Every finding on record at Carecore at Lima

Based on record review, staff interviews, review of Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to implement their water testing per the facility's Legionella plan and policy. The had the potential to affect all 83 resident in the facility. Findings include:Review of the Water Consultant #500's report dated 11/18/24 revealed the facility tested seventeen water sources in the facility for Legionella. The facility could not provide any further water source testing was completed since 11/18/24.Interview on 06/04/26 at 2:11 P.M. with Maintenance Director #225 confirmed the facility was to send out water samples annually to be tested for Legionella disease via Water Consultant #500.Interview on 06/04/26 at 2:19 P.M. with [NAME] President of Operations (VOP) #280 and Maintenance Director #225 stated the facility was waiting delivery of the water testing kits to test for Legionella.Interview on 06/04/26 at 2:32 P.M. with VOP #280 confirmed the facility has not tested the facility water for Legionella since 11/18/24. Review of the Risk Management Plan for Legionella Control in the operation and maintenance of the facility, dated 10/27/24 revealed the control procedures for pipework will flush low use water areas regular (weekly), and the control procedures for outlets will collect warm water samples for Legionella testing and have Water Consultant #500 to sample the water for Validation annually.Review of the Legionella Surveillance and Detection policy, dated 09/2022 revealed the facility is committed to the prevention , detection, and control of water-borne contaminants, including Legionella.Review of the Legionella Water Management program policy dated 09/2022 revealed the facility is committed to the prevention , detection, and control of water-borne contaminants, including Legionella. The water management program is used to identify areas in the water system where Legionella can grown and spread, and reduce the risk of Legionella disease.Review of the CDC guidance titled Water Management Program Validation dated 03/15/24 revealed under Sampling Frequency & Routine Testing, inpatient healthcare facilities and other high-risk settings are encouraged to conduct routine environmental sampling to confirm that their water management program is effective.

Based on medical record review and staff and family representative interviews, the facility failed to notify the resident's representative of residents' refusals to be seen by the dentist. This affected one (#9) of 21 residents reviewed for notification of change. reviewed for dental services. The facility census was 83.Findings include:Review of the medical record for Resident #9 revealed an admission date of 08/19/22. Diagnoses included nontraumatic hemorrhage in brain stem, left hemiplegia, diabetes mellitus, Alzheimer's disease, primary optic atrophy, bilateral, and congestive heart failure.Review of Resident #9's dental care plan revealed the resident had oral/dental health problems related to dental caries. Interventions included to coordinate arrangements for dental care and transportation as needed/ordered.Review of Resident #9's dental treatment notes dated 12/01/25 and 02/23/26 revealed Resident #9 refused to have teeth cleaned. The medical record did not have any documentation to support Resident #9's representative was notified of refusals to be seen by the dentist. Review of the Minimum Data Set (MDS) assessment, dated 05/27/26, revealed Resident #9 had moderate cognitive impairment and had obviously or likely cavities or broken natural teeth.Interview on 06/01/26 at 3:04 P.M. with Resident #9's representative stated Resident #9 complained of tooth pain a lot during visits and not sure when was last seen by the dentist or refusal to be seen by the dentist.Interview on 06/03/26 at 10:24 A.M. with Social Service Director (SSD) #278 stated in 2024, Resident #9's representative stated she did not want to be updated with Resident #9's medications and did not wish to be contacted regarding Resident #9. SSD #278 confirmed she had not been employed by the facility for eight months after 2024 and recently returned to the facility as Social Service Director. SSD #278 stated since her return she had not addressed with Resident #9's representative if she wanted to be updated on changes with Resident #09. SSD #278 confirmed Resident #9's representative had been involved in care conferences in March 2026 and had visited Resident #9 at times.

Based on medical record review, observation, staff and resident interviews, and policy review, the facility failed to ensure surgical wound care was done as ordered. This affected one (#3) of four residents reviewed for wound care. The facility census was 83.Findings include:Review of the medical record for Resident #3 revealed an admission date of 10/01/25. Diagnoses included aftercare following surgical care, nontraumatic compartment syndrome of left lower extremity, and disorder of circulatory system. The quarterly Minimum Data Set (MDS) assessment, dated 04/22/26 revealed Resident #3 was cognitively intact and was admitted with a surgical wound and treatment was in place.Review of the wound evaluation dated 10/01/25 revealed Resident #3 was admitted with a surgical site to left medial lower leg which measured 40 centimeters (cm) in length by 12 cm in width with a scab with 26 sutures. Review of Resident #3's physician orders revealed an order dated 05/27/26 to cleanse wound with wound cleanser, allow to dry, apply skin prep to peri wound, place blue foam to wound bed and cover with large, bordered gauze every Monday, Wednesday, and Friday and as needed.Review of Resident #3's May 2025 Treatment Administration Record (TAR) revealed staff documented treatment was completed on 05/29/26 (Friday).Observation with interview on 06/01/26 (Monday) at 9:51 A.M. revealed Resident #3's dressing to left lower leg was dated 05/27/26 (Wednesday) and appeared to be soiled with brown substance on the outside of the dressing. Resident #3 stated staff were supposed to change the dressing every other day and confirmed the dressing to his surgical site to left lower leg had not been changed since 05/27/26.Interview on 06/01/26 at 10:00 A.M. with Registered Nurse (RN) #271 confirmed Resident #3's dressing to left lower leg was dated 05/27/26 and had a brown substance on the outside of the dressing. RN #271 confirmed Resident #3's dressing to surgical site had not been changed as ordered.Interview on 06/03/26 at 2:39 P.M. with Director of Nursing (DON) confirmed Resident #3's May TAR had documentation that the dressing to Resident #3's dressing to left lower leg surgical site was changed on 05/29/26 but confirmed that was an error in documentation.The wound evaluation dated 06/03/26 revealed Resident #3 continued with surgical site to left medial lower leg which measured 6.2 cm in width by 2.4 cm in length by 0.3 cm in depth with 20 percent (%) slough. The wound evaluation stated the surgical site had improved with delayed wound closure.Review of the facility policy titled Wound Management issued 03/24/26 revealed established standardized processes for the prevention, identification, assessment, treatment, and monitoring of wounds. The facility would maintain every resident's skin integrity through comprehensive assessment, timely interventions, and ongoing evaluation.

Based on medical record review and staff interview, the facility failed to timely schedule an appointment with an eye specialist as physician ordered. This affected one (#9) of one resident reviewed for vision. The facility census was 83.Findings include:Review of the medical record for Resident 9 re#vealed an admission date of 08/19/22. Diagnoses included left hemiplegia, diabetes mellitus, Alzheimer's disease, and primary optic atrophy, bilateral.Review of the physician orders dated 03/25/26 revealed an order for referral to ophthalmologist for cataracts.Review of the Minimum Data Set (MDS) assessment, dated 05/27/26, revealed Resident #9 had moderate cognitive impairment and had impaired vision and did not have glasses.Review of Resident #9's vision care plan revealed a potential for impaired visual function related to cataracts and diabetic proliferative retinopathy. Interventions included arranging consultation with eye care practitioners as required. There was no evidence Resident #9 was seen by an ophthalmologist or an appointment was scheduled to be seen by one.Interview on 06/03/26 at 11:44 A.M. with Director of Nursing (DON) confirmed the facility had not made a referral for Resident #9 to see ophthalmologist for cataracts as ordered on 03/25/26. The DON stated Resident #9 had an appointment in 2025 to see an ophthalmologist but Resident #9 refused to go to the appointment. The DON stated an appointment was made on 06/03/26 for Resident #9 to see ophthalmologist on 08/17/26.

Based on medical record review, staff interview, and policy review, the facility failed to ensure ongoing communication with a dialysis facility regarding dialysis care and services. This affected one (#9) of one resident reviewed for dialysis. The facility identified two residents who received dialysis. The facility census was 83.Findings include:Review of the medical record for Resident #9 revealed an admission date of 08/19/22. Diagnoses of diabetes mellitus, Alzheimer's disease, and congestive heart failure.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had moderate cognitive impairment and received dialysis.Review of Resident #9's physician orders dated 09/18/25 revealed an order for dialysis at the dialysis center on Tuesday, Thursday, and Friday.Review of Resident #9's pre and post dialysis communication forms revealed forms dated 03/21/26 and 05/21/26. There was no documentation to support pre and post dialysis communication forms were completed after 03/21/26 until 05/21/26.Interview on 06/03/26 at 9:30 A.M. with Licensed Practical Nurse (LPN) #256 confirmed Resident #9's medical record did not have documentation to support pre and post dialysis communication forms were after 03/21/26 until 05/21/26. LPN #256 confirmed Resident #9 went to dialysis three times per week, and staff were expected to complete pre and post dialysis communication forms with each dialysis treatment.Review of the facility policy titled Hemodialysis dated August 2025 revealed the purpose was to ensure safe, effective, and compliant dialysis of care for residents in collaboration with certified end-stage renal disease (ESRD) providers. The facility was to ensure coordination between long term care and dialysis teams.

Based on observations and staff interview, the facility failed to post the nurse staffing information for residents, staff, and visitors to view. This had the potential to affect all 83 residents residing in the facility. Findings include: Observations on 06/01/26 at 9:00 A.M., 06/02/26 at 10:00 A.M., and 06/03/26 at 10:00 A.M. of the main lobby and common areas revealed the daily nurse staffing was not posted. Interview on 06/03/26 at 10:14 A.M. with Medical Record Staff #204 stated she reviewed the daily nurse staffing total numbers and hours worked with management team in daily morning meeting but stated she did not post the information for residents or family to review. Medical Record Staff #204 confirmed the facility had not posted the nurse staffing information.

Based on medical record review, facility investigative document review, staff interview, and facility policy review, the facility failed to complete a thorough investigation for an allegation of misappropriation. This affected one (Resident #73) of three resident misappropriation allegations reviewed. The census was 71.Findings Include:Resident #73 was admitted to the facility on [DATE]. His diagnoses were muscle wasting and atrophy, chronic obstructive pulmonary disease, hypotension, hypo-osmolality and hyponatremia, severe sepsis, atherosclerotic heart disease,. hypothyroidism, hyperlipidemia, congestive heart failure, anxiety disorder, atrial fibrillation, obstructive and reflux uropathy, and major depressive disorder. Review of his Minimum Data Set (MDS) assessment, dated 02/20/26, revealed he was cognitively intact.Review of the Self-Reported Incident (SRI) dated 02/27/26, revealed Resident #73 reported on 02/26/26 at 4:45 P.M. that his medications were being taken. Resident #73 was being transported to the hospital at the time he made the allegation. The facility indicated they completed a thorough investigation and found the allegation to be unsubstantiated.Review of facility investigation packet for the SRI revealed they had no staff interview statements for this incident. Also, there was no interview statement completed with Resident #73 to determine what medications were taken, when they were taken, or any other information to gather specifics about the allegation he made.Interview with Director of Nursing (DON) on 03/20/26 at 1:30 P.M. and 2:20 P.M. and Unit Manager (UM) #112 on 03/20/26 at 2:20 P.M. confirmed they did not document any staff interview statements. UM #112 reported that she asked Resident #73 what medications he was talking about, and he mentioned his pain medications. She confirmed no one took a statement from him prior to leaving for the hospital, and no one contacted him or went to the hospital to gather a statement to specify information needed to do a thorough investigation. Review of the facility's Reporting and Investigating Abuse, Neglect, Exploitation, or Misappropriation policy, dated September 2022, revealed all reports of abuse, neglect, exploitation, or theft/misappropriation of resident property are thoroughly investigated by facility management. Findings of all investigations are documented and reported. The individual conducting the investigation as a minimum: reviews the documentation and evidence, reviews the resident's medical record to determine the resident's physical and cognitive status at the time of he incident and since the incident, observes the alleged victim, including his or her interactions with staff and other residents, interviews the person reporting the incident, interviews any witnesses tot he incident, interviews the resident or representative, interviews the resident attending physician as needed, interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, interviews the resident's roommate, family members, and visitors, interviews other residents to whom the accused employee provides care and services, reviews all events leading up to the alleged incident, and document in investigation completely and thoroughly. This deficiency represents non-compliance investigated under Complaint Number 2688587.

Based on medical record review, family interview, staff interview, and facility policy review, the facility failed to include the resident's family/Power of Attorney (POA) in the discharge planning process. This affected one (Resident #72) of three resident discharges reviewed. The census was 71.Findings Include:Resident #72 was admitted to the facility on [DATE]. Her diagnoses were encephalopathy, peripheral vascular disease, unspecified protein calorie malnutrition, acute and chronic respiratory failure, emphysema, respiratory disorder, anxiety disorder, congestive heart failure, hypertensive heart and chronic kidney disease, atherosclerotic heart disease, major depressive disorder, hypertension, muscle weakness, osteoporosis, patient's non-compliance with other medical treatment, urge incontinence, overactive bladder, nicotine dependence, osteoarthritis, adjustment disorder, dependence on supplemental oxygen, nicotine dependence, and insomnia. Review of her Minimum Data Set (MDS) assessment, dated 10/16/25, revealed a Brief Interview of Mental Status Score (BIMS) of 10, indicating she had moderate cognitive impairment. Review of Resident #72 Care Conference document, dated 07/09/25, revealed the current discharge plan was for her to remain in the facility for long term placement. Resident #72 was in attendance; Resident #72's family was not in attendance.Review of Resident #72 care plan, dated 10/07/24, revealed regarding her discharge planning that she wishes the return to the community. But, on 10/07/24, the care plan reflected she was possible long term placement per power of attorney (POA). One of the interventions listed was that social services will meet with resident and family on admission to determine discharge plan.Review of Resident #72's progress note, dated 10/22/25, revealed the facility had Resident #72 meet with the physician assistant to discuss an upcoming discharge back home (it doesn't identify where home is located). The note stated the facility had Resident #72 and physician assistant sign the discharge packet prior to her discharge, which included all of her medication orders and orders for home health services. The discharge packet that was signed prior to her discharge and had the appropriate information in the summary.Review of Resident #72's progress notes, dated 10/17/25 to 10/25/25, revealed no evidence to support the facility consulted with Resident #72's family prior to being discharged on 10/25/25 when they picked her up.Interview with Resident #72's family member on 03/20/26 at 11:15 A.M. revealed she was not consulted for Resident #72's discharge, until the day Resident #72 was to be discharged ; she got a call from Resident #72 stating she needed to be picked up to go home. Resident #72's family member confirmed she is Resident #72's POA and she wanted to be up to date on all of her care and changes in care. She confirmed she had been notified of changes prior to this discharge, but it was very inconsistent. Interview with the Director of Nursing (DON) on 03/20/26 at 1:30 P.M. and 2:20 P.M. confirmed they did not discuss the discharge process with Resident #72's family prior to it occurring. The DON confirmed Resident #72's care plan reflected the POA had given (and the facility accepted) feedback on Resident #72 staying in the facility for long term placement, and that social services will meet with resident and family on admission to determine the discharge plan.Review of the facility's Discharge Planning Policy and Procedure, dated 07/28/25, revealed the facility is committed to ensuring that all resident discharges are conducted in a safe, person-centered, and compliant manner in accordance with CMS regulations. Discharges will be planned collaboratively with the resident, their representative, and the interdisciplinary team, with a focus on continuity of care, resident rights, and regulatory compliance. All discharges must be documented in the medical record, including resident and representative notification. This deficiency represents non-compliance investigated under Complaint Number 2688587.

Based on medical record review, review of hospital records, observations, staff interviews, interview with Wound Physician #500, and review of facility policy, the facility failed to timely assess, monitor, and implement treatments for Resident #43, who was admitted to the facility with a pressure ulcer on the coccyx. This resulted in Actual Harm when Resident #43 was assessed upon admission on 02/18/25 with a pressure ulcer to the coccyx but the staff failed to accurately assess the wound to include measurements/description and the staff failed to notify the physician to obtain/implement treatment orders. Subsequently, Resident #43's coccyx pressure ulcer was assessed by the wound physician on 03/04/25 to be unstageable with necrosis and the coccyx pressure ulcer required excisional debridement (surgery) on 03/04/25 and again on 03/06/25. This affected one (#43) of three residents reviewed for pressure ulcers. The facility census was 76. Findings include: Review of medical record for Resident #43 revealed an admitted [DATE]. The resident was admitted with diagnoses including spinal stenosis, cord compression, malignant neoplasm of bone and protein-calorie malnutrition. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The assessment indicated the resident was dependent on two-assist for activities of daily living care. Resident #43 had one pressure ulcer which was unstageable. Review of the risk assessment dated [DATE] revealed the resident was at risk for skin breakdown. Review of the hospital discharge record on 02/18/25 revealed the resident had a non-blanchable purple wound on the coccyx found in the hospital on 02/15/25. Review of the care plan dated 02/18/25 revealed Resident #43 had impaired skin integrity related to recent surgical procedure, pressure area to coccyx on admission, and immobility. Individualized interventions included consult nurse practitioners for evaluation and treatment as indicated, and turn and reposition per protocol with measurable goals. Review of the medical record revealed a skin observation tool assessment was completed for the dates of 02/18/25 and 02/25/25, which indicated a surgical wound and pressure wound to the coccyx; however, there was no further assessment of Resident #43's wounds including no wound measurements, and no wound stage. Further review of the medical record revealed the physician was not notified and no treatment orders were initiated for the coccyx pressure ulcer. Review of Resident #43's weekly physician notes from the dates of 02/18/25 to 03/03/25 revealed wound assessments were completed for a post-surgical wound of the back. However, there was no documented assessment of the pressure area on Resident #43's coccyx. Review of the Treatment Administration Record (TAR) from 02/18/25 through 03/03/25 revealed there was no treatment for the coccyx wound. Review of a nurse's note dated 02/28/25 at 4:03 A.M. revealed Resident #43 had an unstageable pressure ulcer to the sacrum measuring 6.2 centimeters (cm) by 6.9 cm by 0.3 cm. The wound bed had 50 percent (%) slough and 50% eschar. The wound bed was macerated with the peri-wound being red. The wound was noted to be close to the rectum. The manager was updated. The note lacked notification to the physician and or any treatments being implemented. Review of the shower sheets for Resident #43 revealed on 02/28/25 a bed bath was given and the resident was noted to have an unstageable pressure area to the coccyx. Review of the wound monitoring sheets dated 03/04/25 noted as the first evaluation revealed Resident #43 had a wound which was an unstageable pressure ulcer to the coccyx with necrosis. The wound was measured as being 7.0 cm by 7.20 cm, and a depth of 1.40 cm. The wound bed was undefined with treatments which were Alginate calcium once daily and hydrogel with silver once daily. The wound monitoring sheets were reviewed from January 2025 to 03/06/25 and lacked documentation of Resident #43 being assessed or documented for any type of wound. Review of the VOHRA Initial Wound Evaluation and Management Summary, dated 03/04/25 revealed Resident #43 had a wound on the coccyx. The wound examination of the coccyx revealed the wound was unstageable due to necrosis. The duration was greater than 14 days (it was noted to be present upon admission). The wound measured at 7.0 cm by 7.2 cm by 1.4 cm. The wound had exudate moderate serous with thick adherent devitalized necrotic tissue of 100 percent (%). This wound had undergone a surgical excisional debridement procedure. The wound was surgically excised of devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 1.5 cm. The non-viable tissue in the wound bed decreased from 100% to 95%. Further review, revealed on 03/06/25, the coccyx wound measured 7 cm by 7.2 cm by 1.4 cm with undermining at 3o'clock measuring 3 cm. The wound had moderate serous exudate with thick adherent devitalized necrotic tissue being 100% of the wound. Another surgical excisional debridement procedure to remove necrotic tissue and establish the margins of viable tissue. The surgical procedure excised the devitalized tissue and necrotic muscle level tissue was removed to a depth of 3.3 cm. The non-viable tissue in the wound bed decreased from 100% to 75%. Observation on 03/11/25 at 6:00 A.M. with Wound Nurse #207 of the treatment to Resident #43's pressure ulcer revealed the wound to the coccyx had a foul odor with dark necrotic tissue. The coccyx wound measured 6.5 cm by 5.4 cm by 3 cm. The wound nurse verified the wound was an unstageable pressure ulcer and was unable to confirm the full depth of the wound due to necrotic tissue present. Interview on 03/11/25 at 12:10 P.M. with the Administrator and Regional Nurse #400 verified lack of documentation in the medical record from 02/28/25 to 03/04/25 of orders for treatments to the coccyx, which was noted upon admission, and notification to the physician. Interview with Wound Physician #500 on 03/11/25 at 2:15 P.M. verified the coccyx wound for Resident #43 was not observed until 03/04/25. There was a consultation on 02/25/25 but the physician did not see the resident due to resident being seen by general surgery. The wound physician was not aware of the status of the coccyx wound until 03/04/25. The wound physician performed a debridement but was unable to remove all the necrotic tissue due to the procedure causing the resident pain. The nurse practitioner had to return two days later and perform another surgical procedure to remove more of the necrotic tissue. Review of the facility's policy, Documentation of Wound Treatments dated 10/10, revealed the facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Wound assessments are documented upon admission, weekly, and as needed if resident or wound condition deteriorates. The following elements are documented as part of a complete wound assessment; type of wound, and anatomical location, stage of the wound, measurements (height, width, depth, undermining or tunneling. The description of the wound should include the color of the wound, type of tissue in the wound, condition of peri-wound, presence, amount, and characteristics of wound drainage, presence or absence of odor, and presence of pain. Additional documentation shall include notification to physicians. Review of the facility's policy, Pressure Injury Risk assessment dated ,d+[DATE], revealed the purpose for this procedure is to provide guidelines for the structured assessment and identification of residents at risk for developing new pressure injuries or worsening of existing pressure injuries. The following information should be recorded in the resident's medical record: the condition of the skin (the size, location and description) if any identified areas are present. Initiation of pressure or non-pressure form related to the type of skin alteration and documentation addressing the physician notification. This deficiency represents non-compliance investigated under Complaint Number OH00163267.

Based on observations, medical record review, review of fall investigations, staff and resident interviews, review of hospital records, and review of the facility policies, the facility failed to ensure a safe environment to prevent falls, resulting in actual harm when Resident #23 tripped over the legs of an improperly stored mechanical lift resulting in a facial laceration requiring stitches and a fractured left olecranon (elbow) fracture. Further, the facility failed to ensure neurological checks were completed after falls for Resident #22, failed to ensure fall incidents were thoroughly investigated for Resident #22 and Resident #63, and failed to ensure fall preventions were in place for Resident #22. Lastly, the facility failed to ensure a safe environment to prevent falls for Resident #52. This affected four residents (#23, #22, #63, #52) of five residents reviewed for falls. The facility census was 80. Findings include: 1. Review of the medical record for Resident #23 revealed an admitted [DATE] with diagnoses of cerebral infarction, dementia, and epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23's cognition was assessed via staff, and Resident #23 had impaired cognition. Resident #23 required supervision or touching assistance for chair to bed transfers and walking. Review of the Fall Risk Evaluation dated 06/27/24 revealed Resident #23 had a score of 9.0 and was not at high risk for falls. Review of the current care plan revealed Resident #23 was at risk for falls due to decreased safety awareness, impaired balance and unpredictable seizures. Interventions in place prior to the fall on 09/05/24 included having his bed against the wall, staff to report adverse effects of medications, and therapy to screen if indicated. Review of a progress note dated 09/05/24 at 2:00 A.M. revealed Resident #23 fell in the hallway near the nurses' station. Resident #23 was walking with aides to get a soda and tripped on the legs of a parked mechanical lift and hit his head resulting in a 2-3 centimeter laceration near the corner of his left eye. The fall was witnessed by staff. The physician was notified via voicemail. Review of a progress note dated 09/05/24 at 2:30 A.M. revealed Resident #23 was sent to the Emergency Department (ED) via ambulance. Review of a progress note dated 09/05/24 at 5:48 A.M. revealed Resident #23 received stitches and a CT (computed tomography) scan was negative. Review of a progress note dated 09/05/24 at 6:44 A.M. revealed Resident #23 returned to the facility with no new orders. Review of a progress note dated 09/05/24 at 12:53 P.M. revealed Resident #23's left forearm and elbow appeared swollen and bruised and Resident #23 was guarding. An order was received for an x-ray of the left arm. Review of a progress note dated 09/05/24 revealed Resident #23 was sent to the ED for evaluation of his left arm. Review of a progress note dated 09/05/24 at 7:00 P.M. revealed Resident #23 returned to the facility via stretcher with no new orders. Review of the Interdisciplinary Team progress note dated 09/05/24 at 9:48 A.M. revealed the cause of the fall was equipment in the hallway and the intervention was to educate staff regarding appropriate storage of equipment. Review of the hospital discharge paperwork dated 09/05/24 at 4:41 A.M. revealed Resident #23 received stitches. Review of the hospital discharge paperwork dated 09/05/24 at 3:33 P.M. revealed Resident #23 presented to the ED for evaluation of a fall. Resident #23 was diagnosed via x-ray with a fractured left olecranon (elbow). Resident #23 received fentanyl (pain medication) at the ED. Resident #23's left arm was placed in a long-arm splint and sling. Review of the undated staff education titled, Proper Storage of Equipment, revealed housekeeping, State tested Nurse Aides (STNAs) and nurses were educated. Interview on 09/24/24 at 4:51 P.M. with Registered Nurse (RN) #182 revealed she worked 09/05/24 and was the nurse for Resident #23 when he returned from the hospital with stitches on 09/05/24 at approximately 6:40 A.M. RN #182 stated Resident #23 began to eat breakfast in the dining room, then had a seizure. After the seizure resolved, the staff assisted Resident #23 to his room to rest. RN #182 stated she was familiar with his seizure activity and was not concerned it was related to his head injury. Further interview revealed the staff began to change Resident #23's clothes before lunch and found his left arm swollen. RN #182 contacted the physician who ordered an x-ray, but the mobile x-ray service was unable to get a good view of Resident #23's arm, so Resident #23 was sent back to the ED. Interview on 09/25/24 at 2:39 P.M. with the Director of Nursing (DON) and concurrent review of the facility's fall investigation into Resident #23's fall on 09/05/24 revealed Resident #22 did not require assistance while walking, and was accompanied by staff while walking down the hall to get a soda. Concurrent observation occurred when the DON and surveyor entered the secured unit where the DON demonstrated the physical condition of the fall. The DON stated a mechanical lift was backed against the wall along the 600 hall across from the MDS Coordinator's office. A floor heater was also noted to be along the wall opposite the office. The DON stated the legs were sticking into the walkway. Interview on 09/26/24 at 11:37 A.M. with the DON confirmed the staff education was not dated. The DON stated she did not review a policy; she explained to staff where to store mechanical lifts, such as in the beauty shop or near the shower when the shower was not in use. The DON stated she did not have any formal audits to ensure equipment was stored properly. The DON did not provide a date the education was provided before the conclusion of the survey. Observation and interview on 09/26/24 at approximately 4:00 P.M. with Maintenance Director #104 revealed the 600 hall where the DON indicated the mechanical lift was placed was 93.5 wide. Further observation revealed the mechanical lift base, at floor level, from back wheel to front wheel was 42.5 while the part of the mechanical lift at eye level was more narrow than the legs. The usable width of the hallway floorspace was reduced to approximately 51 (four feet, 3 inches) for Resident #23 and the STNA to walk together down the hall. Review of the policy Fall Risk Assessment, dated 2001, revealed the staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. 2. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses of hemiplegia and hemiparesis, and need for assistance with personal care. Review of the comprehensive admission MDS assessment dated [DATE] revealed Resident #22 had impaired cognition, mobilized with a wheelchair, was dependent for shower/bathing, chair to bed transfers, and tub/shower transfers. Review of the Fall Risk Evaluation dated 07/16/24 revealed Resident #22 was at risk for falls. Review of the current care plan revealed Resident #22 was at risk for falls related to hemiplegia, hemiparesis and weakness. Interventions included keeping a fall mat at bedside (added 09/17/24), encouraging call light use, and keeping the bed in the lowest position. Review of a nursing progress note dated 08/18/24 at 4:25 A.M. revealed Resident #22 was found sitting on the floor in front of her bed with legs outstretched in front of her. Resident #22 was assessed and found to have no injuries. Review of the fall investigation dated 08/20/24 revealed Resident #22 was found on 08/18/24 at 4:20 A.M. sitting on the floor in front of her bed with her legs outstretched. Resident #22 was assessed and no injuries were found. Review of the Interdisciplinary Team's (IDT) review revealed no root cause related to the fall and determined the appropriate intervention was a mat to the floor at the outside of the bed and the other side of the bed placed against to the wall to ensure adequate floor space in the room for mobility equipment. Review of a nursing progress note dated 09/14/24 at 5:56 A.M. revealed Resident #22 was found on the floor. Resident #22 was assessed and found to have no injuries. Review of the fall investigation dated 09/14/24 revealed Resident #22 was found on the floor on 09/14/24 at 5:50 A.M. next to her bed. Resident #22 stated she was reaching for a television remote. A nursing assessment was completed and no injuries were identified. The IDT review revealed the root cause was Resident #22 reaching for personal items; therefore, the intervention was to keep personal items within reach. Review of a nursing progress note dated 09/17/24 at 4:25 A.M. revealed Resident #22 was observed lying on her right side on the floor beside her bed. Resident #22 was assessed and found to have no injuries. Review of the fall investigation dated 09/17/24 revealed Resident #22 was found lying on her right side on the floor next to her bed on 09/17/24 at 4:25 A.M The IDT review revealed the cause of the fall was confusion and attempting to ambulate when not capable of ambulating independently. The IDT developed an intervention of putting a fall mat next to the bed. Review of a nursing progress note dated 09/19/24 at 6:42 P.M. revealed Resident #22 was on the floor next to the dresser. Resident #22 stated she hit her head. Further review of the medical record revealed no evidence neurological checks were completed after Resident #22's unwitnessed falls on 08/18/24, 09/14/24, and 09/19/24. Interview and observation on 09/24/24 at 7:30 A.M. with STNA #162 confirmed Resident #22 was lying in bed with her knees hanging over the edge of the bed and no fall mat was in place. STNA #162 further confirmed, upon review of the electronic medical record, Resident #22's care plan indicated she should have a fall mat beside the bed while in bed. STNA #162 stated Resident #22 often tried to get out of bed. Subsequent interview with STNA #162 and LPN #174 on 09/24/24 at approximately 7:35 A.M. revealed neither staff were aware Resident #22 should have a fall mat. Interview on 09/25/24 at 2:46 P.M. with concurrent review of the facility's fall investigations for Resident #22 revealed the facility reviewed the falls for Resident #22 and determined the trend for her falling in the early morning hours was attributed to her having a urinary tract infection (UTI). However, the fall on 08/18/24 was prior to Resident #22's diagnosis with a UTI on 09/14/24. Additionally, the DON stated the IDT team decided not to implement the fall mat on 08/18/24 and instead decided to only do one intervention at a time, selecting the intervention to move the bed against the wall. The DON confirmed Resident #22 was found on the floor next to her bed after the falls on 09/14/24 and 09/17/24. Interview on 09/26/24 at 11:33 A.M. with the DON confirmed she could not provide neurological assessments for Resident #22's unwitnessed falls on 08/18/24, 09/14/24, and 09/19/24. Further interview with the DON revealed the reason Resident #22's fall mat was not in place during the observation on 09/24/24 was because housekeeping was washing it. The DON stated the fall mats get dirty and need to be washed. Review of the policy Falls and Fall Risk, Managing, dated 2001, revealed the staff will identify and implement relevant interventions to try to minimize serious consequences of falling. 3. Review of the medical record for Resident #63 revealed an admitted [DATE] with diagnoses of encephalopathy, repeated falls and unsteadiness on feet. Review of the quarterly MDS assessment dated [DATE] revealed Resident #63 had impaired cognition, mobilized with a walker, required supervision or touching assistance for chair to bed transfer, substantial/maximal assistance for tub/shower transfer, and for shower/bathing self. Further review revealed she had one fall without injury since the previous assessment. Review of the Fall Risk Evaluation dated 12/14/23 revealed a score of zero. Review of the current care plan for Resident #63 revealed she was at risk for falls related to dementia. Interventions included assisting in positioning and comfort as needed and observe daily and report any observed unsafe conditions. Review of the facility's incident report dated 03/10/24 revealed a State tested Nurse Aide (STNA) called the nurse to assist with Resident #23 off the floor in the shower. STNA stated Resident #63 slipped out of the shower chair. Review of an IDT progress note dated 03/11/24 revealed Resident #63 was in the shower and slipped out of the chair stating she had soap in her eyes. Resident #63's fall was witnessed by staff. No injuries were noted. Review of the facility's incident report dated 06/08/24 revealed the nurse was notified by the STNA that Resident #23 slipped out of the shower chair to the floor landing on her behind. Review of an IDT progress note dated 06/11/24 revealed Resident #63 was in the shower and slid off the chair onto the floor. STNA was present during the shower. Resident #63 was assessed and no injuries were noted. A floor mat was on the floor. Interview on 09/25/24 at 2:46 P.M. with the DON revealed she did not attempt to interview with STNA who was present during Resident #63's fall on 03/10/24. Further interview revealed the DON attempted to call the agency STNA who was present during the fall on 06/08/24 but did not receive a return call. The DON confirmed no intervention was implemented after Resident #63's first fall from the shower chair on 03/10/24. Additionally, the DON stated the intervention after Resident #63's second fall from the shower chair was to add a larger fall mat to the floor in the shower; however, the DON stated the larger mat did not fit. Further interview with the DON regarding a fall intervention for Resident #63 revealed staff were expected to stand closer to prevent Resident #63 from sliding from the shower chair again. Review of the policy Falls and Fall Risk, Managing, dated 2001, revealed the staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 35035 4. Record review for Resident #52 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #52 include encephalopathy, diabetes type two, malnutrition, traumatic amputation of bilateral legs below knees, heart disease, gangrene, altered mental status, and thrombosis with use of anticoagulants. Review of Resident #52's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had intact cognition and was dependent on a wheelchair for ambulation. Review of Resident #52's care plans dated 04/09/24 revealed a focus for risk of falls. Interventions include Resident #52 will receive care and interventions necessary to ensure that his safety is maintained, ensure that the seatbelt is fastened when resident is up in wheelchair, observe Resident #52 in his daily activity and report unsafe conditions for interventions to assist with maintaining his safety. Review of Resident #52's progress notes dated 08/11/24 the resident was attempting to propel himself outside and fell out of the wheelchair and rolled into a hole in the concrete. Per the note the resident suffered no injuries and did not hit his head. Review of the facility's investigation dated 08/11/24 revealed the fall was witnessed. No injuries were noted on the investigation. Resident #52 reported his pain level at a 5 out of 10, in the comments stated resident denied pain at this time. Per the immediate action taken the nurse documented the resident will be educated to ask for assistance when going outside to ensure safety due to the deterioration of the driveway. Interview on 09/23/24 at 11:46 A.M. with Resident #52 revealed the resident stated he had a fall out of his wheelchair on 08/11/24 when he was coming back into the facility by the outside door on the 200-hall. Resident #52 showed the surveyor there are several broken pieces of concrete with bars sticking out near the door and the doorway itself has a raised cracked edge. Resident #52 stated he was attempting to get his motorized wheelchair over the cracked edge when the tires got stuck and his chair fell forward causing him to fall out of the wheelchair onto the ground. Resident #62 stated staff responded quickly to him and got him back into his wheelchair. Resident #52 stated he did not report any injuries to staff at the time of the fall. Interview on 09/23/24 at 3:00 P.M. with Resident #33 revealed the resident witnessed Resident #52's fall on 08/11/24. Per Resident #33, Resident #52 was going back into the facility when his wheelchair front wheels got 'caught in the hole at the doorway'. Resident #33 stated he saw Resident #52 fall forward out of his wheelchair and onto the ground. Resident #33 stated he ran to help but staff had already started to help Resident #52. Resident #33 stated he did not see the resident hit his head and heard the resident tell staff he didn't have any injuries. Interview on 09/24/24 at 3:33 P.M. with the DON verified Resident #62 was outside coming inside when the wheels of his wheelchair was stuck in the doorway threshold and the resident fell out of the wheelchair. The DON stated Resident #52 stated he had no injuries from the fall. Observation and interview on 09/25/24 at 4:00 P.M. with Social Worker (SW) #248 observing the area outside of the doorway into the facility on the 200-hall revealed the concrete was notably raised from the sidewalk to the concrete patio slab. A raised area of about 2-3 inches leaving a space from the sidewalk to the patio was observed. Per SW #248, during the fall investigation it was reported to her the resident was attempting to propel his motorized wheelchair back into the facility when the front wheels caught up on the raised portion of the sidewalk leading to the doorway. SW #248 verified the broken pieces of concrete with what appears to be bars sticking out and stated the facility had not completed any repairs to the sidewalk or patio concrete. Review of the facility policy titled, Fall Risk Assessment', dated 03/2018 revealed staff will seek out to identify environmental risk factors that may contribute to falls. Staff will collaborate to identify and address modifiable fall risk factors and interventions to minimize the risk factor.

Based on observation, interview, and policy review, the facility failed to maintain a safe environment regarding the wheelchair ramp in the front of the building. This had the potential to affect all residents in wheelchairs who would potentially use the ramp. The facility identified 39 residents who used wheelchairs. Additionally, the facility failed to ensure the floor of the shower in the secured unit was free of broken tiles. This affected one (#63) of one reviewed for falls related to broken tiles. The facility census was 80. Findings include: 1. Observation on 09/23/24 at 8:22 A.M. revealed a gap of approximately five inches irregularly shaped exposing stone and grass growing from the gap of broken concrete at the top of the wheelchair ramp coming into the building. Wheelchair ramp is located to the right of the building off the front porch area. Several cracks and open areas in the concrete on the front porch area observed as well. Observation on 09/25/24 at 2:28 P.M. of Resident #12 being pushed in wheelchair by State tested Nursing Assistant (STNA #140) on the wheelchair ramp outside of the front entrance revealed the wheelchair went down the ramp without difficulty. When STNA #140 attempted to push Resident #12 up the ramp the wheelchair wheels stuck at the top of the ramp in the gap and the resident jerked forward in the wheelchair. STNA #140 attempted to get the resident over the gap five times before the wheelchair got over the ramp. Interview on 09/25/24 at 10:13 A.M. with Resident #61 revealed the resident stated she had trouble getting over the gap/crack in the concrete at the top of the wheelchair ramp coming into the building. Resident #61 stated she needs help to get over the crack/gap. Resident #61 stated she has no problems wheeling herself around throughout the facility. Interview on 09/25/24 at 2:30 P.M. with STNA #140 verified Resident #12's wheelchair wheels got stuck in the gap of concrete and it took five times to get the resident over the crack. Review of the policy titled, Homelike Environment, revised February 2021 revealed residents are provided with a safe, clean, comfortable environment. 44815 2. Review of the medical record for Resident #63 revealed an admitted [DATE] with diagnoses of encephalopathy, repeated falls and unsteadiness on feet. Review of the quarterly MDS assessment dated [DATE] revealed Resident #63 had impaired cognition, mobilized with a walker, required supervision or touching assistance for chair to bed transfer, substantial/maximal assistance for tub/shower transfer, and for shower/bathing self. Further review revealed she had one fall without injury since the previous assessment. Review of the current care plan for Resident #63 revealed she was at risk for falls related to dementia. Interventions included assisting in positioning and comfort as needed and observe daily and report any observed unsafe conditions. Review of the facility's incident report dated 03/10/24 revealed a State tested Nurse Aide (STNA) called the nurse to assist with Resident #23 off the floor in the shower. STNA stated Resident #63 slipped out of the shower chair. Review of an Interdisciplinary Team (IDT) progress note dated 03/11/24 revealed Resident #63 was in the shower and slipped out of the chair stating she had soap in her eyes. Resident #63's fall was witnessed by staff. No injuries were noted. Review of the facility's incident report dated 06/08/24 revealed the nurse was notified by the STNA that Resident #23 slipped out of the shower chair to the floor landing on her behind. Review of an IDT progress note dated 06/11/24 revealed Resident #63 was in the shower and slid off the chair onto the floor. STNA was present during the shower. Resident #63 was assessed and no injuries were noted. A floor mat was on the floor. Interview on 09/25/24 at 8:10 A.M. with STNA #162 revealed the tile in the shower on the secured unit was very slippery and there was broken tile and if staff used the shower chair everyone falls because the wheel on the shower chair caught in the broken tile. STNA #162 was aware of falls in the shower for Resident #63 and Resident #50. STNA #162 stated there was a third resident who fell in the shower but she could not recall who it was. Further interview with STNA #162 revealed she was with Resident #63 when Resident #63 caught her foot in a broken tile and fell before the shower began. STNA #162 stated Resident #63 was sent for x-rays but had no injuries. Concurrent observation of the shower revealed two areas of broken tiles, one jagged and affecting four tiles, and one where it appeared most of all four tiles were missing. STNA #162 stated it was the jagged broken area where Resident #63 caught her foot. STNA #162 stated she reported the broken tiles to the previous maintenance director. Observation and interview on 09/25/24 at 9:13 A.M. with Maintenance Director (MD) #104 revealed he worked at the facility for approximately two months and was not aware of any broken tiles in the shower on the secured unit. MD #104 confirmed the floor tiles were 2 inches by 2 inches and there were two areas with broken tiles. The jagged area was irregularly shaped and measured approximately 3.5 inches by 2.25 inches and affected three tiles. The second area measured 4 inches by 4 inches and affected four tiles. Interview on 09/25/24 at 2:46 P.M. with the Director of Nursing (DON) revealed she was aware of Resident #63's two falls in the shower and believed both falls were from Resident #63 slipping from the shower chair. The DON was not aware of any incident wherein Resident #63 fell in the shower due to cracked tiles. This deficiency represents non-compliance investigated under complaint OH0015799.

Based on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure comprehensive care plans were completed concerning all care areas for residents. This affected five residents (#22, #41, #57, #71, and #130) out of 25 residents reviewed for care plans. The facility census was 80. Findings include: 1. Record review for Resident #130 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #130 include polyneuropathy, gout, prostate cancer with metastasis to pelvic bone, and clostridium difficile, (c-diff). Review of Resident #130's Minimum Data Set (MDS) dated [DATE] was in progress at the time of survey. Review of Resident #130's hospital documents dated 09/12/24 revealed the resident had an indwelling catheter placed for the diagnosis of obstructive uropathy. Review of Resident #130's baseline care plan dated 09/20/24 revealed for the bladder assessment the resident was noted as having an indwelling catheter upon admission. Review of Resident #130's comprehensive care plans dated 09/20/24 revealed no focus for bladder or the indwelling catheter. Review of Resident #130's physician orders dating from 09/20/24 to 09/26/24 revealed no orders for the care or continuation of the indwelling catheter in the medical records. Review of Resident #130's Treatment Administration Records (TAR) dated 09/2024 revealed no documentation of catheter care being documented as completed. Interview on 09/23/24 at 9:10 A.M. with Resident #130 revealed the resident had the indwelling catheter inserted while he was at the hospital. Resident #130 stated he did not know what the plan was for the catheter or when the facility was going to be removing the catheter. Resident #130 stated he has asked his nurses about the catheter and they inform him, when he no longer needs the catheter it can be removed. Resident #130 stated he does receive catheter care regularly. Interview on 09/25/24 at 1:30 P.M. with State tested Nurse Aide (STNA) #156 revealed she performed catheter care for Resident #130. STNA #130 stated staff chart completion of care in the computer. STNA #156 stated she reported to the nurse she completed the catheter care and verified the aide knew the resident had an indwelling catheter due to the previous STNA's report. Interview on 09/25/24 at 1:35 P.M. with Registered Nurse (RN) #333 revealed the nurse works for the agency, not the facility. RN #333 stated she received the information in report Resident #130 had an indwelling catheter. RN #333 verified STNA #130 reported to her the catheter care was completed and there were no issues noted with the catheter. RN #333 stated she could not document the catheter care due no orders for the treatment in the records. RN #333 verified the resident had no focus in his care plans for the indwelling catheter. Interview on 09/25/24 at 1:45 P.M. with the Director of Nursing (DON) and Regional Registered Nurse (RRN) #275 verified Resident #130 had the indwelling catheter upon admission. The DON verified while the indwelling catheter was documented on the baseline care plans, there were no interventions, and the catheter was not on the comprehensive care plan. The DON verified there were no orders and no documentation in the medical records regarding the treatment for the indwelling catheter. 44815 2. Review of the medical record for Resident #22 revealed an admitted [DATE] with diagnoses of hemiplegia and hemiparesis, and need for assistance with personal care. Review of the comprehensive admission MDS assessment for Resident #22 revealed she had impaired cognition and an indwelling catheter. Review of the Admit/Readmit Review dated 07/09/24 and locked 07/17/24 revealed Resident #22 had a catheter. Review of the current comprehensive care plan revealed no bowel/bladder or catheter care area were included. Observation on 09/26/24 at approximately 10:00 A.M. revealed Resident #22 sitting in the common area with a catheter. Interview on 09/26/24 at 12:53 P.M. with MDS Coordinator #192 confirmed Resident #22 had a catheter and her care plan contained no care area for her bowel/bladder and catheter. 45751 3. Review of medical record for Resident #41 revealed an admitted [DATE] with diagnoses including but not limited to malignant neoplasm of glottis, acute respiratory failure with hypoxia, tracheostomy status, and dependence on supplemental oxygen. Review of MDS assessment dated [DATE] revealed the resident was cognitively intact. Resident #41 was on oxygen, required suctioning, and was on hospice. Resident #41 was dependent on staff for activities of daily living. Review of care plan dated 09/09/24 revealed infection control/Enhanced Barrier Precautions (EBP)/tracheostomy related to tracheostomy and oxygen dependence secondary to respiratory failure and occlusion in his throat from cancer on his vocal cords; the resident was at risk for further decline and sudden respiratory distress to failure going forward; hospice services in place. Interventions included educate resident, family, and frequent visitors on use of EBP; including how and when to use Personal Protective Equipment (PPE) provided outside the residents room, ensure proper PPE is maintained outside residents room and that the signage identifying that EBP are in use is posted on the residents door. Further review of the care plan revealed no respiratory care plan noted. Interview on 09/25/24 at approximately 1:45 P.M. with the Director of Nursing (DON) verified Resident #41 did not have a respiratory care plan. 4. Review of medical record for Resident #57 revealed an admitted [DATE] with diagnoses including but not limited to cerebral infarction, type two diabetes, congestive heart failure, difficulty walking, anxiety, and hypertension. Review of the MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #57 was dependent for bed mobility and transfers. Resident #57 was substantial/maximal assistance for activities of daily living. Review of care plan dated 07/11/24 revealed no care plan for activities of daily living (ADLs). Interview on 09/25/24 at 1:28 P.M. with the DON verified Resident #57 did not have an ADLs care plan. 5. Review of medical record for Resident #71 revealed an admitted [DATE] with diagnoses including but not limited to type two diabetes, sepsis, bipolar disorder, cutaneous abscess of the buttock, and cutaneous abscess. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. The resident required supervision/touching assistance for ADLs and bed mobility, transfers, and ambulation. Review of physician orders revealed keep area with drains on right buttock clean and cover with ABD pad daily until follow up appointment. Review of care plan dated 07/11/24 revealed a care plan for at risk for skin impairment but no care plan regarding the actual skin impairment to the resident's right buttock with interventions. Interview on 09/25/24 at 10:33 A.M. with the DON verified no care plan was initiated for the actual skin issue. DON verified the resident had the skin issue since admission. Review of the policy, Care Plan, Comprehensive Person-Centered, dated 2001, revealed the comprehensive person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, staff interview, and review of the menu spreadsheet, the facility failed to provide adequate protein portions to residents on a mechanical soft diet. This affected 14 residents (#2, #3, #4, #6, #16, #17, #28, #32, #37, #43, #53, #63, #68, and #130) identified on a mechanical soft diet. The facility census was 80. Findings include: Observations during meal service on 09/25/24 beginning at 10:46 A.M. revealed [NAME] #206 plating meals using a green handled scoop for the mechanical soft pork loin. Interview and observation on 09/25/24 at approximately 12:00 P.M. with [NAME] #206 revealed the green handled scoop had no measurements, but [NAME] #206's understanding was it was a 3-ounce scoop. Interview and observation of the green handled scoop on 09/25/24 at 12:06 P.M. with Dietary Manager (DM) #198 confirmed the scoop had no measurements on it. Further observation of another green handled scoop, taken from the drawer, revealed it measured 2 and 2/3 ounces. Continued interview and observation of a website with DM #198 revealed the green handled scoop she purchased was 3 and 1/4 ounces. Observation of the two scoops filled with water revealed the unlabeled scoop held less water than the scoop labeled 2 and 2/3 ounces. Interview and observation on 09/25/24 at 12:16 P.M. with Regional Registered Dietitian #500 confirmed the unlabeled scoop was smaller than the one measuring 2 and 2/3 ounces and could not verify what portion of pork loin was provided to residents on a mechanical soft diet. Review of the menu spreadsheet for the noon meal on 09/25/24 revealed the portion of mechanical soft pork loin should be 3 ounces.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure staff used appropriate hand hygiene while preparing meals. Additionally, the facility failed to ensure the dish machine washed dishes at the proper temperature. This had the potential to affect all residents except two (#41 and #42) who were identified as receiving no food from the kitchen. The facility census was 80. Findings include: 1. Observations during meal service on 09/24/24 beginning at approximately 5:05 P.M. revealed [NAME] #202 wearing disposable gloves while plating roast beef sandwiches and cubed potatoes for the evening meal. [NAME] #202 held tongs in her right hand to pick up roast beef and used her left hand to place the beef onto a bun. [NAME] #202 then used her right hand to place cheese and lettuce on the bun, and her right hand to place lettuce on the bun. [NAME] #202 then used her right hand to scoop potatoes onto the plate, and used both hands to close the sandwich. Continued observation revealed [NAME] #202 changing her gloves without washing her hands. [NAME] #202 opened a package of bread, put two slices in a skillet, picked up a squeeze bottle of oil and squeezed it into the pan, then opened a new package of hamburger buns, held the bag with one hand and reached in with the other and placed buns on four plates to begin making more ready-to-eat roast beef sandwiches. Interview with Dietary Manager (DM) #198 on 09/24/24 at 5:38 P.M. revealed she observed [NAME] #202 concurrently with the surveyor and confirmed [NAME] #202 was not practicing appropriate hand hygiene and DM #198 would provide education. DM #198 further confirmed touching bags of bread or rolls was considered a contaminated surface. Observation during meal service on 09/25/24 beginning at 10:46 A.M. revealed [NAME] #206 plating meals. [NAME] #206 wore disposable gloves and used separate serving utensils for pork, broccoli, mashed potatoes, gravy, mechanical soft pork and mechanical soft broccoli. Continued observation at approximately 10:50 A.M. revealed [NAME] #206 changed her gloves, opened a package of bread, removed four slices of bread, scooped mechanical soft pork loin onto the bread and used a knife to cut the two sandwiches into squares while holding the bread with her left hand. Concurrent interview at 10:52 A.M. with [NAME] #206 confirmed she used the same pair of gloves to open a bag of bread, scoop meat, and cut the sandwich for Resident #16 and confirmed she should have changed her gloves before touching ready-to-eat food. Review of the undated policy titled, Bare Hand Contact with Food and Use of Plastic Gloves, revealed gloved hands are considered a food contact surface that can become contaminated or soiled and should be changed anytime a contaminated surface is touched. 2. Observation on 09/24/24 at 4:18 P.M. of the label attached to the dishwasher revealed recommended wash temperatures of 120 degrees Fahrenheit (F) minimum and rinse temperature of 120 degrees F minimum. Concurrent observation and interview with DM #198 on 09/24/24 beginning at 4:18 P.M., after running three cycles of the dishwasher revealed a wash temperature of 91 degrees F. Continued observation at 4:29 P.M., after additional wash cycles revealed a wash temperature of 108 degrees. DM #198 confirmed the wash temperature of the washing machine did not meet the minimum wash requirements.

Based on observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure a pest free environment. This had the potential to affect 35 residents (#2, #5, #6, #7, #8, #9, #11, #13, #14, #15, #16, #20, #21, #22, #23, #29, #30, #35, #37, #43, #45, #46, #47, #48, #55, #61, #63, #64, #68, #70, #72, #74, #180, #181, and #182) on the secured unit. The facility census was 80. Findings include: Observation on 09/23/24 at 11:18 A.M. of the secured unit dining room during the noon meal revealed two moths flying around the dining room. Observation on 09/23/24 at 1:21 P.M. during an interview with Resident #37 revealed a moth flying around his room. Observation and interview on 09/23/234 at 3:27 P.M. with a resident who wished to remain anonymous revealed the amount of moths bothered them. One moth was observed in the room at the time of the interview. Interview on 09/23/24 at 3:42 P.M. with Licensed Practical Nurse (LPN #174), who routinely worked the secured unit, confirmed there were lots of moths throughout the building. LPN #174 was told the exterminators said it was because they had bird food inside the building for the outside bird feeders. LPN #174 said a lot of residents complained about the moths. Observation on 09/24/24 at approximately 7:25 A.M. in the secured unit's dining room revealed two moths flying around residents and staff. Observation on 09/25/24 at 7:31 A.M. of the secured unit's dining room revealed Resident #14 swatting away a moth. An interview with Resident #14 at the time was unsuccessful. Concurrent interview with Registered Nurse (RN) #182 confirmed moths were in the dining room and confirmed residents complained about them. Interview on 09/26/24 at 11:55 A.M. with Maintenance Director (MD) #104 revealed he worked at the facility for approximately two months and had no awareness of moths. MD #104 further stated the exterminator company visited routinely and was responsive to facility concerns. Observation on 09/26/24 at 3:30 P.M. revealed a moth flying around the nurses station on the secured unit. Concurrent interview with LPN #174 stated she had not reported the concerns regarding moths to anyone because she felt it was clearly observable to maintenance or any other staff who came onto the secured unit. Review of a receipt from the exterminator company dated 09/06/24 revealed the facility was sprayed for outside insects. Further review of the receipts revealed the exterminator company visited the facility routinely and per request. Receipts listed insects, but no receipts identified moths. Review of the policy, Homelike Environment, revised 02/2021, revealed the facility would maximize a clean, sanitary, and orderly environment.

Based on observation, interview, and policy review. the facility failed to ensure weekly skin assessments were being completed thoroughly. This affected one resident (#71) of three residents reviewed for skin issues. Additionally, the facility failed to ensure treatments were completed as ordered and an order for suture removal was completed. This affected two residents (#23 and #29) of three residents reviewed for skin. The facility census was 80. Findings include: 1. Review of medical record for Resident #71 revealed an admitted [DATE] with diagnoses including but not limited to type two diabetes, sepsis, bipolar disorder, cutaneous abscess of the buttock, and cutaneous abscess. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. The resident required supervision/touching assistance for Activities of Daily Living (ADLs) and bed mobility, transfers, and ambulation. Review of physician orders revealed keep area with drains on right buttock clean and cover with ABD pad daily until follow up appointment. Review of Skin Review Weekly dated 09/23/24 revealed the form was blank. No description, measurements, location, type of wound, and treatment that was ordered was listed on the form. Interview on 09/25/24 at 10:33 A.M. with the Director of Nursing (DON) verified the weekly skin note dated 09/23/24 did not contain the information requested such as surgical wound, location, measurements, and treatment ordered. The DON verified the skin assessments should be completed thoroughly. 2. Review of medical record for Resident #29 revealed an admitted [DATE] with diagnoses including but not limited to myoneural disorder, spondylosis, congestive heart failure, anxiety, major depressive disorder, and unspecified convulsions. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Resident #29 required supervision or touching assistance for ADLs. Review of current physician orders revealed apply compression stockings in the A.M. and remove at bedtime (tubi-grips or ace wraps), and unna boots to bilateral extremities then wrap with coban as needed. Review of the Treatment Administration Record (TAR) for September 2024 revealed the treatment for compression stockings/ace wraps was signed off as completed on 09/23/24. Observation on 09/23/24 at 2:02 P.M. revealed the residents legs were not wrapped and the lower legs appeared to have abrasions/scratches with seeping fluid. Observation on 09/24/24 at 10:31 A.M. of Resident #29's legs revealed his legs were not wrapped. Resident #29's legs were observed to be seeping fluid at this time. Interview on 09/23/24 at 2:02 P.M. with Resident #29 revealed the resident stated the nurses do not wrap his legs like they should. Resident #29 stated the nurses do not wrap his legs some days. Interview on 09/24/24 at 10:33 A.M. with Licensed Practical Nurse (LPN) #174 revealed the nurse verified she worked on 09/23/24 and stated Resident #29 refused to let her wrap his legs on 09/23/24 after several attempts. LPN #174 verified she did not place wraps on Resident #29's legs on 09/24/24. Interview on 09/24/24 at 1:55 P.M. with Resident #29 revealed the resident denied ever refusing for his legs to be wrapped. Observation at the time of the interview revealed the residents legs were wrapped. 44815 3. Review of the medical record for Resident #23 revealed an admitted [DATE] with diagnoses of cerebral infarction, dementia, and epilepsy. Review of the quarterly MDS assessment dated [DATE] revealed Resident #23's cognition was assessed via staff, and Resident #23 had impaired cognition. Resident #23 required supervision or touching assistance for chair to bed transfers and walking. Review of a progress note dated 09/05/24 at 2:00 A.M. revealed Resident #23 fell in the hallway near the nurses' station. Resident #23 was walking with aides to get a soda and tripped on the legs of a parked mechanical lift and hit his head resulting in a 2-3 centimeter laceration near the corner of his left eye. The fall was witnessed by staff. The physician was notified via voicemail. Review of a progress note dated 09/05/24 at 2:30 A.M. revealed Resident #23 was sent to the Emergency Department (ED) via ambulance. Review of a progress note dated 09/05/24 at 5:48 A.M. revealed Resident #23 received stitches and a CT (computed tomography) scan was negative. Review of a progress note dated 09/05/24 at 6:44 A.M. revealed Resident #23 returned to the facility with no new orders. Review of the hospital discharge paperwork dated 09/05/24 revealed Resident #23's stitches should be removed in five to six days either by the facility physician or at the hospital. Review of a current physician order dated 09/07/24 revealed Resident #23's left outer eye sutures should be cleaned with soap and water every day, and left open to air; apply dressing as needed for drainage. Observation and interview on 09/26/24 at 1:35 P.M. with Registered Nurse (RN) #182 confirmed Resident #23's stitches were still in place. RN #182 stated she just cleaned them today. Further observation revealed the stitches and surrounding tissue showed no signs or symptoms of infection. Further interview with RN #182 revealed she was the nurse on duty when Resident #23 returned from the hospital with stitches on 09/05/24 and no accompanying paperwork or orders were received from the hospital. RN #182 was unaware Resident #23's stitches should have been removed.

Based on observation, review of the facility policy, record review, resident interview, and staff interview, the facility failed to provide appropriate treatments and services for residents with indwelling catheters. This affected one resident (#130) out of three residents reviewed for indwelling catheters. The facility census was 80. Findings include: 1. Record review for Resident #130 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #130 included polyneuropathy, gout, prostate cancer with metastasis to pelvic bone, and clostridium difficile, (c-diff). Review of Resident #130's Minimum Data Set (MDS) dated [DATE] was in progress at the time of survey. Review of Resident #130's hospital documents dated 09/12/24 revealed the resident had an indwelling catheter placed for the diagnosis of obstructive uropathy. Review of Resident #130's baseline care plan dated 09/20/24 revealed for the bladder assessment the resident was noted as having an indwelling catheter upon admission. Review of Resident #130's comprehensive care plans dated 09/20/24 revealed no focus for bladder or the indwelling catheter. Review of Resident #130's physician orders dating from 09/20/24 to 09/26/24 revealed no orders for the care or continuation of the indwelling catheter in the medical records. Review of Resident #130's Treatment Administration Records (TAR) dated 09/2024 revealed no documentation of catheter care being documented as completed. Interview on 09/23/24 at 9:10 A.M. with Resident #130 revealed the resident had the indwelling catheter inserted while he was at the hospital. Resident #130 stated he did not know what the plan was for the catheter or when the facility was going to be removing the catheter. Resident #130 stated he has asked his nurses about the catheter and they inform him, when he no longer needs the catheter it can be removed. Resident #130 denied any pain associated with the indwelling catheter. Interview on 09/25/24 at 1:30 P.M. with State tested Nurse Aide (STNA) #156 revealed she performed catheter care for Resident #130. STNA #130 stated staff chart completion of care in the computer. STNA #156 stated she reported to the nurse she completed the catheter care and verified the aide knew the resident had an indwelling catheter due to the previous STNA's report. STNA #156 stated she did not know if there was any place to document the catheter care for Resident #130 in the medical records. Interview on 09/25/24 at 1:35 P.M. with Registered Nurse (RN) #333 revealed the nurse works for an agency, not the facility. RN #333 stated she received the information in report from the previous shift nurse stating Resident #130 had an indwelling catheter. RN #333 verified STNA #130 reported to her the catheter care was completed and there were no issues noted with the catheter. RN #333 stated she could not document the catheter care due no orders for the treatment in the records. RN #333 verified the resident had no focus in his care plans or physician orders for the indwelling catheter in the medical records. Interview on 09/25/24 at 1:45 P.M. with the DON and Regional Registered Nurse (RRN) #275 verified Resident #130 had the indwelling catheter upon admission. The DON verified while the indwelling catheter was documented on the baseline care plans, there were no interventions, the catheter was not on the comprehensive care plans. The DON verified there were no orders and no documentation in the medical records regarding the treatment for the indwelling catheter or the plan for removal for Resident #130. Review of the facility policy titled, Catheter Care, dated 08/2022 revealed the facility staff will assess the ongoing need and plan for removal of each indwelling catheter. Per the policy the staff will document all catheter care in the medical records and report any unusual findings.

Based on record review, resident interview, and staff interview, the facility failed to provide pain medication for a resident per physician orders. This affected one resident (#33) out of five residents reviewed for medications. The facility census was 80. Findings include: Record review for Resident #33 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #33 included hemiplegia, facial weakness, aphasia, asthma, chronic obstructive pulmonary disease, and heart disease. Review of Resident #33's care plans dated 08/08/24 revealed a focus for risk for dental health problems due to missing, broken and carious teeth due to poor oral health and lack of professional dental care. Interventions include administer medications per physician order. Review of Resident #33's physician orders dated 09/19/24 revealed the resident was prescribed Hydrocodone-Acetaminophen 5-325 milligram (mg) every four hours as needed for tooth pain for three days. No other orders for pain medication was noted in the medical records after 09/19/24. Review of Resident #33's hospital paperwork dated 09/18/24 revealed Resident #33 was seen at the hospital for dental pain and infection. Resident #33 was discharged on [DATE] with orders to receive Hydrocodone-Acetaminophen 5-325 mg every four hours as needed for tooth pain for three days and Clindamycin (antibiotic) 300 milligrams (mg) four times a day for 10 for a tooth infection. Review of Resident #33's hospital paperwork dated 09/22/24 revealed the resident was seen at the hospital for dental pain. Resident #33 was discharged on [DATE] with orders to receive Hydrocodone-Acetaminophen 5-325 mg every eight hours as needed for tooth pain for two days. Review of Resident #33's progress notes dated 09/18/24 at 11:23 P.M. revealed the nurse documented Resident #33 complained of severe teeth pain with swollen gums noted. Per the nurse's note the resident requested a narcotic pain medication. Per the note no written script for pain medication was in the records and the nurse was unable to pull the pain medication from the emergency cart. The nurse documented the resident then requesting to go to the hospital, the nurse provided a packet for the resident. Per the note, Resident #33 signed himself out of the facility and went to the hospital. Review of the progress notes dated 09/22/24 at 3:00 A.M. revealed the nurse documented the resident was complaining of dental pain. Per the note the resident was seen on 09/19/24 at the hospital concerning the dental pain and was prescribed the pain medication for the next three days. The nurse documented the prescription was completed and the resident was requesting to go back to the hospital due to increased pain to his gums. The nurse documented she contacted the primary physician of the resident's complaints and the physician stated to inform him of any new orders. Review of the progress note dated 09/22/24 at 6:04 A.M. revealed the resident returned to the facility from the hospital with new orders for the pain medication every eight hours as needed for two days. Per the note the physician was notified of the new orders from the hospital. Review of the note dated 09/23/24 at 11:22 P.M. revealed the nurse documented she offered Resident #33 Tylenol for pain until the prescribed narcotic pain medication came from pharmacy. Review of Resident #33's vital signs for pain monitoring revealed from 09/01/24 to 9/16/24 the resident stated his pain level was zero out of 10. On 09/17/24 the resident stated his pain level was a eight out of 10. The pain levels was documented as an eight out of 10 on 09/19/24, 09/20/24, and 09/22/24. Interview on 09/23/24 at 2:00 P.M. with Resident #33 revealed the resident complained about not being able to see the dentist. Resident #33 stated the dentist refused to work on his teeth the last time the dentist was in the facility due to Resident #33 not receiving a medication he was supposed to get before the visit. Resident #33 stated around two weeks ago he noticed his teeth were becoming more painful and requested his primary physician to prescribe some pain medication to help the resident through the pain until he can be seen by the dentist again to have the teeth pulled. Resident #33 stated he did not have any pain before 09/17/24. Resident #33 denied any loss of appetite or changes to his daily routine. Resident #33 did state he was in pain mostly at night which was causing him loss of sleep. Interview on 09/24/24 at 1:30 P.M. with the Social Worker (SW) #248 revealed on 09/11/24 Resident #33 was seen by the facility's dentist and was scheduled to receive a procedure of extraction for his teeth on 09/18/24. Per SW #248 stated the resident had not complained about pain until recently when the dentist saw him on 09/11/24 and 09/18/24. Per SW #248, there was a plan to have the resident's teeth extracted when the facility's new dentist will come to the facility. Interview on 09/24/24 at 3:10 P.M. with Resident #33 revealed the resident was sitting outside the facility under the carport. Resident #33 stated after the second visit with the dentist he was told due to him not getting the antibiotics he would have to wait until next month before the dentist could pull his teeth. Resident #33 stated he was in pain and asked for a pain medication after the dentist appointment on 09/18/24 and was refused pain medications. Resident #33 stated he signed himself out of the facility and went to the hospital where he received an order for antibiotics and pain medication. Resident #33 stated he did not request every pain pill when he was allowed to, only when he was in pain, until 09/22/24 when the nurse informed him his pain medication would need a new prescription. Resident #33 stated the pain has not stopped him from doing his daily living tasks but he is upset he cannot have a pain free day. Resident #33 stated he refused Tylenol due to the medication making him sick to his stomach. Resident #33 stated the facility has not offered him any other interventions for pain relief. Interview on 09/24/24 at 3:22 P.M. with Registered Nurse (RN) #344 revealed Resident #33 had requested a pain medication during his morning medication pass and the nurse verified there were no active orders in the records for any pain medication. RN #344 stated she reported it to the DON. Interview on 09/24/24 at 3:35 P.M. with the Director of Nursing (DON) verified there was an order sent from the hospital on 09/22/24 for Resident #33's pain medication. The DON stated the pharmacy refused to refill the prescription and stated it was never relayed to the facility by the pharmacy the medication would not be supplied. The DON verified Resident #33 had not received any pain medication after he reported pain from 09/22/24 to 09/24/24.

Based on resident interview, staff interview, and test tray, the facility failed to serve palatable meals. This affected two residents (#57 and #60) of two residents reviewed for meals. The facility was 80. Findings include: Review of a test tray on 09/25/24 at 11:55 A.M. with Registered Nurse #178 revealed a plate with roast pork loin, mashed potatoes, and broccoli. Gravy covered the mashed potatoes and pork loin. The broccoli was served in a separate bowl on the plate. The plate presentation was pleasing. The temperature of the food was warm. The pork was seasoned well and tender. The mashed potatoes were bland with very little flavor. Additionally, the gravy had minimal flavor. Further, the broccoli was cooked to an appropriate texture but was bland and unseasoned. RN #178 confirmed the mashed potatoes, gravy, and broccoli tasted bland and lacked seasoning. Interview on 09/25/24 at 12:23 P.M. with Resident #60 revealed she thought the mashed potatoes and gravy tasted bland. Interview on 09/25/24 at 12:26 P.M. with Resident #57 revealed she felt the mashed potatoes were not flavorful.

Based on record review, observations staff and resident interviews and policy review the facility failed to ensure a residents dressing changes were completed per physician orders. This affected one (#20) out of three residents reviewed for skin breakdown. The facility census was 70. Findings include: Record review of Resident #20 revealed an admitted [DATE]. Diagnoses included complete traumatic amputation of left great toe, spina bifida, inflammatory polyneuropathy, paraplegia, osteomyelitis, non-pressure chronic ulcer, adult failure to thrive, gastro-esophageal reflux disease, pressure ulcer of unspecified site, major depressive disorder, opioid dependence, anorexia and stimulant abuse. Review of the Minimum Data Set (MDS) assessment completed on 01/01/24 revealed Resident #20 with a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 indicating the resident was cognitively intact. Functional imitation in range of motion revealed no impairment both upper extremities, and impairment to both lower extremities. Further review of Resident #20's medical record revealed the resident had an order for the left 2nd toe to cleanse with saline, apply medihoney, then calcium algnate, cover with foam every day shift for wound care; an order for the right hip to cleanse with saline, apply medihoney, then calcium algnate, cover with foam every day shift for wounds; an order for the left foot to cleanse with saline, apply xeroform and foam dressing every day shift for wound care, an order for the left ischium to cleanse with saline, apply medihoney, calcium alginate, cover with foam every day shift for wound; and order for the right ishium to cleanse with saline, apply medihoney, calcium algnate, cover with foam every day shift. Review of Resident #20's treatment administration record (TAR) for March 2024 revealed the treatments for the right ischium, left ischium, left foot, right hip and left 2nd toe dressing were not done and not initialed off as being completed on 03/21/24. Observation and interview on 03/22/24 at 10:27 A.M. with Resident #20 revealed multiple dressings were dated 03/20/24. Resident #20 stated her dressing changes were to be changed daily. The observations revealed dressings on right ischium dated 03/20/24, left ischium dated 03/20/24, left foot dated 03/20/24, right hip dated 03/20/24, and left 2nd toe dated 03/20/24. Interview on 03/22/24 at 10:32 A.M. with the Assisted Director of Nursing (ADON) #9 confirmed dressings on Resident #20 were last changed on 03/20/24 and the treatment record did not reflect the dressing were changed on 03/21/24. Interview with ADON #9 also confirmed she would ensure the dressings get changed at this time. Interview on 03/22/24 at 1:35 P.M. with the Director of Nursing (DON) confirmed Resident #20 did not have her dressings to her L-2nd toe, R-hip, L-foot, L-ischium, and R-ishium changed on 03/21/24 and that the resident had asked the nurse to come back later due to having company and the nurse reported she forgot to go back and change the resident's dressings. Interview also confirmed the DON contacted the nurse responsible today, 03/22/24 and she was going to have the nurse initial a refusal for Resident #20 dressing changes on 03/21/24. When questioned why the nurse would initial that the resident refused when the DON confirmed the resident asked her to come back, and the nurse reported she forgot, the DON stated there isn't another choice to choose. DON advised there is an option for 5 Hold / See Nurses Notes. Review of the Wound Care procedure, dated October 2010 revealed the staff are to verify there is a physician's order for this procedure. Document any problems or complaints, signature and title of the person recording the data. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interview, observation, policy review and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure monitoring of a pressure sore was completed to ensure appropriate care and treatment was provided to prevent deterioration of a pressure ulcer. This resulted in actual harm when Resident #50's pressure ulcer was not monitored on a weekly basis to ensure proper treatment and interventions were in place resulting in the pressure ulcer deteriorating from a stage two to an unstageable pressure ulcer. This affected one (#50) of two residents reviewed for pressure ulcers. The facility identified four residents currently residing in the facility with pressure ulcers greater than a stage one. Facility census was 76. Findings include: Review of Resident #50's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review Quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #50 was assessed as severely cognitively impaired, was totally dependent on staff for all activities of daily living and was at risk for pressure ulcer development with no current pressure ulcers assessed with [REDACTED]. Review of the comprehensive care plan documented Resident #50 was at risk for development of pressure ulcers related to impaired bed mobility, history of skin breakdown, impaired nutrition and incontinence. The interventions included air mattress to bed daily, pressure reducing seating present on tilt back chair, cleanse and dry after incontinence episodes and apply [MEDICATION NAME], inspect skin every-day and report changes to the nurse, monitor nutritional status, nurse to perform weekly skin assessments and as needed, document and notify the physician of areas of concerns and turn and reposition every two hours. Review of the skin grid pressure sheet dated 03/04/19 documented Resident #50 was found to have a pressure ulcer to her right buttocks measuring 2.0 centimeters (cm) by 1.5 cm by 0.1 cm. The wound bed was described as pink-red with the peri wound white and fragile. There was no drainage noted, no foul odor, no tunneling and [MEDICATION NAME] was applied. The staging of the pressure ulcer was not assessed; however, it met the definition of a stage two pressure ulcer according to the facility assessment form and from information from the NPUAP. Review of a physician order [REDACTED]. Review of the care plan dated 03/06/19 documented Resident #50 had alteration of skin integrity of the buttock. The interventions included up in chair for meals only, air mattress to bed every-day, provide treatment as ordered, turn and reposition every two hours and refer to wound clinic with follow up as ordered. Review of physician's orders [REDACTED]. Review of weekly skin assessments completed on 03/06/19, 03/13/19, 03/20/19 and 03/27/19 mentioned the previously identified wound to the right buttock but lacked any documentation of the area being measured and assessed as required for pressure ulcers to ensure appropriate treatments and intervention were in place. Review of the advanced wound practitioners note dated 04/05/19 documented Resident #50 had an unstageable pressure injury to her right buttocks. The wound measures 1.2 cm by 2 cm by 0.1 cm. The wound bed was described as having 80 percent of soft black eschar with a small amount of serous drainage. Review of a physician order [REDACTED]. Review of the advanced wound practitioner note dated 04/10/19 revealed Resident #50 had a right buttock wound that remained unstageable. The wound measured 1.5 cm by 1 cm by 0.5 cm. The wound bed was described with 50 percent yellow slough with a small amount of serous drainage. Review of the weekly skin assessment dated [DATE] documented open area remains on the right buttock. There lacked any documentation of the pressure ulcer being assessed as required. Review of the skin grid pressure sheet dated 05/01/19 documented the right buttock pressure area was unstageable. The wound measured 1.1 cm by 0.9 cm by 2.8 cm. The wound bed was covered with a large amount of moist yellow-brown drainage which had a foul odor. Further review of the assessment documented the physician was notified of the decline in the wound. Review of the nursing note dated 05/01/19 documented the physician was notified of the status of the right buttock wound. According to the nurses note there were no new orders obtained at this time. Review of physician orders [REDACTED].#50's dressing change to her right buttock. Review of Treatment Administration Record from 05/01/19 through 05/15/19 lacked evidence of any treatment in place for Resident #50's pressure ulcer to her right buttock. Review of the skin grid pressure sheet dated 05/09/19 documented the right buttock pressure area was unstageable. The wound measured 1.2 cm by 1.0 cm by 2.8 cm. The wound was described as unable to see the wound bed due to brownish slough with a moderate amount of drainage and the wound was unchanged. Review of the skin grid pressure sheet dated 05/15/19 documented the right buttock pressure area was unstageable. The wound measured 1.3 cm by 1.0 cm by 3.0 cm. The wound bed was covered 100 percent with brownish-gray moist slough with a large amount of brown foul drainage. Further review documented the wound had declined and the physician was notified. Review of the physician order [REDACTED]. Review of the physician order [REDACTED]. Further review documented to follow-up with the wound specialist on 06/18/19 as scheduled. Review of the weekly skin assessments completed 05/22/19, 06/05/19 and 06/12/19 mentioned the previously identified pressure wound. The assessments lacked any documentation of the area being measured and assessed as required for pressure ulcers to ensure appropriate treatments and interventions were in place. Review of the wound specialist progress note dated 06/18/19 documented Resident #50's wound measured 0.7 cm by 1.5 cm by 2.8 cm and documented the wound was now a stage four pressure ulcer. On 07/02/19 at 11:08 A.M., interview with the Director of Nursing (DON) verified the facility does not have any pressure ulcer assessments completed for Resident #50 from 03/04/19 through 04/03/19 when the resident was seen by the wound practitioner and the residents wound was assessed as unstageable. She further verified there also lacked pressure ulcer assessments from 04/10/19 through 05/01/19. In addition, the DON verified there was no evidence of an appropriate treatment in place and/or verified the medical record lacked documentation of an ordered treatment being implemented for the unstageable pressure ulcer from 05/01/19 through 05/15/19. The DON verified she has no idea what happened and some kind of treatment had to have been done due to the assessments of the wound on 05/09/19 and 05/15/19 when a documented treatment was put into place. She also verified there was no assessment of the pressure ulcer as required from 05/15/19 to 06/18/19 when she was seen by the wound specialist. The DON further verified the pressure ulcer should have been monitored weekly with measurements and a description to ensure appropriate treatment and interventions were in place to prevent deterioration of the wound. On 07/02/19 at 1:25 P.M. an observation was made of Resident #50's pressure ulcer. At this time, the wound treatment was observed and completed by the Assistant Director of Nursing (ADON). The wound had a moderate amount of serous drainage with no odor. The area measured 0.8 cm by 0.8 cm with a depth of 2.2 cm. The ADON verified the wound was currently a stage four and healing. She also verified pressure ulcers are to be assessed on a weekly basis to ensure proper treatment and interventions are in place. Review of the facility undated policy and procedure for pressure ulcer/injury risk assessment purpose is to provide guidelines for structured assessments and identification of residents developing pressure ulcers/injuries. If a skin alteration is identified, initiate the appropriate assessment for the alteration in skin and document any changes needed in the care plan. Interventions must be based on current, recognized standards of practice. Review of information from the NPUAP revealed pressure ulcers should be assessed initially including measurements of the wound and there should be ongoing monitoring. According to the NPUAP the monitoring of a pressure ulcer should be ongoing to ensure healing of the wound. The NPUAP defined a stage two pressure ulcer as a partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Further review revealed an unstageable pressure ulcer is a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage three or Stage four pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed.

Based on medical record review, review of fall investigations, observations, resident and staff interview, and review of facility policy, the facility failed to ensure Resident #33's fall interventions were in place as indicated in Resident #33's care plan. The lack of implementing interventions resulted in actual harm when Resident #33 fell , hit her face on the floor and was subsequently hospitalized related to a closed head injury. This affected one (#33) of two residents sampled for falls. Additionally, the facility failed to ensure hazardous chemicals were kept secured. The facility identified two (#63 and #64) of 76 residents who were identified as cognitively impaired, independently mobile and that could potentially access these chemicals. The facility census was 76. Findings include: 1. Review of Resident #33's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #33's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of ten indicating Resident #33 was moderately cognitively impaired. Resident #33 required supervision with bed mobility, transfer, walking, locomotion, dressing, eating, toilet use, and personal hygiene. Resident #33 displayed no behaviors during the review period. Review of Resident #33's care plan revised 06/27/19 revealed supports and interventions for nutritional risk, risk for pain, risk for impaired skin integrity, mood concerns, [MEDICAL CONDITION], and risk for falls. Resident #33's fall interventions included the following: on 04/13/19 an intervention was added to ensure the resident was wearing appropriate footwear when ambulating or mobilizing in the wheelchair, ensure call light was in reach and encourage use, decrease clutter with commonly used items in reach, report adverse medication effects to physician, and to encourage rest periods to avoid over tiring; on 04/19/19 an intervention was added for Physical Therapy (PT) to evaluate for a walker; on 04/23/19 there were added interventions to encourage resident to sit in bedside chair if resident wanted to sit up; on 04/27/19 an intervention was added for a low bed to floor with floor mat next to the bed; and on 06/27/19 an intervention was added to place non-skid strips on the floor in front of the chair and next to the bed. Review of Resident #33's fall risk assessment completed on 04/27/19 revealed Resident #33 was at moderate risk for falls. Review of Resident #33's physician orders revealed an order dated 06/05/19 for Apixaban (blood thinner) five mg (milligrams) two times a day and Aspirin, 81 mg one time a day. Review of Resident #33's fall investigations revealed Resident #33 had an unwitnessed fall on 04/18/19 with no injury. As a result of the fall, Resident #33's fall interventions were updated to include low bed to the floor with a floor mat next to the bed. Further review of the fall investigations revealed Resident #33 had an unwitnessed fall on 06/25/19 at approximately 11:30 P.M. Resident #33 was found on the floor sitting in front of her bed. Resident #33 was holding her covers to her nose and had a bump on the right side of her forehead. Resident #33 was mumbling and not able to say what happened. Resident #33 was assessed, vitals taken, physician was contacted and Resident #33 was sent to the hospital via paramedics. Resident #33's family was notified. Resident #33 returned to the facility on [DATE] with no new orders and a [DIAGNOSES REDACTED]. Further review of Resident #33's medical record revealed the resident was sent to the emergency roiagnom on [DATE] per the family request. A Computed [NAME]ography (CT) scan of the head was conducted and a closed fracture of a nasal bone with routine healing was identified and was documented as being treated for [REDACTED].#33 returned to the facility on [DATE]. Observation on 06/30/19 at 1:28 P.M. of Resident #33 revealed Resident #33 propelling herself around her room in her wheelchair. Resident #33 had dark black bruises around both of her eyes and a raised purple/black bruise on the right side of her forehead. Interview on 06/30/19 at 1:30 P.M. with Resident #33 revealed she was alert and oriented. Resident #33 reported she fell when she was getting out of bed to go to the bathroom. Resident #33 stated she fell , hit her face on the floor, and broke her nose. Resident #33 stated the staff took care of her right away and she went out to the hospital. Resident #33 stated she stayed overnight and came back to the same room when she returned to the facility. Resident #33 stated her eyes and forehead were a little swollen, but they were improving. Resident #33 stated she took herself to the bathroom and they kept reminding her to use her call light. Resident #33 was not aware of any other fall interventions. Interview on 07/02/19 at 4:57 P.M. with Licensed Practical Nurse (LPN) #86 revealed she was the nurse on duty on 06/25/19 when Resident #33 fell . LPN #86 reported she was called to Resident #33's room by State tested Nursing Assistant (STNA) #2 because the resident had fallen. LPN #86 stated she was not aware what Resident #33 hit her head on but observed Resident #33 sitting by her bed with a bump on her head and blood on the bed and the floor. LPN #86 verified there was no mat on the floor at the time of the fall. LPN #86 reported Resident #33 was mumbling something about trying to get to the bathroom but was not acting like herself. LPN #86 reported Resident #33 was normally able to make her needs known, transfer herself, and take herself to the bathroom. However, Resident #33 also had trouble sleeping and could be very tired at times. The staff encouraged Resident #33 to use her call light when she was feeling weak but Resident #33 had not put her call light on. LPN #86 reported they assessed her, made notifications, called nine-one-one (911) and transferred Resident #33 immediately to the hospital by squad. Interview on 07/02/19 at 5:12 P.M. with STNA #2 revealed she was the aide on duty the night of 06/25/19 when Resident #33 fell . STNA #2 reported Resident #33 was mumbling something about trying to get out of bed when she was asked what happened. Resident #33 was bleeding from her nose, had a big knot on her head, and swelling had started around her eyes. STNA #2 reported she was the staff that cleaned up the blood and though it was an unwitnessed fall it was apparent from the location of the blood, Resident #33 had hit her face on the floor. STNA #2 stated Resident #33's bed was in the low position and verified there was no mat next to Resident #33's bed at the time of the fall. STNA #2 reported the nurse called 911 and Resident #33 was sent to the hospital. STNA #2 reported Resident #33 was a fall risk, was able to make her needs known, but had some confusion at times, and required just some supervision with her activities of daily living. STNA #33 reported they would keep a close eye on her because Resident #33 had trouble sleeping at night and wouldn't use her call light consistently when she was feeling tired and needed help. STNA #2 reported Resident #33 had not put her call light on the night of 06/25/19. Review of the facility policy titled, Assessing Falls and Their Causes revised (MONTH) 2019 revealed resident's care plans were to be reviewed to assess for any special needs of the resident. Residents were to be assessed for falls at admission and regularly afterward for potential risk for falls. 2. Observation on 06/30/19 at 9:10 A.M. of the bathroom near the 300 hall nurses station found the bathroom door unlocked, opened, an aerosol can of air freshener marked with a warning label to avoid skin and eye contact. Two independently mobile residents were observed outside the open door of the bathroom. Interview on 06/30/19 at 9:15 A.M. with Housekeeping Staff (HS) #15 revealed the unmarked bathroom was considered the women's bathroom but anyone could use it. HS #15 reported the bathroom was kept unlocked. Observation on 06/30/19 at 10:09 A.M. of the women's bathroom near the 300 hall nurses station found the bathroom door unlocked, an aerosol can of air freshener marked with a warning label to avoid skin and eye contact. An independently mobile resident in a wheelchair was observed outside the opened door. Interview on 06/30/19 at 10:11 A.M. with Licensed Practical Nurse (LPN) #83 verified an aerosol can of air freshener with a warning label to avoid skin and eye contact and the product was left unattended on the sink. LPN #83 removed the chemical from the bathroom. Interview on 07/01/19 at 8:50 A.M. with the Administrator revealed two resident, Resident #63 and #64 had dementia/confusion and were independently mobile and that could potentially be affected by the unsecured chemicals. Review of the facility policy titled, Hazard Communication Policy and Procedure, dated 01/01/16 revealed staff were to be trained regarding hazards and identities of chemicals to ensure a safe living area for the residents.

Based on medical record review, observations, staff and resident interviews, policy review and review of medication information from Medscape, the facility failed to ensure a resident's pain was properly managed. This resulted in actual harm when Resident #173 experienced uncontrolled severe pain and had difficulty sleeping. This affected one (#173) of one resident reviewed for pain management. The facility identified 42 residents on a pain management program. The facility census was 76. Findings included: Review of Resident #173's medical record revealed the resident was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Review of admission observation dated 06/20/19 revealed she was cognitively intact. Functional status was independent for bed mobility, transfers, eating and toilet use. Review of a pain assessment dated [DATE] for Resident #173 revealed the document did not have a numeric rating or a verbal descriptor scale completed. The assessment further revealed the pain affected sleep, mood, socialization, activities of daily living, and physical activity. Review of the admission assessment dated [DATE] revealed per hospital records Resident #173 had an open sigmoid colectomy with a coloproctostomy and partial omentectomy. Review of physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The [MEDICATION NAME] was given on 06/30/19 at 2:06 P.M. Review of the care plan dated 06/20/19 for Resident #173 revealed the resident has pain related to a surgical wound status [REDACTED]. Review of the progress notes dated 06/29/19 at 3:22 P.M. revealed the resident was unhappy and complained of pain a couple of times during the day. Further review of a progress note dated 06/30/19 at 1:30 A.M. revealed Resident #173 continued to complain about her pain and rated the pain a 10 out of 10. The note reported the resident's narcotics were still not in, the nurse called and spoke to the Nurse Practitioner (NP) about the resident's pain and the nurse was encouraged to give the maximum dose of an [MEDICATION NAME] and offer an ice pack and if the pain continued, to send the resident to the hospital. Interview and observation of Resident #173 on 06/30/19 at 11:22 A.M. revealed she hadn't received her pain medication for a couple of days. She said [MEDICATION NAME] was her medication and it was being used for her colon surgery due [MEDICAL CONDITION]. She stated, I get really bad cramps. Resident #173 stated she had a cramp, she cried out in pain and said she couldn't do this and rated her pain as 10 out of 10. Resident #173 stated the pain was unbearable and she had difficulty sleeping. Resident #173 stated she told the facility if they can't control her pain, to send her back to the hospital. Resident #173 stated she was told on admission her pain would be controlled. Resident #173 stated the facility was supposed to be rushing her pain medications out today. A subsequent observation of Resident #173 on 06/30/19 at 12:52 P.M. revealed she grimaced with pain while holding her stomach. Interview with Licensed Practical Nurse (LPN) #49 on 06/30/19 at 11:40 A.M. revealed the pharmacy was waiting for the physician to approve Resident #173's narcotic pain medication. LPN #49 stated she got in report this morning the physician had been faxed, which was the only way the facility can contact him, and the physician did not get back with the facility. She stated she called the NP to see if she could approve the medication and she couldn't, but the NP tried to get in touch with the physician with no success. LPN #49 stated the facility didn't have the [MEDICATION NAME] and the emergency box didn't have it either. LPN #49 stated Resident #173 has been crying in pain today. LPN #49 stated finally the Director of Nursing (DON) came into the facility because of the annual survey and was able to get in touch with the physician directly and the approval was made for the facility to receive Resident #173's [MEDICATION NAME]. Review of policy entitled Administering Pain Medications (not dated) revealed the pain management program is based on a facility-wide commitment to resident comfort. Pain management was defined as the process of alleviating the resident's pain to a level that was acceptable to the resident and was based on his or her clinical condition and established treatment goals. Review of medication information from Medscape revealed [MEDICATION NAME] ([MEDICATION NAME]) is an opioid [MEDICATION NAME] used for moderate-to-severe pain. The medication should be taken as prescribed by the physician. Further review revealed precise and systematic pain assessment is required to make the correct [DIAGNOSES REDACTED]. During a Pain Assessment the resident's pain is assessed on a zero to 10 scale with zero being no pain and 10 being the most severe pain. It was also indicated that pain medications work best if used at first signs of pain, if delay the medication may not work as well.

Based on record review, observation, staff interview and review of Skin Sweep policy, the facility failed to prevent the development of a deep tissue injury that worsened into a Stage III pressure ulcer. This resulted in actual harm to Resident #45 who developed a deep tissue injury from the staff wrapping the residents toe too tight. The area required debridement and a Stage III pressure ulcer developed. This affected one Resident (#45) of three reviewed for pressure ulcers. The facility identified five residents with pressure ulcers. The current census was 71. Findings include: Review of the medical record for Resident #45 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the comprehensive Minimum Data Set, (MDS), dated [DATE] revealed Resident #45 had intact cognition. Review of Resident #45's care plans dated 01/07/18 revealed the resident was a risk for pressure ulcers. The goal of the focus was for Resident #45 to be free from redness, blisters, or discoloration. Interventions included to inspect skin with care and report any areas of concern to nurse. Review of Resident #45's nursing progress notes revealed on 02/27/18 the nurse observed Resident #45's toenail on the left great toe had fallen off in the resident's sock. Per the note the toe was noted to be bleeding, a dressing was applied to the toe and the Nurse Practitioner (NP) was notified. Review of the progress noted dated 02/27/18 by the NP revealed staff requested evaluation of Resident #45's toenail. Blood was noted on the resident's foot and the resident reported he pulled the toenail off in his sock. Per the note the toe was cleansed and Triple Antibiotic Ointment (TAO) and a dressing was applied. The toe was to be monitored and the podiatrist was to be consulted for Resident #45. Review of physician orders [REDACTED]. Further review of Resident #45's care plans dated 02/28/18 revealed a focus to skin integrity impairment related to right great toe nail came off. Interventions included avoid shoes, do not get right foot wet and bilateral boots every shift. Per the revision on 03/21/18 revealed to apply [MEDICATION NAME] to the black areas to the left foot/toe, DO NOT wrap too tightly, and be sure gauze is not too tight. Review of the Treatment Administration Records, (TAR), dated 02/2018 and 03/2018 revealed TAO and gauze dressing on Resident #45's left foot was completed twice a day per physician order. Further review of the TAR for 03/2018 revealed on 03/21/18 the treatment was changed to [MEDICATION NAME] to black areas, [MEDICATION NAME] cream to fresh skin and wrap with gauze dressing. Review of the skin assessments dated from 02/2018 to 03/2018 revealed on 03/07/18 the nurse documented a previously identified pressure ulcer and a previously identified non-pressure ulcer area Per the assessment the nurse documented the resident had a pre-existing toenail on the left foot. The foot was wrapped with gauze and a pressure dressing. No further assessments of Resident #45's left foot wound was noted in the resident's chart. No physician progress notes [REDACTED]. Review of the podiatrist's progress notes dated 03/20/18 obtained by the facility on 05/31/18, revealed per the podiatrist, Resident #45 pulled off his left great toenail and the nursing home was wrapping the foot to stop the bleeding. The podiatrist documented the resident developed dark discoloration, blistering to circumference of the great toe. Discoloration to the lateral foot was noted. The podiatrist noted findings, it appears that while wrapping the toe to stop the bleeding it was wrapped too tight and a deep tissue injury resulted. Per the podiatrist note the toe was debrided and a pressure ulcer of the left great toe was staged as a pressure ulcer stage three. Review of Resident #45's physician orders [REDACTED]. Wrap the foot with gauze make sure the dressing is loose. Do not wrap tightly. Apply [MEDICATION NAME] to the lateral side of the foot and blister. Be sure the dressing is not too tight. Review of the podiatrist note dated 04/03/18 revealed the resident presented with a great toe ulcer as well as a blister to the lateral side of the left foot. Resident #45 developed these [MEDICAL CONDITION] from the nursing home wrapping the foot too tight. Review of the TAR for 04/2018 and 05/2018 revealed the treatments were completed as ordered. During an observation on 05/28/18 at approximately 10:00 A.M. Resident #45 was noted with a loose gauze wrapped around the left foot. Interview on 05/31/18 at 8:20 A.M. with MDS #100 while requesting documentation on Resident #45's foot wound, MDS nurse #100 revealed Resident #45 had not been seen by the facility's wound nurse. Per MDS #100 the resident was referred to the podiatrist after the toenail was pulled off and the wound was not assessed in the facility. Per MDS #100 there was no podiatrist documentation notes in the resident's medical record. Interview on 05/31/18 at 8:45 A.M. with the Director of Nursing (DON) revealed there were no progress notes from the podiatrist in Resident #45's chart. There were also no assessments of Resident #45's left foot wound in the chart. Per the DON the facility staff had no knowledge a deep tissue injury had occurred after 02/27/18 from the facility staff wrapping the dressing too tightly. The DON stated the wound nurse at the facility had not assessed or treated Resident #45's wound. Per the DON the nurses who changed the dressing prior to resident being seen by the physician should have documented any changes in the wound in the medical record skin assessments. Follow up interview on 05/31/18 at 10:30 A.M. the DON stated she had no knowledge of the stage three pressure ulcer or the deep tissue injury to Resident #45's foot caused by the facility staff because she did not receive any notes from the podiatrist. After reviewing the progress notes from the podiatrist with the DON, the DON stated progress notes from outside physicians were not obtained by the facility to be added to the resident's chart. The DON stated the nursing staff should have noted the deep tissue injury and the stage three pressure ulcers during the skin assessment but admitted the skin assessments were not being conducted appropriately. Review of the undated policy titled, 'Nursing Update, SKIN SWEEPS', revealed any area that affects skin integrity must be documented and measured in centimeters in the skin assessments. Per the policy skin color and changes to the skin consistency must be documented.