Every finding on record at Carecore at Gaymont

Based on observation, medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure activities of daily living (ADLs) were performed timely for residents who required assistance, This affected four (#24, #25, #26, and #53) of four residents reviewed for ADLs. The facility census was 73.Findings include:1. Review of the medical record for Resident #24, revealed an admission date of 01/07/11, with diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery (CVA), generalized muscle weakness, major depressive disorder, diabetes mellitus, unspecified lack of coordination, oral dysphagia, pharyngeal dysphagia, abnormal posture, other reduced mobility, hypocalcemia, pain, personal history of COVID-19, oropharyngeal dysphagia, shortness of breath, hyperlipidemia, benign prostatic hyperplasia, gastro-esophageal reflux disease, other cervical disc degeneration, hypertension, and unspecified sequelae of unspecified cerebrovascular disease. Review of Resident #24's most recent quarterly Minimum Data Set (MDS) assessment, dated 06/09/26, revealed a Brief Interview of Mental Status (BIMS) score of 07, indicating Resident #24's cognition was severely impaired. Further review of this MDS assessment revealed Resident #24 was dependent for all functional abilities including, but not limited to, ambulation, eating, hygiene, bathing, dressing, repositioning, and transfers. Review of Resident #24's care plan revealed Resident #24 has an ADL self-care performance deficit related to cognitive impairment and CVA with a goal of maintaining current level of function with activities of daily living. The care plan interventions included assist with ADLs (dressing, grooming, personal hygiene, locomotion, oral care, etc.) as needed. Observation revealed Resident #24's nails were long and contained an unidentified brown substance under them. Interview with Resident #24 revealed he does not like his nails that long and would like them trimmed, but no one from the facility has done it for him. Interview with Licensed Practical Nurse (LPN) #124 and LPN #151 verified Resident #24's nails were long and contained an unidentified brown substance under them. Further interview with LPN #124 and LPN #151 confirmed Resident #24 required facility staff to trim his nails, and he wanted his nails trimmed. 2. Record review for Resident #53 revealed an admission date of 03/05/21. Diagnoses included vascular dementia, contracture of muscle, multiple sites, abnormal posture, and speech disturbances. Review of the quarterly MDS dated [DATE] revealed Resident #53 was rarely or never understood, was always incontinent of bowel and bladder, was dependent for toileting hygiene, and chair/bed to chair transfer. Review of the care plan dated 06/15/26 revealed Resident #53 had an alteration in elimination of bowel and bladder related to dementia, impaired mobility, physical limitations, unaware of need to void or defecate, and will not alert staff of need to void or defecate. Interventions included check and change as required for incontinence. Observation on 07/20/2026 at 9:30 A.M. revealed Resident #53 was sitting in her in chair in front of the television in the dining room/lounge area resting with her eyes closed. Continued observation of Resident #53 on 07/20/26 at 11:00 A.M. and 12:42 P.M., revealed Resident #53 was sitting in her in chair in front of the television in the dining room/lounge area resting with her eyes closed. Observation on 07/20/2026 1:53 P.M. revealed Resident #53 was moved by Certified Nursing Assistant (CNA) #187 from the television area to her room, and her chair was placed next to her bed. Interview on 07/20/2026 at 1:55 P.M. with CNA #187 revealed she started her shift at 6:30 A.M. and Resident #53 was already up in her chair and placed in the television area by the night shift staff prior to when she arrived. CNA #187 revealed she was getting ready to check and change Resident #53 and confirmed this was the first time since she arrived for her shift that Resident #53 was being checked and changed. CNA #187 verified knowledge of Resident #53 being incontinent of bowel and bladder. CNA #187 stated, we need more staff, there is only two of us for 23 residents. CNA #115 then entered Resident #53's room and also confirmed this was the first time on this shift that Resident #53 was checked for incontinence or changed due to not having enough staff. Observation of incontinence care provided by CNA #187 and #115 revealed Resident #53's brief was saturated and the resident's buttocks was red. Additional observations on 07/21/2026 at 9:37 A.M., 10:30 A.M., 12:00 P.M., and 1:30 P.M. revealed Resident #53 was sitting in her in chair in front of the television in the dining room/lounge area resting with her eyes closed. Observation on 07/21/2026 at 3:07 P.M. revealed Resident #53 was lying in her bed with her eyes closed. CNA #186 revealed her and CNA #115 just laid Resident #53 down at 2:45 P.M. and changed her for the first time this shift. Interview on 07/21/2026 at 3:32 P.M. with CNA #115 confirmed Resident #53 was gotten up by night shift and had not been checked for incontinence or changed until she was laid down for the first time on that day at 2:45 P.M. CNA #115 confirmed Resident #115 was wet when she was changed. 3. Record review for Resident #26 revealed an admission date of 11/12/19. Diagnoses included Alzheimer's disease, lack of coordination, and venous insufficiency. Review of the annual MDS dated [DATE] revealed Resident #26 was rarely or never understood, had short- and long-term memory problems, was frequently incontinent of urine, always incontinent of bowel, dependent for toileting hygiene and chair/bed to chair transfer. Review of the care plan dated 06/17/26 revealed Resident #26 has an alteration in elimination of bowel and bladder due to confusion, dementia, physical limitations, unaware of need to void or defecate, and will not alert staff of need to void or defecate. Interventions included to check and change as required for incontinence, wash, rinse and dry perineum, and to change clothing as needed after incontinence episodes. Observation on 07/20/2026 at 9:31 A.M. revealed Resident #26 was sitting in her in chair in front of the television in the dining room/lounge area resting with her eyes closed. Continued observation of Resident #26 on 07/20/26 at 11:01 A.M. and 12:43 P.M. revealed Resident #26 was sitting in her in chair in front of the tv in the dining room/lounge area resting with her eyes closed. Observation on 07/20/2026 at 1:11 P.M. of incontinence care for Resident #26 provided by CNA #115 revealed Resident #26 had a strong urine odor. Resident #26 had been incontinent of urine and had a red buttock. CNA #115 confirmed night shift got Resident #26 up before she started her shift at 6:30 A.M. and sat Resident #26 in the dining room. CNA #115 also confirmed this was the first time since the start of her shift that Resident #26 was checked or changed. Additional observations on 07/21/2026 at 9:37 A.M., 10:30 A.M., 12:00 P.M., and 1:30 P.M. revealed Resident #26 was sitting in her chair in the dining room sleeping. At 3:05 P.M. Resident #26 was observed laying in bed. Interview on 07/21/2026 3:06 P.M. with CNA #186 revealed Resident #26 was laid down and provided incontinence care about 2:30 P.M. with CNA #115. Interview on 07/21/2026 at 3:30 P.M. with CNA #115 confirmed Resident #26 was up before 6:30 A.M. and not laid down, checked or changed until 2:30 P.M., CAN #115 stated there is not enough staff. 4. Record review for Resident #25 revealed an admission date of 01/15/20. Diagnoses included Parkinson's disease, cognitive communication deficit and muscle weakness. Review of the annual MDS dated [DATE] revealed Resident #25 was severely cognitively impaired, always incontinent of urine and frequently incontinent of bowel and was dependent for toileting hygiene and chair/bed to chair transfer. Review of the care plan dated 05/26/26 revealed Resident #25 had an alteration in elimination of bowel and bladder, confusion, dementia, history of urinary tract infections, impaired mobility, physical limitations, unaware of need to void or defecate and will not alert staff of need to void or defecate. Interventions included check and change as required for incontinence including washing, rinsing and drying the perineum. Observation and interview on 07/21/2026 at 10:10 A.M. with CNA #176 revealed Resident #25 was sitting up in her chair. CNA #176 revealed she was getting ready to change her but needed to go find someone to assist with transferring the resident into her bed. CNA #176 revealed Resident #25 had been up since 6:15 A.M., CNA #176 stated she tries to check and change residents every two to three hours but sometimes there was not enough staff so four hours was a normal time interval to check and change residents depending on if she could find someone to assist with transfers. Observation of incontinence care revealed Resident #25 was saturated with urine; the peri area and buttocks were deep red with dry flaking skin noted to the coccyx area. Phone interview on 07/22/2026 at 5:35 P.M. with Resident #25's family member revealed she visited frequently and found Resident #25 not changed timely. Stating that Resident #25 was often found incontinent with a foul odor and sitting in wet chair pads. Interview on 07/21/2026 at 10:53 A.M. with Director of Nursing (DON) revealed residents were to be checked and changed every two hours. Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, dated March 2018, revealed residents will be provided with care, treatment and services as appropriate to maintain to improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. This deficiency represents non-compliance investigated under Master Complaint Number 3122368 and Complaint Numbers 2998519 and 2800650.

Based on observation, record review, interview, and review of the facility policy revealed the facility failed to ensure Resident #1 and #47's open areas were addressed timely and failed to ensure Resident #12 and #58's physician orders were followed as prescribed. This affected two (Resident #1 and #47) of three residents reviewed for open areas and affected two (Resident #12 and #58) of five residents reviewed for following physician orders. The facility census was 73.Findings include: 1. Record review for Resident #47 revealed an admission date of 06/28/24. Diagnoses included chronic obstructive pulmonary disease (COPD), type two diabetes mellitus and Parkinson's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively intact, had no behavioral symptoms, used a wheelchair for mobility, required set up or clean up assist with lower body dressing and chair/bed to chair transfers. Resident #47 had no open lesions or pressure ulcers. Review of the Skin Review Weekly dated 07/20/26 at 10:53 P.M. completed by Licensed Practical Nurse (LPN) #191revealed Resident #47 had no new skin issues observed or reported this shift. Review of the physician orders for Resident #47 revealed an order dated 05/26/26 for ace wraps to bilateral lower extremities on in the morning and off at night. Observation on 07/20/2026 at 9:58 A.M. revealed Resident #47 was lying in bed. Resident #47 did not have ace wraps on his legs, and his bilateral feet were very dry with thick white crust. Observation revealed Resident #47's right lower leg had multiple open areas, some circular in shape, some partially scabbed with abrasions which appeared to be scratch marks. The open areas were mainly on the front of the leg with a few on the back. Resident #47 revealed it had been like that for several days and revealed it was itchy. Interview on 07/21/2026 at 2:21 P.M. with Licensed Practical Nurse (LPN) #165 confirmed she was Resident #47's primary care nurse and revealed Resident #47 did not have an order for ace wraps to his bilateral lower extremities. Reviewed the Treatment Administration Record (TAR) and physician orders with LPN #165 and confirmed LPN #165 signed the physician order on the TAR for 07/21/26 that she applied Resident #26's ace wraps to the bilateral lower extremities in the A.M.; LPN #165 confirmed she signed the order as completed but never applied the ace wraps. LPN #165 observed and confirmed Resident #47 did not have ace wraps on his lower legs and confirmed Resident #47 had multiple open areas, some partially healed, and abrasions to his right lower leg, front and back. LPN #165 stated, The open areas are for the wound nurse to do, I don't have anything to do with that. LPN #165 revealed the Wound Nurse came yesterday. Interview on 07/21/2026 at 2:31 P.M. with Wound Care Nurse/Assistant Director of Nursing (ADON) #108 revealed she did wound rounds with the Wound Care Certified Nurse Practitioner (CNP) every Monday. Wound Care Nurse/ADON #108 revealed they did not visit Resident #47 yesterday because they were not aware he had any wounds and revealed if a nurse finds wounds we have them address the areas. The nurse would document the observation of the wound and notify the her, the Wound Care CNP and the Primary Physician/CNP. Observed Resident #47's right lower leg front and back and confirmed the open areas and abrasions and revealed she was not made aware of the open areas. Wound Care Nurse/ADON confirmed Resident #47 did not have orders for treatment to the areas and revealed she would notify Wound Care CNP. 2. Record review for Resident #1 revealed an admission date of 06/24/21. Diagnoses included morbid obesity, type two diabetes mellitus, muscle weakness, and need for assistants with personal care. Review of the Medicare five-day MDS dated [DATE] revealed Resident #1 was cognitively intact. Resident #1 was occasionally incontinent of urine and frequently incontinent of bowel, required partial to moderate assistance with toileting hygiene, substantial /maximal assistance with sit to stand and chair/bed to chair transfer. Interview on 07/20/2026 at 1:47 P.M. with Resident #1 revealed, My butt is sore, it's open from when I have bowel movement, when they wipe me they wipe hard and it opens it. Medical record review revealed no documentation of Resident #1 having an open area to her buttocks area. Observation on 07/22/2026 at 9:23 A.M. of toileting with Resident #1 provided by CNA #115 revealed CNA #115 assisted Resident #1 to the bedside commode with use of the walker. CNA #115 provided peri care after Resident #1 urinated. Observation of the peri care revealed CNA #115 alerted Resident #1 before she wiped her buttocks that she was going to wipe now. As CNA #115 wiped Resident #1's buttocks, Resident #1 screamed out loudly in pain. Observation of Resident #1's buttocks revealed a long open slit down the gluteal cleft (the vertical groove between the buttocks that runs down towards the rectum) with small open areas on both sides of the inner buttocks. CNA #115 revealed the open areas have been there as long as she could remember. Resident #1 revealed, I can take a lot of pain, but that pain is very intense, it only [NAME] when they wipe me. Interview on 07/22/2026 at 9:34 A.M. Wound Care Nurse/ADON #108 revealed no one told her Resident #1 had open areas to her buttocks area and revealed they should have. Wound Care Nurse/ADON #108 confirmed Resident #1 did not have treatment orders for an open area to her buttocks. Interview on 07/22/2026 at 9:40 A.M. with CNA #128 revealed she was Resident #1's CNA frequently. CNA #128 revealed the open areas to Resident #1's buttocks had been there for months and revealed she told nurses about the areas in the past including the previous Wound care nurse. Interview on 07/22/26 at 1:10 P.M. with Wound Care Nurse/ADON #108 wound confirmed she assessed Resident #1's buttocks area and obtained orders for treatment to the open area. 3. Review of Resident #12's medical record revealed an admission date of 09/10/25. Diagnoses included nontraumatic intracerebral hemorrhage, severe protein-calorie malnutrition, hypertension, gastrostomy, and hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. Review of Resident #12's quarterly MDS assessment dated [DATE] revealed Resident #12's cognitive skills for daily decision making were moderately impaired. Furthermore, Resident #12 was at risk for developing a pressure ulcer. Review of Resident #12's care plan dated 05/28/26 revealed Resident #12 was at risk for impaired skin integrity with interventions that included to apply medicated creams as ordered and to provide medications and treatments as ordered by the physician. Review of Resident #12's physician orders revealed an order dated 05/24/26 for lac-hydrin or Dermaphor to the bilateral legs followed with kerlix and wrapped with two ace wraps per leg from base of toes to below the back of the knee to be applied in the morning before getting out of bed and to be taken off at bedtime. Observation and concurrent resident interview on 07/21/26 at 10:07 A.M. revealed the physician ordered dressings were not on Resident #12's legs. Upon interview, Resident #12 shook his head, no, when asked does the facility put dressings on your legs. Interview on 07/21/26 at 4:33 P.M. with the Director of Nursing (DON) verified she was unaware of why Resident #12 had that physician order. Furthermore, the DON verified the order had not been completed since the order was given. The DON stated the wound Nurse Practitioner (NP) discontinued the order on 07/20/26 due to Resident #12 no longer needing the treatment. Review of the facility policy titled Wound Care, with a revision date of October 2010 revealed to verify that there is a physician order for the procedure and to apply treatments as indicated. 4. Review of Resident #58's medical record revealed an admission date of 07/26/23. Diagnoses included muscle wasting and atrophy, osteoporosis, vitamin D deficiency, and pure hypercholesterolemia. Review of Resident #58's annual MDS assessment dated [DATE] revealed Resident #58 had severely impaired cognition with a BIMS score of three. Furthermore, Resident #58 was dependent for putting on and taking off footwear, Review of Resident #58's care plan dated 06/30/26 revealed Resident #58 had an activity of daily living (ADL) self-care performance deficit with an intervention that included to apply compression socks in the morning and to take them off at bedtime. Review of Resident #58's physician orders revealed an order with a start date of 10/10/24 for compression stockings to be put on in the morning and off at bedtime. Observation on 07/20/26 at 10:15 A.M. of Resident #58 revealed Resident #58 did not have her compression stockings on while sitting in her wheelchair with her shoes on. Interview on 07/20/26 at 10:52 A.M. with CNA #176 verified Resident #58 did not have her compression stockings on when she was supposed to have them put on before she got up and into her wheelchair for the morning. Review of the facility policy titled Activities of Daily Living (ADL), Supporting, with a last revision date of March 2018 revealed appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene and dressing. This deficiency represents non-compliance investigated under Complaint Number 2972189.

Based on observation, medical record review, resident interview, staff interview, review of manufacturer's instructions, review of product label, and policy review, the facility failed to ensure Med Pass (a concentrated, high-calorie, and high-protein liquid nutrition drink given during routine medication administration times) was not left at bedside and was properly stored. This had the potential to affect 17 (#6, #21, #25, #28, #30, #32, #38, #42, #45, #48, #51, #58, #64, #68, #69, #71, #72) residents identified by the facility as having orders for Med Pass. Additionally, the facility failed to ensure medications were not left at the bedside when administered to three residents (#1, #38, and #56). Furthermore, the facility failed to ensure the medication room was locked, and medications were not accessible to residents. The facility census was 73.Findings include:Observation on 07/22/26 at 7:47 A.M. revealed a 32-ounce bottle of Med Pass that was dated as opened on 07/20/26 and approximately one-quarter used on top of the medication cart used for Oak Hall. Review of the manufacturer's instruction and product label for Med Pass revealed directions to refrigerate prior to serving. When ready to serve, twist cap open, pull safety tab, and pour. reseal unused portion. Storage and handling, store in cool, dry area, do not expose to moisture or heat, do not freeze. After opening, consume product withing four days if properly refrigerated. After opening, consume product within four hours if not refrigerated. Interview on 07/22/26 at 7:49 A.M. with Registered Nurse (RN) #142 verified the 32-ounce bottle of Med Pass that was dated as opened on 07/20/26 and approximately one-quarter used was being stored on top of the medication administration cart for residents (#2, #4, #5, #9, #12, #29, #35, #52, #56, #67, and #99) on Oak Hall. Further interview with RN #142 verified the manufacturer's instructions and product label. RN #142 verified the Med Pass was not stored per manufactures instructions and product label. Review of the undated facility policy titled, Medication Labeling and Storage, revealed medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. 2. Review of the medical record for Resident #56, revealed an admission date of 06/20/26 with diagnoses including: hypokalemia, major depressive disorder, weakness, general muscle weakness, unsteadiness on feet, need for assistance with personal care, neurocognitive disorder with Lewy bodies, personal history of other venous thrombosis and embolism, polyneuropathy, encounter for other orthopedic aftercare, generalized anxiety disorder, stress incontinence, displaced intertrochanteric fracture of right femur, unspecified fall, hyperlipidemia, obesity, major depressive disorder, urge incontinence, straining to void, hypothyroidism, other lack of coordination, dysphagia, other speech disturbances, vitamin D deficiency, seasonal allergic rhinitis, overactive bladder, amnesia, iron deficiency anemia, acute cystitis, dementia, and hypertension Review of Resident #56's most recent admission Minimum Data Set (MDS) assessment, dated 07/01/26, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #56's cognition was intact. Further review of this MDS assessment revealed Resident #56 required partial or moderate assistance with all functional abilities including, but not limited to, eating, hygiene, toileting, hygiene, hygiene, dressing, transferring, and repositioning. Review of the medical record for Resident #56 revealed a physician order, dated 06/20/26, for one 800 milligram (mg) tablet of Gabapentin to be administered to Resident #56 by mouth (PO) at bedtime for neuropathy. Review of the medical record for Resident #56 revealed a physician order, dated 06/20/26, for one 400 mg capsule of Gabapentin to be administered to Resident #56 PO one time a day for neuropathy. Observation on 07/23/26 at 7:17 A.M. revealed RN #142 exiting Resident #56's room with a medication cup which contained pills. Interview with RN #142 at the time of observation revealed RN #142 had entered Resident #56's room to assess her and administer morning medication and she observed the cup of medication on the resident's bedside table. RN #142 states that Resident #56 is not physician-ordered to self-administer her medication. Further observation 07/23/26 at 7:17 A.M. with RN #142 revealed there were six pills found at Resident #56's bedside. These pills were:-one large oblong white tablet with D-25 marked on one side, identified as Gabapentin 800 mg-one small round pink tablet with no markings, identified as vitamin B12-one small round pink tablet with P1 marked on one side, identified as Synthroid 25 micrograms (mcg)-one white capsule with no markings, identified as acidophilus-one round white tablet marked L106, identified as Bupropion 300mg-one unmarked round white tablet, identified as cholecalciferol Interview at the time of observation with RN #142 verified these findings. Interview on 07/2326 at 7:26 A.M. with Licensed Practical Nurse (LPN) #300 verified she administered the six medications, found by RN #142 on Resident #56's bedside table, to Resident #56 and did not observe her take the medications. Further interview with LPN #300 revealed she administered the 800 mg Gabapentin to Resident #56 in error and there were no 400 mg doses available in the medication cart. Review of the undated facility policy titled, Administering Medications, revealed medications are administered in a safe and timely manner, and as prescribed. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined they have the decision-making capacity to do so safely. 3. Record review for Resident #38 revealed an admission date of 04/24/26. Diagnosis included chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis and need for assistance with personal care. Review of the quarterly MDS dated [DATE] revealed Resident #38 was cognitively intact, required assistance with activities of daily living, and received oxygen therapy. Review of the physician orders for Resident #38 revealed orders for ipratropium-albuterol inhalation solution 0.5-2.5 three milligrams (mg)/three milliliters (ml) one vial inhale orally every six hours as needed for shortness of breath dated 04/24/26. Review of the care plan dated 05/09/26 revealed Resident #38 had altered respiratory status/difficulty breathing, bronchitis, COPD, emphysema. Interventions included administering medications as ordered and observing as needed for effectiveness and side effects. Observation on 07/20/2026 at 10:09 A.M. revealed Resident #38 was resting in bed. Observation revealed four vials of albuterol inhalation solution were sitting out in the open on Resident #38's nightstand. Resident #38 revealed she takes one in the morning and one at night without assistance of the nursing staff. Observation on 07/21/2026 at 11:18 A.M. revealed Resident #38 was resting in bed. Observation revealed three vials of albuterol inhalation solution were sitting out in the open on Resident #38's nightstand. Resident #38 confirmed she takes one in the morning and one at night. The albuterol was provided by the nursing staff so she could take it when she needed it. Interview on 07/21/2026 11:22 AM with LPN #165 revealed Resident #38 took her breathing treatments when she wanted. Resident #38 revealed she took one today the LPN #165 stated we just ask her when she took the treatment and document it. Review of the Medication Administration Record (MAR) for July 2026 with LPN #165 revealed there was no documentation of Resident #38 receiving the as needed albuterol inhalation solution for the entire month. Observation on 07/22/2026 at 1:44 P.M. with DON confirmed there were three vials of albuterol inhalation solution sitting on top of Resident #38's nightstand unsecured. DON revealed there were no residents in the facility that were to be self-administering medication and revealed medications should be kept secured under lock and key at all times. Follow up record review on 07/21/2026 11:42 A.M. of Resident #38's medical record with LPN Unit Manager #104 revealed Resident #38 did not have an order, assessment or care plan to self-administer medications and medications should be secured. 4. Record review for Resident #1 revealed an admission date of 06/24/21. Diagnoses included acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of the Medicare five-day MDS dated [DATE] revealed Resident #1 was cognitively intact and required assistance with activities of daily living. Resident #1 received oxygen therapy. Review of the care plan dated 06/12/26 revealed Resident #1 had altered respiratory status/difficulty breathing. Chronic respiratory failure with hypoxia, morbid obesity, CHF, and oxygen use as ordered. Interventions included administering medications/puffers as ordered and observing as needed for effectiveness and side effects. Review of the physician orders for Resident #1 revealed an order for Ventolin HFA inhalation aerosol solution 108 two inhalation inhale orally every four hours as needed for SOB dated 06/21/26. Observation on 07/21/2026 at 11:32 A.M. with Assistant Director of Nursing (ADON) #108 confirmed Resident #1 had a Ventolin inhaler sitting on the bedside table. Resident #1 revealed she used the Ventolin inhaler two times a day independently and has been for months. Interview on 07/21/2026 at 11:35 A.M. with LPN #170 revealed Resident #1 would tell the nurses when she took the Ventolin inhaler and revealed she had kept the inhaler in her room and used it herself for as long as she could remember. Record review on 07/21/2026 at 11:37 A.M. with LPN Unit Manager #104 verified Resident #1 did not have an order to self-administer medication, there was no assessment completed for Resident #1 to self-administer medication and there was no care plan completed to self-administer medication. LPN Unit manager confirmed medications should be kept secured at all times. 5. Observation on 07/20/26 at 10:44 A.M. of the TCU/Maple nurses station revealed no staff present in the nurses' station. The TCU/Maple nurses station door was open and unlocked and the medication room within the nurse's station was also opened and unlocked. The medication room contained many different medications in liquid, pill, and cream forms. Interview on 07/20/26 at 10:47 A.M. with the Regional Director of Clinical Operations (RDCO) #304 verified the TCU/Maple nurses' station did not have any staff present in the nurse's station and the medication room within the nurse's station was also opened and unlocked. Furthermore, RDCO #304 verified the medication room contained many different medications. Review of the facility policy titled, Medication Labeling and Storage undated revealed the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. This deficiency represents non-compliance investigated under Master Complaint Number 3122368 and Complaint Number 2986521.

Based on observation, interview, and review of the facility policy revealed the facility failed to assure hair nets were properly worn by staff while working in the kitchen and failed to assure kitchen equipment was maintained in a clean manner. This had the potential to affect all residents residing at the facility except one resident, Resident #9, identified by the facility not receiving meals from the kitchen. The facility census was 73.Findings include:Observation on 07/20/2026 at 8:05 A.M. of the kitchen area revealed [NAME] #179 was preparing meal trays and placing them on the cart to be served. [NAME] #179 had her hair in a bun with the hair net covering the bun only.Dietary Aid #232 was prepping food items and also had her hair in a bun with the hair net covering the bun only. Dietary Aid #169 was cleaning dishes and also had her hair in a bun with the hair net covering the bun only. Observation with Dietary Aid #169 of the inside of the oven where pans of food were located revealed the oven was corroded with grease and grime on the top and all sides. There was a very thick layer of black char on the bottom of the oven. The top of the plate warmer had a thick layer of oily dust and grime. Observation on 07/20/2026 at 8:16 A.M. with Dietary Manager (DM) #110 verified [NAME] #179, Dietary Aid #232 and #167 had their hair in a bun with the hair net only covering the bun. DM #110 confirmed that each of the three staff members had hair on the top, sides and under the buns exposed while working in the kitchen. DM #110 also confirmed the oven, and the top of the plate warmer was very dirty. Interview on 07/21/2026 at 11:45 A.M. with DM #110 revealed after her research, she found that the kitchen staff should have had all their hair covered with a hair net while working in the kitchen. Review of the facility policy titled, Dietary Employee Personal Hygiene undated revealed all dietary staff must wear hair restraints to prevent hair from contacting food. Review of the undated facility policy titled, Sanitization, revealed the food service area is maintained in a clean and sanitary manner. All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracked or chipped areas that may affect their use or proper cleaning. This deficiency represents non-compliance investigated under Complaint Number 2986251.

Based on record review, staff interview and family interview, and review of the facility policy, the facility failed to timely notify the primary/emergency contact of a resident's significant change in condition. This affected one (#91) of three residents reviewed for notification. The facility census was 73.Findings include:Review of the medical record for Resident #91 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included chronic obstructive pulmonary disease, hypertension, muscle weakness and need for assistance with personal care.Review of the progress note dated [DATE] at 3:45 P.M. revealed Resident #91 was alert and oriented to person, place and time. Resident #91 had a regular pulse, respirations of 20, oxygen saturation was 98% on room air, did not use oxygen, and required management and evaluation of the care plan, observation and assessment of resident's condition, and teaching and training to return to the community or prior baseline function. Review of the progress note for Resident #91 dated [DATE] at 4:20 A.M. completed by Licensed Practical Nurse (LPN) #133 revealed the nurse spoke with the on call in regard to resident being short of breath, having difficulty breathing, being tachycardic and hypertensive and using accessory muscles to breath. Certified Nurse Practitioner (CNP) #802 ordered chest x ray and stated to continue to monitor resident. Resident vitals were blood pressure 136/96, pulse (heart rate) 108, oxygen saturation 89% on three liters of oxygen per nasal cannula.Review of the progress note for Resident #91 dated [DATE] at 7:50 A.M. completed by Registered Nurse (RN) #108 revealed CNP #802 entered Resident #91's room to assess the resident at which time the resident found absent of vitals. CNP #802 alerted the nurse and RN #108 went into the room to verify. RN #108 and the CNP #802 verify absence of vitals at 7:40 A.M., resident is deceased . CNAs (Certified Nursing Assistant) alerted to perform postmortem care. RN #108 contacted Resident #91's wife. The wife reported she was already on her way to visit her husband and was now in facility. Wife states she will contact their children and would like some time alone with her loved one. Staff provided privacy and encouraged wife to contact staff if there was anything she needed.Interview on [DATE] at 3:55 P.M. with RN #108 revealed on [DATE] she was the charge nurse for Resident #91. RN #108 revealed she started the shift at 6:30 A.M. and stated she received report (for Resident #91) and was told the resident had a change in condition which was respiratory in nature and that the on call had been notified and the CNP was going to see the resident in the morning. RN #108 stated her shift started 6:30 A.M., report took 30 minutes and that she had not yet seen Resident #91. Interview on [DATE] at 4:04 P.M. with Resident #91's wife revealed that no one called her regarding her husband, claiming to live about three minutes from the facility and would have been right over to sit with him. Resident #91'2 wife stated when she left the previous afternoon, they knew to call me for everything. The wife reported she was disappointed that the facility never called her. Resident #91's wife stated she would not have sent her husband to the hospital but would have been with him as they had been married for 69 years. Interview on [DATE] at 2:25 P.M. with Director of Nursing (DON) revealed if a resident was having a change in condition, the nurse should notify the family immediately. The DON revealed a change of respirations would be considered a significant change, especially if the provider on call had to be called.Review of the facility policy titled, Change in a Resident's condition or status revealed our facility promptly notifies the resident, his or her attending physician and the resident's representative of changes in the resident's medical/mental condition and or status.This deficiency represents non-compliance investigated under Complaint Number 2972189.

Based on observation, medical record review, resident interview, staff interview, and policy review, the facility failed to ensure a safe, clean, comfortable, homelike environment. This affected three (#18, #44, and #47) of five residents reviewed for a safe, clean, comfortable, homelike environment. The facility census was 73.Findings include: 1. Review of Resident #18's medical record revealed an admission date of 10/21/24. Diagnoses included epilepsy, unspecified lack of coordination, dysphagia, gastrointestinal hemorrhage, vitamin D deficiency, anemia, hyperlipidemia, and hypertension. Review of Resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 12. Furthermore, Resident #18 required the use of a non-invasive mechanical ventilator. Review of Resident #18's care plan dated 06/23/26 revealed Resident #18 had an altered respiratory status and utilized a non-invasive ventilator with interventions that included to observe for signs and symptoms of respiratory distress and report to the physician as needed and to provide (Continuous Positive Airway Pressure) CPAP with titrated pressure at 11 centimeters of water pressure (cmH2O) at night. Observation and concurrent interview of Resident #18's room with Resident #18's family member on 07/20/26 at 10:42 A.M. revealed Resident #18's CPAP mask was tangled in the bed and with the bed controls and was laying on the floor. Observation of the inside of the CPAP mask revealed the mask had a build up inside of the mask and the mask appeared to be soiled. Resident #18's family member stated this bothered her as her CPAP mask should not be on the floor and the inside of the mask should be cleaned. Further observation of Resident #18's room revealed there to be multiple areas of missing paint, multiple areas of the walls being indented/holes, and the baseboards of Resident #18's room were dirty. Interview on 07/20/26 at 11:19 A.M. with Certified Nurse Aide (CNA) #115 verified Resident #18's CPAP mask was laying on the floor, and the inside of the CPAP mask was dirty. CNA #115 verified the missing paint in multiple areas of the room, the indents/holes in the walls and wood around Resident #18's room and verified the hole in the wall next to Resident #18's bathroom. 2. Review of Resident #44's medical record revealed an admission date of 12/23/25. Diagnoses included multiple sclerosis, age related osteoporosis, major depressive disorder, hypertension, and atrophy of the thyroid. Review of Resident #44's quarterly MDS assessment dated [DATE] revealed Resident #44 had intact cognition with a BIMS score of 15. Review of Resident #44's care plan dated 07/21/26 revealed Resident #44 had impaired psychiatric/mood status related to depression with interventions that included to provide a calm, safe environment when Resident #44 is emotional or frustrated and allow time to voice feelings and to offer choices whenever possible in order to promote a feeling of self-worth and control over the environment. Observation and concurrent interview with Resident #44 on 07/20/26 at 11:40 A.M. revealed a black/brown substance to be on Resident #44's ceiling. Furthermore, Resident #44's windows did not properly fit, and Resident #44 had shoved paper into the window to attempt to block the draft/wetness from outside coming in. Resident #44 stated the draft from outside was cold. Furthermore, Resident #44 stated she was deathly afraid of spiders and if she did not stuff the paper in her windows, she feared spiders would crawl in through her window. Interview on 07/21/26 at 11:19 A.M. with the Director of Maintenance (DOM) #112 verified the facility had a ceiling leak and that may be what was causing the black/brown substance to Resident #44's ceiling. Furthermore, DOM #112 verified the window did not properly fit and had areas that were open to the outside allowing dampness and a draft into Resident #44's room. 3. Record review for Resident #47 revealed an admission date of 06/28/24. Diagnoses included chronic obstructive pulmonary disease (COPD), type two diabetes mellitus and Parkinson's disease. Review of the quarterly MDS dated [DATE] revealed Resident #47 was cognitively intact, had no behavioral symptoms, used a wheelchair for mobility, required set up or clean up assist with lower body dressing and chair/bed to chair transfers. Observation on 07/20/2026 at 9:57 A.M. revealed Resident #47 was lying in bed. Resident #47's motorized scooter located near the end of the bed had a thick film of dust and grime covering the front and back of the scooter, on all sides top to bottom. Resident #47 revealed there use to be an aid who washed all the chairs but now she was too busy and stated, I wish someone could help clean it, it is really bad. Observation and interview on 07/21/2026 at 4:45 P.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #104 verified Resident #47's motorized scooter had a large buildup of dust and grime covering the scooter. Resident #47 confirmed he never refused his scooter to be cleaned and revealed he wanted it done. Record review on 07/23/2026 at 10:38 A.M. with LPN UM #104 of the wheelchair cleaning schedule revealed Resident #47's motorized scooter was to be cleaned every Wednesday. LPN UM #104 revealed the nursing assistants were to clean the chairs every night per the schedule on night shift and revealed after she checked each wheelchair, she found 50% of the resident's wheelchairs were dirty and not cleaned per the schedule. Review of the undated facility policy titled, Personal Wheelchair Cleaning, revealed Resident owned wheelchairs must be kept clean and sanitary to reduce the risk of infection. Facilities should clean and disinfect wheelchairs on a routine schedule, when visibly soiled, after contact with blood and body fluids and as needed. CMS requires nursing homes to maintain infection control practices and a sanitary environment. Review of the facility policy titled Safe and Homelike Environment with a revised date of 04/20/26 revealed housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment. This deficiency represents non-compliance investigated under Complaint Number 2986521.

Based on observation, medical record review, resident interview, staff interview, and review of the facility policy the facility failed to assure pain medications were reordered timely and available for administration when requested. This affected one (#38) resident of three resident reviewed for pain. The facility census was 73. Findings include:Record review for Resident #38 revealed an admission date of 04/24/26. Diagnoses included low back pain, spondylosis without myelopathy or radiculopathy lumbar region, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was cognitively intact. Resident #38 received scheduled and as needed pain medications for almost constant pain. Review of the care plan dated 05/09/26 revealed Resident #38 was at risk for alteration in comfort related to pain. Interventions included to administer pain medication as ordered. Review of the physician orders revealed an order for hydrocodone acetaminophen oral tablet 5-325 milligram (mg) give one tablet by mouth every eight hours as needed (PRN) for pain dated 05/21/26. Review of the Medication Administration Record (MAR) revealed Resident #38 received her last dose of hydrocodone acetaminophen oral tablet 5-325 mg on 07/19/26 at 6:33 P.M. which was documented as effective for the pain.Observation on 07/20/2026 at 10:02 A.M. revealed Resident #38 was resting in bed. Resident #38 was holding her right shoulder with her left hand and revealed she ran out of pain medication the previous evening. Resident #38 had tears in her eyes, revealed the pain was in her right shoulder and rated the pain a 10 on a scale of one to 10. During the interview, Registered Nurse (RN) #230 entered the room and revealed Resident #38 had an order for her pain medication (hydrocodone acetaminophen oral tablet 5-325 mg) to be administered every eight hours as needed. RN #230 revealed the hydrocodone acetaminophen oral tablet 5-325 was not available when Resident #38 asked for it and revealed she asked for it earlier this A.M. but he was unsure how long ago. RN #230 revealed the previous nurse who worked forgot to reorder the medication, RN #230 had a call to the pharmacy and was waiting for their approval to pull the medication from the starter box.Interview on 07/21/2026 at12:03 P.M. with the Director of Nursing (DON) revealed requested pain medications should be administered within five to 10 minutes of the resident requesting the medication and confirmed that residents have ran out of pain medication in the past due to the nurses on the floor not reordering the as needed pain medication from pharmacy. Interview on 07/22/2026 at 2:58 P.M. revealed she waited about one hour to one and a half hours to receive her pain medication on 07/20/26 due to the medication not being available. Interview on 07/27/26 at 9:05 A.M. with Registered Nurse (RN) #149 revealed medication should be ordered five days prior to the last dose. RN #149 states that there is a visual reminder to reorder medications when the area behind the blister pack is navy blue, not white. Review of the facility policy titled, Administering Medication revised April 2019 revealed medications are administered in a safe and timely manner, and as prescribed.This deficiency represents non-compliance investigated under Complaint Number 3072589.

Based on observations, medical record review, resident interview, staff interviews, and policy review, the facility failed to develop and implement a comprehensive, effective, and individualized nutritional program to ensure nutritional recommendations were addressed timely, nutritional interventions were implemented as recommended, and/or to recognize and address severe resident weight loss. Actual Harm occurred when Resident #122, who was admitted with an unplanned significant weight loss and tested positive for COVID -19 two days after admission, experienced a severe weight loss of 17.6% pounds, within 21 days of admission. Upon admission on 04/03/24, Resident #122 weighed 75 pounds and on 04/25/24 Resident #122 weighed 61.8 pounds. The nutritional recommendations for Resident #122 that were made on 04/09/24 were not implemented and Resident #122 did not receive the recommended supplements of a frozen nutritional treat twice a day. This affected one (#122) of two residents reviewed for nutrition. The facility census was 70. Findings include: Review of Resident #122's medical record revealed an admitted [DATE] with medical diagnoses including stroke, protein calorie malnutrition, anemia, and chronic obstructive pulmonary disease (COPD). Review of the admission nursing assessment dated [DATE], revealed Resident #122 was admitted from the hospital with significant weight loss that was unplanned. Review of Resident #122's written plan of care for nutrition dated 04/04/24 revealed provide nutritional supplements as ordered by the physician. Review of Resident #122's admission weight dated 04/04/24 revealed Resident #122's weight was 75.0 pounds. Review of the dietitian admission evaluation note completed on 04/09/24 revealed Resident #122 was admitted from another nursing home facility following a hospitalization . Resident #122 tested positive for COVID-19 on 04/05/24. The assessment revealed Resident #122 was able to feed herself on a regular diet. The notes revealed Resident #122's body mass index (BMI), a measurement of body fat based on height and weight, was 15.6 indicating the resident was underweight (healthy range is 18.5 to 24.9). The dietitian recommended a frozen nutritional treat two times a day to encourage protein and calorie intake and promote healing and gradual weight gain. Review of Resident #122's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #122 had cognition impairment with a Brief Interview for Mental Status (BIMS) score of 12. Resident #122's height was four feet eight inches and the weight listed was 75 pounds. Additionally, the assessment revealed Resident #122 had a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) to her coccyx. Review of the Nutrition Care Area Assessment (CAA) dated 04/10/24 revealed the resident had a low BMI and there was a need for a plan of care for nutrition. Review of Resident #122's weight dated 04/11/24 revealed Resident #122's weight was 62.8 pounds. This was a 12.2-pound weight loss since admission which indicated a 16.3 percent severe weight loss. Review of the dietitian's note dated 04/16/24 revealed Resident #122's weight was 62.8 pounds on 04/11/24 and this was a significant weight decrease. The dietitian's note stated to 'continue' frozen nutritional treat two times a day to encourage intake and promote healing. The dietitian's note did not address the nutritional interventions were not implemented as recommended on 04/09/24 and there were no new nutrition interventions recommended. Review of Resident #122's weight dated 04/18/24 revealed Resident #122's weight was 64.2 pounds. Review of Resident #122's medication administration records, treatment administration records, and physician orders for April 2024, revealed no evidence of frozen nutritional treat started until 04/23/24. Review of the physician's orders dated 04/23/24 revealed an order to provide frozen nutritional treat, two times a day. Interview on 04/23/24 at 10:23 A.M. with Registered Dietitian (RD) #137 revealed she was not able to enter physician's orders into the resident's medical record. RD #137 has to give her nutrition recommendations to the nursing staff to enter into the resident's medical record. RD #137 confirmed on 04/09/24, when she made the recommendation for the frozen nutritional treat to be started twice a day to the nursing staff, the orders were not entered. RD #137 confirmed there was no evidence Resident #122 was receiving the recommended nutritional supplement until 04/23/24, when the physician order was placed into the computer. RD #137 confirmed the dietitian's progress notes dated 04/16/24 did not address Resident #122's severe weight loss from 04/04/24 through 04/11/24 at 62.8 pounds or any new interventions at that time. RD #137 confirmed she did not check to ensure her recommendations from 04/09/24 were actually entered and implemented for Resident #122. Review of a physician order dated 04/23/24 (following the interview with RD #137) revealed an order for additional nutritional interventions of Boost Breeze (a high calorie nutritional supplement drink) and weekly weights on Thursdays. Interview and observation on 04/23/24 at 12:46 P.M. revealed Resident #122 did have the frozen nutritional supplement offered. Resident #122 stated she could not remember if she had ever gotten a frozen nutritional treat before. Observation on 04/25/24 at 8:07 A.M. revealed Resident #122's weight was obtained by State tested Nursing Aide (STNA) #106. Resident #122 weighed 61.8 pounds. This was a 2.2-pound weight loss (3.7%) in one week, and a 13.2-pound weight loss in 21 days, indicating a 17.6 percent severe weight loss since admission to the facility. Review of the policy titled, Weight Assessment and Interventions, dated 2001, revealed the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss/gain, as appropriate, in light of the resident's right to refuse food/fluid, the resident's right to consume food/fluid of choice, and the resident's express wishes in Advanced Directive, if any. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss/gain = (usual weight - actual weight) / (usual weight) x 100]: a. 1 month - 5% weight loss/gain. b. 3 months - 7.5% weight loss/gain. c. 6 months - 10% weight loss/gain. The Dietitian or his/her designee should discuss undesired weight gain with the resident, resident's legal representative and/or resident's responsible party. Interventions for undesirable weight loss/gain may be based on any of the following (not all inclusive): a. Resident choice and preferences; b. Nutrition and hydration needs of the resident; c. Functional factors that may impact meal consumption; d. Environmental factors that may affect appetite or desire to participate in meals; e. Chewing and swallowing abnormalities and the need for diet modifications; f. Medications that may interfere with appetite, chewing, swallowing or digestion; g. The use of supplementation as recommended by dietician and/or physician; h. The use of feeding tubes; i. End of life decisions and advance directives.

Based on review of the medical record, observation, resident interview, staff interview, and policy review, the facility failed to ensure resident rooms were timely cleaned and maintained in good repair. This affected four (#11, #53, #38, #21) of six residents reviewed for environment. The facility census was 70. Findings include: 1. Review of the medical record revealed Resident #11 had an admitted [DATE]. Diagnoses included type two diabetes mellitus and hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Observation on 04/22/24 at 7:47 A.M., in Resident #11's room revealed the cord on the call light cord had a frayed area exposing the inner wire. Further observation revealed the resident's window shade was broken and there were several stained areas on the tile floor. Interview on 04/22/24 at 2:54 P.M., State tested Nursing Assistant (STNA) #142 verified the stains on Resident #11's floor and the frayed call light cord. STNA #142 revealed she would notify maintenance. Observation on 04/23/24 at 3:25 P.M., revealed the resident's floor was stained and the window shade was broken. Interview on 04/23/24 at 3:25 P.M., with the Laundry and Housekeeping Supervisor (LHS) #127 verified the broken shade and the stains on the resident's floor. LHS #127 revealed the tile floor needed stripped in the resident's room. 2. Review of the medical record for Resident #53 revealed an admitted [DATE]. Diagnoses included type two diabetes mellitus, and hemiplegia and hemiparesis following cerebral infarction. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Observation on 04/22/24 at 9:39 A.M., revealed a dried spilled area on the floor next to the bed. Further observation revealed the resident's window shade was broken. Interview on 04/22/24 at 9:39 A.M., with Resident #53 revealed it bothered her the staff had not cleaned up the milk she had spilled on the floor two days ago and her broken window shade. Resident #53 revealed she had reported the spilled milk to a nursing assistant. Observation on 04/23/24 at 3:17 P.M., revealed the dried spilled area on floor next to the resident's bed was now covered with two wash cloths and the window shade was still broken. Interview on 04/23/24 at 3:17 P.M., with LHS #127 verified the dried spill on the floor and the resident's broken window shade. LHS #127 revealed floors in resident rooms should be cleaned daily. 3. Review of the medical record for Resident #38 revealed an admitted [DATE]. Diagnoses included osteoarthritis and essential tremor. Review of the quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition. Observation on 04/23/24 at 11:34 A.M., Resident #38 and Resident #38's family member revealed the resident's window shade had been broken since the resident admitted to the facility. Interview on 04/23/24 at 3:21 P.M., LHS #127 verified the broken window shade in Resident #38's room. 4. Review of the medical record revealed Resident #21 had an admitted [DATE]. Diagnoses included epilepsy, glaucoma, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Observation on 04/23/24 at 3:21 P.M., revealed the window shade in Resident #21's room was broken. Interview on 04/23/24 at 3:21 P.M., with LHS #127 verified the broken window shade in Resident #21's room. Interview on 04/23/24 at 4:21 P.M., with Resident #21 revealed her window shade had been broken a long time and she told maintenance about it but in never got fixed. Review of the undated policy titled, Cleaning and Disinfecting Residents Room, revealed housekeeping surfaces (floors and tabletops) would be cleaned on a regular basis, when spills occur, and when these surfaces were visibly soiled. Review of the policy titled, Maintenance Service, dated December 2009, revealed functions of maintenance personnel included maintaining the building in good repair and free from hazards and providing routinely scheduled maintenance service to all areas.

Based on observation, staff and resident interview, record review, and policy review, the facility failed to ensure residents receiving supplemental oxygen had complete physician's orders for oxygen administration. This affected three (#45, #62, and #224) of three residents reviewed for respiratory care. The facility identified 13 residents who required the use of supplemental oxygen. The facility census was 70. Findings include: 1. Review of the medical record for Resident #45 revealed an admitted [DATE]. The resident was hospitalized from 04/11/24 to 04/19/24, for a spontaneous pneumothorax (collapsed lung). Medical diagnoses included malignant neoplasm of the lung and/or bronchus, chronic obstructive pulmonary disease (COPD), malnutrition, and weakness. Review of Resident #45's care plan, dated 02/27/24, revealed the resident to have impaired respiratory status related to COPD and cancer of the bronchus or lung. The interventions for the respiratory focus did not include an intervention of supplemental oxygen administration. Review of Resident #45's interdisciplinary progress notes revealed a note dated 04/19/24 at 12:00 P.M., indicating the resident had readmitted from a local hospital. The note indicated the resident was receiving supplemental oxygen. Review of Resident #45's physician's orders revealed no order for supplemental oxygen in the resident's record. Observation on 04/22/24 at 10:03 A.M., revealed Resident #45 lying in bed. The resident had a nasal cannula in place connected to an oxygen concentrator delivering supplemental oxygen at a rate of 3 liters per minute (lpm). There was an additional oxygen concentrator at the foot of the resident's bed, and a portable oxygen tank in a mobile stand in the resident's room. An interview with Resident #4, at the time of the observation, revealed the resident had a diagnosis of lung cancer, a recent hospitalization for a collapsed lung, and stated she had worn the oxygen since before she had gone to the hospital. Interview on 04/23/24 at 2:37 P.M., with Minimum Data Set (MDS) Nurse #162 verified Resident #45 had been using supplemental oxygen since her change in condition which led to her hospitalization . She verified Resident #45 did not have an order for supplemental oxygen until 04/22/24, when she placed the order into the electronic health record. MDS Nurse #162 identified the nurse who completed the readmission must have overlooked that the resident required supplemental oxygen upon the resident's return to the facility. Review of Resident #45's physician's orders revealed a new order dated 04/22/24 at 5:43 P.M., for continuous oxygen at 3 liters per nasal cannula every shift related to COPD. 2. Review of the medical record for Resident #62 revealed an re-admitted [DATE]. Medical diagnoses included COPD, emphysema, malignant neoplasm of the left lung or bronchus, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. Review of Resident #62's care plan, dated as initiated 07/06/23 and revised on 07/10/23, revealed the resident has an impaired respiratory status related COPD, emphysema, history of smoking, respiratory failure and shortness of breath. Care plan approaches include to administer oxygen as ordered by the physician. Review of Resident #62's physician's orders revealed an order dated 07/19/23 which stated liters received 2 L(liters) via nasal cannula. The order did not specify if the liters received were referring to oxygen, and there was no mention of whether the resident was supposed to receive continuous or intermittent oxygen administration. Observation on 04/22/24 at 1:26 P.M., revealed an oxygen concentrator in Resident #62's room, in the on position and set to 2 lpm, connected to nasal cannula tubing which was observed draped across Resident #62's bed. Resident #62 was seated in her recliner in her room. Observation on 04/23/24 at 9:10 A.M., revealed Resident #62 in her room, with her oxygen tubing draped over the left armrest of her recliner. Resident #62 states she is sometimes short of breath but wasn't sure if she was supposed to wear the oxygen all the time or not. Interview on 04/23/24 at 2:37 P.M., with MDS Nurse #162 verified Resident #62's order for oxygen did not specify oxygen or whether it should be administered continuously or on an intermittent basis. MDS Nurse #162 verified the order should specify whether supplemental oxygen should be administered on a continuous or an intermittent basis so it is clear to staff. 3. Review of the medical record for Resident #224 revealed an admitted [DATE]. Medical diagnoses included COPD, diabetes mellitus, and orthopedic aftercare. Resident #224 was discharged to home on 04/24/24. Review of Resident #224's care plan, dated 04/12/24, revealed the resident had impaired respiratory status related to COPD with an intervention which included to provide oxygen as needed for difficulty breathing. Review of Resident #224's interdisciplinary progress notes revealed orders dated 04/13/24 at 10:13 A.M., 04/14/24 at 2:28 P.M. and 04/19/24 at 9:47 A.M., referencing Resident #224 requiring the use of supplemental oxygen. Review of Resident #224's physician's orders revealed an order dated 04/22/24 at 6:14 P.M., for continuous supplemental oxygen per nasal cannula at 2 lpm. Observation on 04/22/24 at 12:50 P.M., of Resident #224 revealed the resident in bed, with supplemental oxygen in place per nasal cannula. An interview with Resident #224, at the time of observation, revealed she had worn oxygen since her admission to the facility. Interview on 04/23/24 at 2:37 P.M., with MDS Nurse #162 verified Resident #224 had received supplemental oxygen since admission, but did not have a physician's order until the evening of 04/22/24. MDS Nurse #162 stated she did not believe the resident wore oxygen at home but had worn it off and on since admission to the facility. Review of the undated policy titled, Oxygen Administration revealed the purpose is to provide guidelines for safe oxygen administration. The first step listed in the policy was to verify that there is a physician's order for this procedure. The policy additionally states to review the physician's orders pr the facility's protocol for oxygen administration.

Based on observation, record review, resident interview, staff interview, and policy review, the facility failed to ensure call lights were in reach of residents. This affected two (#51 and #122) of 19 residents reviewed for call lights. The facility census was 70. Findings include: 1. Review of the medical record for Resident #51 revealed an admitted [DATE]. Medical diagnoses included end stage renal disease (ESRD), cerebral infarction (stroke), anxiety and depression. Review of Resident #51's Minimum Data Set (MDS) quarterly assessment, dated 03/28/24, revealed the resident had a cognitive impairment but was noted as able to understand others and make herself understood. Review of Resident #51's care plan, dated 03/17/22, revealed the resident to have an assisted daily living (ADL) self-care performance deficit related to chronic kidney disease, cognitive impairment, and depression. The care plan included interventions which included placing the call light within reach. Observation and interview on 04/23/24 at 9:04 A.M., revealed Resident #51 seated in her manual wheelchair with an overbed table containing a partially eaten breakfast tray. Resident #51 stated she was freezing cold, was finished with her breakfast, and wanted to lie down. Resident #51 stated she had no way of calling for staff assistance as her call light was out of reach. She gestured to the bed where the call light was observed wrapped around the mobility bar on the side of the bed against the wall. Interview on 04/23/24 at 9:06 A.M., with the Administrator verified Resident #51's call light was not in reach. She returned the call light to Resident #51 and went to summon additional assistance from direct care staff. Observation and interview on 04/23/24 at 12:57 P.M., revealed Resident #51 seated in her wheelchair eating lunch. She was facing the television in her room with her bed behind her. Resident #51 stated she was done eating and wanted to lie down but again did not have her call light. The call light was observed underneath blankets on the bed behind the resident. Observation and interview on 04/23/24 at 1:00 P.M., with State tested Nurse Aide (STNA) #101 verified Resident #51's call light was not in reach. STNA #101 provided Resident #51 with her call light and verified she was able to use it to make her needs known. 16453 2. Review of Resident #122's medical record revealed an admitted [DATE], with medical diagnoses including stroke, protein calorie malnutrition, anemia chronic obstructive pulmonary disease (COPD). Review of Resident #122's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #122 is cognitively impaired with a BIMS (Brief interview for mental status) score of 12. Observation and interview on 04/23/24 at 2:50 P.M., revealed Resident #122 was in bed laying on her left side facing the window. Resident #122 stated the call light is on the floor and I have to crap. Further observation revealed the call light was located on the floor on the right side of the bed. Observation and interview on 04/23/24 at 3:00 P.M., with State tested Nursing Assistant (STNA) #101 confirmed the call light was on the floor, on the right side of the bed. STNA #101 stated he would assist Resident #122 to go to the bathroom as needed. Review of the policy titled, Answering Call Light, dated September 2022, indicated the section under general guidelines identified ensure the call light is accessible to the resident.

Based on review of the medical record, resident interview, staff interview, and policy review, the facility failed to ensure a resident's preference for showers was honored. This affected one (#4) of one resident reviewed for choices. The facility census was 70. Findings include: Review of the medical record for Resident #4 revealed an admitted [DATE]. Diagnoses included chronic kidney disease, hypertension, and systolic heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for bathing/showers. Review of the task documentation for scheduled bathing revealed the resident had received bed baths on 03/27/24 and 04/10/24. The resident received showers on 03/30/24, 04/03/24, 04/06/24, 04/13/24, 04/17/24, and 04/20/24. Review of the nurses notes dated 03/27/24 through 04/11/24 revealed no documentation the resident had refused her shower or wanted a bed bath instead of a shower on 03/27/24 and 04/10/24. Interview on 04/22/24 at 8:21 A.M., with Resident #4 revealed she preferred showers in the mornings on Wednesdays and Saturdays. Resident #4 revealed she was not given the choice of a shower twice in the last month because the staff were too busy. Interview on 04/23/24 at 4:09 P.M., with the Director of Nursing (DON) verified the resident was documented as having bed baths on 03/27/24 and 04/10/24. The DON was unaware why the staff gave the resident a bed bath instead of a shower. Review of the undated policy titled, Resident Rights, revealed all residents would be treated with kindness, respect, and dignity and the residents had a right to self-determination.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure a resident's code status was consistent throughout the medical record. This affected one (#53) of one resident reviewed for advanced directives. The facility census was 70. Findings include: Review of the medical record revealed Resident #53 had an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, hypertension, type two diabetes mellitus, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the plan of care initiated [DATE] revealed the resident's code status was Do Not Resuscitate Comfort Care-Arrest (DNRCC-A) meaning providers would treat patient as any other without a DNR order until the point of cardiac or respiratory arrest at which point all interventions would cease and the DNR Comfort Care protocol would be implemented. Review of the undated electronic medical record face sheet revealed the resident was listed with a full code status (cardiopulmonary resuscitation (CPR) measures). Review of the physician's orders dated [DATE] in the electronic medical record revealed the resident was listed with a full code status. Review of the paper chart revealed in the advance directives tab the resident had a signed Do Not Resuscitate (DNR) order for DNRCC-Arrest (DNRCC-A) dated [DATE]. Review of a Care Plan Meeting Attendance and Notes document dated [DATE] revealed the resident's code status was reviewed and the resident had chosen a DNRCC-A code status. Interview on [DATE] at 2:43 P.M., with Licensed Practical Nurse (LPN) #152 verified the resident's code status did not match in the electronic medical record and the paper medical record. Review of the undated policy titled, Advance Directives, revealed physician's orders would be consistent and updated with the resident's treatment preferences and/or advance directive. Code status would be determined based on physician's orders.

Based on observations, medical record review, staff interview, and policy review, the facility failed to ensure a resident with a pressure ulcer was provided pressure ulcer prevention interventions. This affected one (#122) of two resident identified by the facility with pressure ulcers. The facility census was 70. Findings include: Review of Resident #122's medical record revealed an admitted [DATE], with medical diagnoses including stroke, protein calorie malnutrition, anemia, and chronic obstructive pulmonary disease (COPD). Review of Resident #122's admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #122 had cognition impairment with a Brief interview for Mental Status (BIMS) score of 12. Resident #122's height was four feet eight inches and the weight listed was 75 pounds. The assessment additionally revealed Resident #122 had a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed, granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss) to her coccyx. Review of Resident #122 wound evaluation notes dated 04/03/24 confirmed she was admitted with a stage III pressure ulcer located on the coccyx. The records identified a treatment was ordered. Review of Resident #122's admission physician orders dated 04/03/24 identified no pressure ulcer interventions, except for a wound treatment. Review of a 04/22/24 (first day of survey) physician order revealed an order for an alternating air mattress for wounds, check function every shift. The physician order did not list the settings the air mattress should be set on (ie; alternating/static; and weight settings) or in accordance with manufacture's instructions. Observation on 04/22/24 at 12:51 P.M., of Resident #122 in a wheelchair in the main dinning room. Resident #122 was observed sitting directly on the wheelchair seat with no cushion and or pressure relief devices. Resident #122 was observed to be placed into a soft recliner chair on 04/22/24 at 1:11 P.M. Resident #122 was again observed with no pressure relief cushions to the recliner chair in her room. Resident #122 was observed to have an alternating air mattress located on the bed. Interview on 04/24/24 at 10:17 A.M., with Resident #122 confirmed she mostly sleeps in her recliner. Observation and interview on 04/22/24 at 1:16 P.M., with Registered Nurse (RN) #162 confirmed there was no pressure relief devices located in Resident #122's wheelchair and or recliner and she had been up in both. The interview confirmed the physician order dated 04/22/24 does not have the settings the air mattress should be on or in accordance with the manufacture's instructions. Review of a wound evaluation completed by the facility Certified Wound Nurse #200 dated 04/15/24, revealed the wound evaluation identified recommendations to include Pressure reduction mattress per facility protocol, off load heels per facility protocol, wheelchair pressure reduction cushion per facility protocol, reposition per facility protocol, and nutritional consult per facility protocol. Requests were made from 04/23/24 through 04/25/24 during the annual survey for the facility written pressure reduction mattress, offloading heel, wheelchair cushion and nutritional consults protocols. The facility was never able to provide these protocols. Review of the policy titled Prevention of Pressure Injuries dated April 2020, identified the purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. The Support Surfaces and Pressure Redistribution section identified; 1. Select appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice.

Based on staff interview, record review, and policy review, the facility failed to comply with the requirements for binding arbitration agreements of allowing up to 30 days to rescind the agreement and allow for a neutral arbitrator according to policy This affected three (#04, #37, and #52) of three residents reviewed for binding arbitration. The facility identified ten residents who had signed the facility's binding arbitration agreement. The facility census was 70. Findings include: 1. Review of the medical record revealed Resident #04 had an original admitted [DATE] and a re-admitted [DATE]. Diagnoses included chronic kidney disease, hypertension, and systolic heart failure. Review of a form titled Arbitration Agreement, dated 04/24/20, revealed Resident #04 signed the form as agreeing to the facility's binding arbitration agreement on 04/24/20. The agreement stated any need to involve arbitration to resolve disputes would be completed by a listed arbitration firm and made no mention that the resident could select a neutral arbitrator. The form additionally listed the resident had only fourteen days to rescind the arbitration agreement once signed. 2. Review of the medical record for Resident #37 revealed an admitted [DATE]. Medical diagnoses included chronic pain, hyperlipidemia, anxiety, and depression. Review of a form titled Arbitration Agreement, dated 04/11/20, revealed Resident #37 signed the form as agreeing to the facility's binding arbitration agreement on 04/11/20. The agreement stated any need to involve arbitration to resolve disputes would be completed by a listed arbitration firm and made no mention that the resident could select a neutral arbitrator. The form additionally listed the resident had only fourteen days to rescind the arbitration agreement once signed. 3. Review of the medical record for Resident #52 revealed an admitted [DATE]. Medical diagnoses included hypertensive heart disease, heart failure, diabetes mellitus and depression. Review of a form titled Arbitration Agreement, dated 06/25/21, revealed Resident #37 signed the form as agreeing to the facility's binding arbitration agreement on 06/25/21. The agreement stated any need to involve arbitration to resolve disputes would be completed by a listed arbitration firm and made no mention that the resident could select a neutral arbitrator. The form additionally listed the resident had only fourteen days to rescind the arbitration agreement once signed. An attempted interview on 04/24/24 at 9:09 A.M., to reach the arbitration firm as listed on the facility's arbitration agreement was unsuccessful, with the website identified as not having an active server and an attempt to phone the number listed on the form revealed it led to an unrelated business. Interview on 04/24/24 at 10:24 A.M., with the Administrator verified the facility's arbitration form contained outdated contact information and provided new contact information for the listed arbitration firm. Interview on 04/24/24 at 2:38 P.M. with Receptionist #163 revealed she is responsible for completing admission paperwork upon admission. Receptionist #163 verified that residents are not required to sign the arbitration agreement as a condition of admission, and most of them don't. Receptionist #163 verified the current form the facility was using listed an arbitration firm who would be used and the form did not acknowledge or provide an option to use a neutral arbitrator. Additionally, Receptionist #163 verified the form stated the resident would have only 14 days to revoke the arbitration agreement, and was unaware the regulatory requirement specified the resident had 30 days to rescind the agreement. Interview on 04/24/24 at 3:55 P.M., with [NAME] President of Clinical Services (VPCS) #310 verified the facility had been using the wrong form for binding arbitration agreements. VPCS #310 provided a copy of the new form which indicated the arbitration process allowed for a selection of a neutral arbitrator and for residents to rescind the binding arbitration within 30 days of signing the form. Review of the policy titled Binding Arbitration Agreements, revised November 2023, revealed the residents or representatives are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether or not to enter into such agreements. Arbitration agreements provide for the selection of a neutral arbitrator who is an impartial and unbiased third-party decision maker. Upon admission, or any time during the resident's stay, the resident or representative may be presented with the opportunity to utilize a binding arbitration agreement to resolve disputes, as long as the terms and conditions of the agreement comply with federal regulations.

Based on medical record review, observation, staff interview, and review of the facility policy the facility failed to ensure resident room ceilings were maintained in good repair. This affected five residents (#25, #45, #50, #59, #72) of six residents reviewed for the physical environment. The facility census was 71. Findings include: 1. Review of the medical record for Resident #50 revealed an admitted [DATE] with diagnoses including schizophrenia and dementia. Review of the annual Minimum Data Set (MDS) assessment for Resident #50 dated 01/10/24 revealed the resident had severe cognitive impairment. Review of the medical record for Resident #25 revealed an admitted [DATE] with diagnoses including dementia and type two diabetes mellitus. Review of the annual MDS assessment for Resident #25 dated 12/19/23 revealed the resident had severe cognitive impairment. Observation on 03/01/24 at 10:37 A.M. in the shared room of Residents #25 and #50 revealed an area approximately two feet by one and half feet on the ceiling with 50 or more discolored brown circular areas. Interview on 03/01/24 at 10:40 A.M. with Dietary Manager (DM) #100 confirmed the presence of discolored areas on Resident #25 and #50's ceiling. Interview on 03/01/24 at 10:43 A.M. with Director of Maintenance (DOM) #101 confirmed the stains on Resident #25 and #50's ceiling were there from a water leak that occurred approximately a year ago. 2. Review of the medical record for Resident #72 revealed an admitted [DATE] with diagnoses including dementia and type two diabetes mellitus. Review of the quarterly MDS assessment for Resident #72 dated 01/04/24 revealed the resident had severe cognitive impairment. Observation on 03/01/24 at 10:45 A.M. revealed there was a small brown discolored area on the ceiling in Resident #72's room. Interview on 03/01/24 at 10:45 A.M., DM #100 and DOM #101 confirmed there was a brown discolored area on Resident #72's ceiling. 3. Review of the medical record for Resident #45 revealed an admitted [DATE] with diagnoses including paraplegia, type two diabetes mellitus, and congestive heart failure. Review of the quarterly MDS for Resident #45 dated 02/08/24 revealed the resident had intact cognition. Observation on 03/01/24 at 10:56 A.M. revealed there was a brown discolored area on Resident #45's ceiling which was approximately six feet in length by two inches in width. Interview on 03/01/24 at 10:57 A.M. with DOM #101 confirmed there was a brown discolored area on Resident #45's ceiling. 4. Review of the medical record for Resident #59 revealed an admitted [DATE] with diagnoses including dementia, depression, and anxiety disorder. Review of the annual MDS assessment for Resident #59 dated 12/07/23 revealed the resident had severe cognitive impairment. Observation on 03/01/24 at 10:58 A.M. revealed there was approximately four feet by two-inch-long brown discolored area on Resident #59's ceiling. Interview on 03/01/24 at 10:59 A.M. with DOM #101 confirmed there was large brown discolored area on Resident #59's ceiling. Interview on 03/01/24 at 11:05 A.M. with DOM #101confirmed the housekeepers should be educated to notify maintenance when room repairs were needed. Review of the policy titled Maintenance Service dated December 2009 revealed maintenance service would be provided to all areas of the building, grounds, and equipment. Maintenance personnel would maintain the building in compliance with current federal, state, and local laws, regulations, and guidelines. The building would be maintained in good repair and free from hazards.

Based on medical record review, staff interview, and review of facility job description, the facility failed to ensure Medication Technicians did not provide clinical assessment of resident needs. This affected one (#1) of three residents reviewed for clinical assessments. The facility census was 67. Findings include: Review of the Resident #1's medical record revealed an admitted [DATE]. Diagnoses included schizoaffective disorder, dementia, osteoarthritis, atherosclerotic heart disease, and congestive heart failure (CHF). Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/26/23, revealed Resident #1 was severely cognitively impaired and received as needed pain medication. Review of the plan of care initiated 01/12/23 revealed Resident #1 was at risk for pain related to gastroesophageal reflux (GERD). Interventions included to administer medications as ordered, monitor for changes in behavior and mood that may indicate pain, and monitor for verbal and non-verbal signs and symptoms of pain. Additional review of a plan of care focus area initiated 02/09/23 revealed Resident #1 was at risk for abnormal bleeding or hemorrhage related to aspirin therapy. Interventions included to administer medications as ordered and monitor/document/report to the physician signs and symptoms of abnormal bleeding. Review of the physician orders revealed to monitor Resident #1 for signs and symptoms of bleeding every shift and monitor pain and document every shift. Review of the Treatment Administration Record (TAR) from 04/01/23 through 05/31/23 revealed Medication Technician (MT) #183 documented assessment of Resident #1's pain and signs and symptoms of bleeding on 04/22/23, 05/06/23, and 05/13/23. Interview on 06/12/23 at 2:02 P.M. with the Director of Nursing (DON) revealed a MT was like a nurse aide with a specialty to pass oral medications. The DON explained MTs passed oral medications and, in between, provided resident care. The DON stated if the MT believed there was a resident concern, such as pain, they were to get the nurse to complete a resident assessment. The DON stated any nursing activity outside of administering scheduled oral medication was outside the scope of practice for a MT. The DON verified on 04/22/23, 05/05/23, and 05/13/23, MT #183 documented pain levels and monitoring of signs and symptoms of bleeding for Resident #1. The DON confirmed there was no documentation indicating a licensed nurse had completed these assessments and verified the MT should not have documented the assessments were completed. Review of the Certified Medication Aide job description, dated 08/01/16, revealed the position was responsible for set up and administering medications under the supervision and direction of a Charge Nurse. This deficiency demonstrates non-compliance investigated under Complaint Number OH00143296.

Based on medical record review, staff interview, review of facility policy, and review of the Ohio Certification and Licensure website, the facility failed to ensure a potential narcotic misappropriation was reported to the State Survey Agency. This affected one (#70) of one resident reviewed for misappropriation. The facility census was 67. Findings include: Review of Resident #70's medical record revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included necrotizing fasciitis, systemic inflammatory response syndrome, acute kidney failure, and anxiety disorder. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was cognitively intact and received hospice care. Review of a plan of care focus area initiated 03/31/23 revealed Resident #70 had the potential for pain related to peripheral vascular disease, immobility, pressure ulcers, and osteoarthritis. Interventions included to administer medications per physician orders. Additional review of a plan of care focus area initiated 05/01/23 revealed Resident #70 had a terminal prognosis with hospice related to necrotizing fasciitis. Interventions included to administer medications per physician order and notify hospice if pain medication was ineffective. Review of the physician order dated 05/24/23, revealed Resident #70 was ordered fentanyl transdermal patch 75 micrograms/hour (mcg/hr) apply one patch transdermally every 72 hours. Review of the Controlled Substance Log revealed on 05/25/23 at 2:30 A.M., a 75 mcg/hr fentanyl patch was applied to Resident #70's left shoulder. Review of a nursing progress note dated 05/26/23 at 1:27 P.M. revealed a fentanyl patch was not present on Resident #70. The nurse was waiting on a return call from hospice to see about a new order. Review of the Ohio Certification and Licensure website from 05/25/23 to 06/11/23 revealed the facility did not report the potential misappropriation of Resident #70's fentanyl patch. Interview on 06/12/23 at 4:50 P.M. with the Director of Nursing (DON) revealed Resident #70 was on hospice services and was ordered a fentanyl patch for pain management. In the early morning hours of 05/25/23, a 75 mcg/hr patch was applied to the resident's left shoulder. The patch remained in place during the day on 05/25/23. The night shift nurse did not check for placement until the morning of 05/26/23. It was at that time the patch was noted to be missing from Resident #70's left shoulder. The DON stated the resident's skin was seeping and he had poor skin integrity due to necrotizing fasciitis and they believed the patch just fell off of the resident. The DON stated Resident #70's sheets were changed frequently due to his skin seeping and it was unknown how many linen changes the resident had after the patch was applied. The DON stated staff looked for the patch in the garbage and on sheets but they were never able to locate the missing fentanyl patch. The DON confirmed hospice was contacted and the fentanyl patch was discontinued and new orders were received to increase other pain medications. While the DON stated she completed an investigation and provided staff education on controlled substances, she did not consider the missing fentanyl patch could be a misappropriation and verified it was not reported to the State Survey Agency. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, revealed if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source was suspected, the suspicion must be reported immediately to the Administrator and other officials according to state law. In addition, the administrator or individual making the allegation reports to the state licensing/certification agency responsible for surveying/licensing the facility within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours for allegations that do not include abuse or serious bodily injury. This was an incidental finding discovered during the complaint investigation.

Based on medical record review, review of the facility's investigation, staff interview, and review of the facility policy, the facility failed to complete a thorough investigation into a potential misappropriation of a resident's narcotics. This affected one (#70) of one resident reviewed for misappropriation. The facility census was 67. Findings include: Review of Resident #70's medical record revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included necrotizing fasciitis, systemic inflammatory response syndrome, acute kidney failure, and anxiety disorder. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was cognitively intact and received hospice care. Review of a plan of care focus area initiated 03/31/23 revealed Resident #70 had the potential for pain related to peripheral vascular disease, immobility, pressure ulcers, and osteoarthritis. Interventions included to administer medications per physician orders. Additional review of a plan of care focus area initiated 05/01/23 revealed Resident #70 had a terminal prognosis with hospice related to necrotizing fasciitis. Interventions included to administer medications per physician order and notify hospice if pain medication was ineffective. Review of the physician order dated 05/24/23, revealed Resident #70 was ordered fentanyl transdermal patch 75 micrograms/hour (mcg/hr) apply one patch transdermally every 72 hours. Review of the Controlled Substance Log revealed on 05/25/23 at 2:30 A.M., a 75 mcg/hr fentanyl patch was applied to Resident #70's left shoulder. Review of a nursing progress note dated 05/26/23 at 1:27 P.M. revealed a fentanyl patch was not present on Resident #70. The nurse was waiting on a return call from hospice to see about a new order. Review of the facility's investigation, completed 05/26/23, revealed staff interviews were conducted related to the missing fentanyl patch and staff education was conducted on the disposal of pain medication patches and controlled substances. The investigation did not include evidence of any additional investigation, including contacting the police, conducting staff toxicology screens, or resident interviews. Interview on 06/12/23 at 4:50 P.M. with the Director of Nursing (DON) revealed Resident #70 was on hospice services and was ordered a fentanyl patch for pain management. In the early morning hours of 05/25/23, a 75 mcg/hr patch was applied to the resident's left shoulder. The patch remained in place during the day on 05/25/23. The night shift nurse did not check for placement until the morning of 05/26/23. It was at that time the patch was noted to be missing from Resident #70's left shoulder. The DON stated the resident's skin was seeping and he had poor skin integrity due to necrotizing fasciitis and they believed the patch just fell off of the resident. The DON stated Resident #70's sheets were changed frequently due to his skin seeping and it was unknown how many linen changes the resident had after the patch was applied. The DON stated staff looked for the patch in the garbage and on sheets but they were never able to locate the missing fentanyl patch. The DON confirmed staff interviews were conducted and staff education was provided on controlled substances and the disposal of pain patches, but the police were not contacted regarding a potential controlled drug diversion, no staff were tested for controlled substances, and no residents were interviewed. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, revealed if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source was suspected, the suspicion must be reported immediately to the administrator and other officials according to state law, including, but not limited to, local law enforcement. In addition, the investigation must include, at a minimum, interviews of the person reporting the incident, interview of the resident or resident's representative, and interviews of other residents who may have been impacted. This was an incidental finding discovered during the complaint investigation.

Based on record review, interview and policy review, the facility failed ensure pain medication was available for administration. This affected one (Resident #01) of three residents reviewed for pain medications. The facility census was 63. Findings include: Review of the medical record for Resident #01 revealed an admitted [DATE] and a discharge date [DATE]. Diagnoses included pain, [CONDITION(S)] with lower urinary tract symptoms, stable burst fracture of lumbar vertebra initial encounter for closed fracture, malignant neoplasm of upper respiratory tract, and generalized anxiety disorder. Review of the discharge Minimum Data Set (MDS) assessment, dated 02/07/22, revealed Resident #01 had intact cognition. Review of the plan of care dated 02/02/22 revealed the Resident #01 potential for pain due to back fracture of lumbar vertebra and terminal condition. Interventions included administer medications as physician orders and monitor for side effects and effectiveness. Notify the physician if current pain medications are ineffective or if the resident is experiencing side effects. Review of physician orders dated 02/04/22 revealed Resident #01 was ordered [MEDICATION(S)] patch 72 Hour 50 micrograms per hour (mcg/hr), apply one patch transdermal one time a day every three days for pain. Review of medication administration record (MAR) dated 02/06/22 for Resident #01 the [MEDICATION(S)] patch was not applied on 02/06/22 as ordered. Review of the progress note dated 02/06/22 at 5:31 P.M. revealed the old [MEDICATION(S)] patch was not removed and the medication was on order from the pharmacy. During interview on 02/23/22 at 8:51 A.M., the Director of Nursing (DON) verified the [MEDICATION(S)] patch was not removed on 02/06/22. There was no [MEDICATION(S)] available to administer as it was on order with the pharmacy. Review of the written statement from Licensed Practical Nurse (LPN) #334 revealed on 02/06/22 Resident #01 was scheduled to have his [MEDICATION(S)] patch changed. There was no new [MEDICATION(S)] patch to replace the old patch. LPN #334 contact Resident #01's physician, who ordered the to keep the old patch on and a new prescription would be telephoned to the pharmacy. Review of the facility policy titled Administering Medications, dated April 2019, revealed medications are administered in a safe and timely manner, and as prescribed. This deficiency substantiates Complaint Number OH 250.

Based on observations, record review, and staff interview, the facility failed to implement fall interventions for two (#67 and #38) of three sampled residents reviewed for falls. This resulted in actual harm for Resident #67 who fell from her bed when it was left in the high position, landing on her back and sustaining a left hip fracture. This also affected Resident #38 who did not have functioning alarms or floor mats in place. The facility census was 99. Findings include: 1. Review of the medical record for Resident #67 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the nurses notes dated 05/24/14 at 10:35 A.M., revealed the resident was found on the floor and reported, "I think I broke by hip." Review of the incident reported dated 05/24/14, revealed Resident #67 was found on the mat in her room lying on her back moaning and complaining of hip pain. Bilateral floor mats were in place on both sides of the bed. The bed was about two feet up from the floor, not in the lowest position. The resident remained on the floor until Emergency Medical Service (EMS) personnel arrived for transport to the hospital. The resident was diagnosed with [REDACTED]. The resident returned to the facility on [DATE], with 11 staples from the surgical incision to the right hip, a Stage II right heel pressure ulcer and a Stage II coccyx pressure ulcer. Review of the fall risk assessment dated [DATE], assessed Resident #67 to be at high risk for falls. Review of the fall risk care plan related to impaired sensory function and cognitive deficits was initiated on 10/21/13. On 09/20/13, the care plan was revised for the high/low bed to be in the lowest position when Resident #67 was in bed and to have floor mats to the sides of the bed. On 07/24/14 at 9:40 A.M., the treatment to the right heel was observed with Licensed Practical Nurse (LPN) #202. At the start of the treatment, LPN #202 raised the bed for ease in conducting the right heel treatment. At 10:00 A.M., LPN #202 reported she was finished with the treatment and was about to exit the room without returning the bed to the lowest position. Surveyor questioned regarding the position of the bed and LPN #202 responded "oh yes, I did raise the bed to do the treatment. I forgot to lower it back down". She proceeded to lower the bed to the lowest position. Interview with Director of Nursing (DON) on 07/24/14 at 1:20 P.M., verified a registered nurse had provided care to Resident #67 on 05/24/14 and failed to put the bed in the lowest position. She further stated Resident #67 was assessed at high risk for falls and was to have a high/low bed in the lowest position when the resident was in bed and mats to the floor on each side of the bed. The DON also indicated the facility did not have a falls policy or specific protocol for staff to follow when residents fall. She stated residents were assessed for fall risk upon admission and interventions implemented as needed. The DON also stated the facility did not have any evidence of staff re-training or in-service education following the fall with fracture for Resident #67. 2. Resident #38 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The incident log identified Resident #38 to have a fall a fall on 07/05/14 with minor injury. Review of the nurses notes dated 07/05/14 at 6:50 P.M., revealed Resident #38 was found on the floor lying on her right side. The note indicated the nursing assistant reported the resident was showing facial grimacing when touching the right elbow. The incident report dated 07/05/14, revealed the resident was found on the floor lying on her right side. There was no information in the notes or the incident report to indicate if floor mats were in place. The report indicated a tab alarm was in place, properly applied, but did not alarm. The immediate nursing intervention was identified as shortening the string on the tab alarm to allow the alarm to separate upon movement and alert staff the resident was in need of assistance. The resident was assessed at the hospital and did not have a sprain or fracture. Review of fall assessments dated 03/10/14 and 05/14/14, assessed Resident #38 to be at high risk for falls. Review of the fall care plan initiated on 11/08/13 and current through 09/01/14, revealed the resident was to be in a high/low bed with the bed in the lowest position, a pressure pad alarm on at all times and mats to the floor when the resident was in bed. Interview with the DON on 07/24/14 at 1:20 P.M., revealed she did not have any additional information to provide regarding the above fall. She stated Resident #38 was listed on the incident log as a fall with minor injury. The DON explained the minor injury was the pain and discomfort from falling on her arm but that X-rays were negative for any fractures or sprains. This deficiency substantiates Complaint Number OH 452.