she was at moderate risk of pressure sore risk Review of Resident #21's wound notes revealed on 02/19/19 the coccyx wound was staged as a healing stage four pressure injury (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur.) The coccyx wound measured 1.8 cm in length by 1.0 cm wide and 0.3 cm deep. Review of the (MONTH) 2019 monthly physician orders revealed the following orders. Skin prep to heels two times a day, encourage Prevalon boots, during day and night, pressure reduction cushion to wheel chair, a low air loss mattress, reposition her frequently, and encourage to float her heels. Resident #21 had a treatment to her coccyx to clean the coccyx wound with normal saline, pack [MEDICATION NAME] dressing, twice daily. Review of Resident #21's wound notes dated 03/26/19 revealed the coccyx wound measured 0.3 cm in length by 0.3 cm in width and 0.5 cm deep. Observation of Resident #21 on 03/28/19 at 8:28 A.M. revealed she was in a common area seated in a wheel chair. At 8:37 A.M. Resident #21 was in the dining room eating seated in the same wheel chair. At 9:22 A.M. Resident #21 was in her wheel chair in a common area her feet elevated resting on the wheel chair foot pad with cushions and feet elevated with the heels of her feet against the foot rest. At 10:26 A.M. Resident #21 was seated in the same chair in the same position asleep. At 11:00 A.M. staff took Resident #21 to her room to change her. Observation of Resident #21 on 03/28/19 at 1:28 P.M. revealed she was in room seated in her wheel chair. At 1:30 P.M. Resident #21 was put into bed on her back. Her heels were not floated, and no boots were applied to her feet. Resident #21 was observed at 2:48 P.M. in the same position in bed. Observation of Resident #21 on 03/29/19 at 9:15 A.M. revealed she was in a common area her feet were elevated with slippers on resting on pillow. At 10:11 A.M. Resident #21 was in the same position. Interview with STNA #414 on 03/29/19 at 9:12 A.M. revealed Resident #21 had a pressure ulcer. STNA #414 stated Resident #21 did not resist care. Interview with STNA #414 at 11:48 A.M. revealed Resident #21 was repositioned and put to bed about every two hours and she never saw Resident #21 wear Prevalon boots. STNA #414 indicated Resident #21 wore compression hose and slippers. STNA #414 stated she puts a pillow under Resident #21's feet. Interview with LPN #387 on 03/29/19 at 11:58 A.M. revealed Resident #21 should be turned and repositioned every two to three hours and her heels should not rest on the foot rest. Interview with the DON on 03/29/19 at 12:24 P.M. revealed Resident #21 should be turned and repositioned every two hours. She stated two hours turning and reposition was the gold standard and what she expected the STNAs and the nurses to adhere to. The DON confirmed the resident's heel should not rest on the foot rest. This deficiency substantiates Complaint Number OH 014.