Every finding on record at Centerburg Pointe

Based on record review, interviews and observations, the facility failed to ensure proper hand hygiene for two Residents #245 and Resident #290. This affected two Residents (#245 and #290) of the six residents reviewed. The facility census was 71.Findings include:1.Review of the medical record for Resident #245 revealed an admission date of 02/03/23 with diagnosis to include but not limited to cerebral infarction, depression, hypertension, hypercholesterolemia, gout, atherosclerotic heart disease, hemiplegia, presence of prosthetic heart valve, thoracic aortic aneurysm, atrial fibrillation, heart failure, obstructive sleep apnea, morbid obesity, shortness of breath, hyperlipidemia, anxiety disorder, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #245 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated no cognitive impairment. Review of the care plan dated 08/31/24 for Resident #245 revealed a care plan for activities of daily living (ADL) functional which stated Resident #245 had impaired musculoskeletal status related to osteoarthritis, gout, lack of coordination, hemiplegia, dependence on wheelchair, muscle weakness, and difficulty in walking. The interventions included administer medications as ordered.Review of the physician order for Resident #245 revealed thiamine mononitrate (vitamin B1) tablet 100 milligrams (mg), amount to administer one tablet, oral.Observation on 02/24/26 at 8:03 A.M. of Licensed Practical Nurse (LPN) #250 who removed the medications for Resident #245. LPN #250 shook out two thiamine pills into the container lid, then used her bare finger to hold one thiamine pill in the lid and shook the other thiamine pill back into the container. Interview on 02/24/26 at 8:21 A.M. with LPN #250 who confirmed she had not been wearing gloves and used her finger to hold the thiamine tablet in the pill lid. LPN #250 stated she should have thrown them out and started over.2.Review of the medical record for Resident #290 revealed an admission date of 06/04/25 with diagnoses to include but not limited to epilepsy, acute and chronic respiratory failure with hypoxia, stenosis of larynx, iron deficiency anemia, depression, obesity, anxiety disorder, dependence on respirator, unspecified lack of expected normal physiological development in childhood, borderline personality disorder, congestive heart failure, asthma, dysphagia, oropharyngeal phase, tracheostomy, difficulty in walking, gastro-esophageal reflux disease, lack of coordination, hypotension, cognitive communication deficit, and need for assistance with personal care.Review of the quarterly MDS dated [DATE] revealed a BIMS of 09 which indicated moderate cognitive impairment.Observation on 02/24/26 at 8:57 A.M. of Registered Nurse (RN) #820 who prepared medications for administration to Resident #290. RN #820 had three medication pill cups on the medication cart and put the medications into the different cups per Resident #290's preference for taking her medications. RN #820 stated Resident #290 prefers some medications crushed, takes some medications whole, and had two liquid medications. There were medications in a medication cup with two capsules, RN #820 picked up one small white pill with her bare hands and moved it to a different medication cup. Then RN #820 put on gloves, opened the two capsules and put the powder into a medication cup, then she crushed three medications and put them in the same medication cup as the capsules. Then RN #820 poured the liquid clobazam medication cup into the liquid Keppra medication cup. RN #820 took all the medications into Resident #290's room and set the medication cups on the bedside table. Then RN #820 put on gloves and a gown without washing her hands or using hand sanitizer. RN #820 gave Resident #290 the mixed liquid medications first and Resident #290 grimaced. RN #820 gave Miralax to Resident #290 to wash down the mixed liquid medications. Next, RN #820 gave Resident #290 the whole pills in one medication cup which Resident #290 swallowed followed by Miralax in water Then RN #820 gave Resident #290 the powered capsules and crushed medications with no pudding. The resident continued with the Miralax and water.Interview on 02/24/26 at 9:12 A.M. with RN #820 confirmed she had picked up a pill from one medication cup with her bare hands. RN #820 stated she should have used gloves or a spoon to remove the pill. RN #820 confirmed she did not wash her hands or use hand sanitizer before putting on gloves and a gown before administering Resident #290's medications. Resident #290 was on Enhanced Barrier Precautions.Review of the facility policy General Dose Preparation and Medication Administration dated 12/01/07 revealed prior to preparing or administering medications, authorized and competent facility staff should follow the facility's infection control policies. Appropriate hand hygiene should be performed before and after direct resident contact. Medications should not come in contact with any surface except for the medication cup. Facility staff should avoid touching the medication with bare hands when opening a bottle or unit dose package.Review of the facility Infection Prevention and Control Program Policy dated 02/18/26 revealed employees participate in performance improvement activities by promoting enhanced hand hygiene and adherence to respiratory hygiene/cough etiquette.The following deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, staff interview, medical record review and policy review, this facility failed to ensure a 5% or less medication error rate was maintained when five medication errors out of 26 opportunities were observed resulting in a medication error rate of 19%. This affected one (Resident # 86) of the three residents observed for medication administration. The facility census was 68.Findings include: Review of Resident # 68's medical record revealed an admission date of 10/16/25. Diagnoses included hypertension, chronic obstructive pulmonary disease, traumatic brain injury and obstructive hydrocephalus. Review of Resident # 68's current physicians orders for November 2025 revealed the following orders:-Lisinopril (for high blood pressure) tablet 10 milligrams (mg). Hold medication if systolic blood pressure (SBP) is less than 110, pulse less than 60. Give once a day.-Aspirin (anti-inflammatory) tablet chewable 81 mg-crushed; give four tablets via gastric tube once a day.-Cholecalciferol (vitamin D3) 25 micrograms (mcg) capsule; give one tablet via gastric tube once a day.-Methylphenidate HCL (a central nervous system stimulant) tablet 5mg-crushed, give one tablet via gastric tube twice a day.-Norvasc (used to lower blood pressure) tablet 5 mg. Hold medication if SBP less than 110 or pulse less than 60. Give once a day.-Propranolol (used to lower blood pressure) tablet 20mg; give one tablet via gastric tube twice a day.-Therapeutic-M (multivitamin) tablet 9 mg-iron 400 mcg; give one tablet via gastric tube once a day.- Pro-Stat (supplement); administer 30 cubic centimeters (cc) one time a day-Enteral Feeding: Tube Feeding: Free Water Special Instructions: Tube Feeding: Free Water: Administer 180 ml every four hours to equal cc/day- no total given. Flush tube with 60 cc free water before and 30 cc between medications, every shift. Observation of medication administration on 11/26/25 at 8:20 A.M. with Registered Nurse (RN) #393 revealed the nurse obtained vitals for Resident #68. Blood pressure and pulse observed as 95/56 and 92. RN #393 stated she would hold Lisinopril and Norvasc due to parameter orders and notify the physician. RN #393 began gathering all other scheduled medications for Resident #68 followed by crushing and combining all medications together and placing the Prostat liquid and crushed medications into a 120cc drinking cup. RN #393 was then observed adding approximately 90cc of water to the cup. RN #393 then checked placement and residual for Resident #68 and flushed gastric tube with approximately 30cc's of water. All medications were administered at the same time using a syringe and not separate with water flushed in between. Interview on 11/26/2025 at 8:30 A.M. with RN #393 confirmed Resident #68's medications were crushed, combined and administered all at once and a water flush was not completed between each medication. RN #393 also confirmed there was an order to crush medications but not to combine them. Review of the facility policy titled Medication Administered through an Enteral Tube, dated 10/31/16 revealed under dose administration, Medication should be prepared and given separately. Do not mix medications together in a medication syringe and Administer liquid medications first, then follow with medications requiring dilution also to Flush with at least 15 ml of water after each individual medication is administered. This deficiency represents non-compliance investigated under Complaint Number 2580250 and 1293221.

Based on medical record review, staff interview, review of facility investigation report, review of personnel file, and review of facility policy, the facility failed to report to law enforcement an incident of staff to resident abuse. This affected one resident (#55) of four residents reviewed for facility self-reported incidents and had the potential to affect all 68 residents residing in the facility. The facility census was 68.Findings include:Resident #55 was admitted to the facility on [DATE] with pertinent diagnoses including: chronic diastolic (congestive) heart failure, need for assistance with personal care, cognitive communication deficit, restlessness and agitation, Type II Diabetes Mellitus without complications, heart disease and depression. Review of quarterly Minimum Data Set (MDS) dated [DATE] for Resident #55 revealed she was severely cognitively impaired and had physical behavioral symptoms (hitting, kicking, pushing) towards others on one to three days of the review. Resident #55 required substantial/maximal assistance for toileting, showering/bathing, upper body dressing, lower body dressing and personal hygiene, rolling left to right, moving from sitting to lying and transferring to toilet. Resident #55 used a manual wheelchair and needed partial/moderate assistance for wheeling 50 feet and was dependent for wheeling 150 feet.Review of care plan entry for Resident #55 dated 04/02/24 revealed Resident #55 had behaviors towards staff and a history of refusing care. Interventions suggested included convey an attitude of acceptance towards the resident and maintain a calm environment and approach to the resident.Review of facility investigation report for Self Reported Incident (SRI) OH261885 summary of investigation revealed On Sunday, June 22, 2025 the alleged staff Certified Nursing Assistant (CNA) perpetrator (CNA #599) went into the alleged resident victim's (Resident #55's) room to assist the resident to Activities and the resident had a bowel movement. The alleged staff perpetrator (CNA #599) went to get another CNA (CNA #611) to assist with providing the alleged resident victim (Resident #55) with incontinence care. While providing care to the alleged resident victim, the resident became combative and stated I will hit you. The alleged perpetrator (CNA #599) stated she would hit her back. The alleged resident victim spit toward the alleged staff CNA perpetrator (CNA #599) and the alleged staff CNA perpetrator (CNA #599) covered the alleged resident victim's mouth with their hand to prevent the resident from spitting on the alleged staff CNA perpetrator again. The other staff CNA (CNA #611) immediately intervened and made sure the alleged resident victim was safe, taking them out of the room to the nurse station. Review of facility investigation report for SRI OH261885 written statement by Certified Nursing Assistant (CNA) #599 dated 06/22/25 revealed CNA #599 stated that she put her hand over Resident #55's mouth in response to Resident #55 spitting. In this written statement, CNA #599 said she asked the resident not to spit on her anymore.Review of the facility investigation report for SRI OH261885 written statement completed by CNA #611 dated 06/22/25 revealed CNA #611 wrote that CNA #599 had said to Resident #55 that she would punch her in the face and when Resident #55 spit towards CNA #599, CNA #599 then grabbed Resident #55 by the face and said you do not spit on me. Review of Employee Separation Form for STNA #599 revealed STNA #599 was terminated, effective 06/22/25. The document noted the termination was involuntary and reason noted was for physical abuse to resident.Further review of SRI OH261885 revealed the facility had not notified the the police regarding the incident. Review of progress notes for Resident #55 revealed note from 06/22/25 in which the DON documented the Power of Attorney (POA) did not want police to be notified.Interview on 11/26/25 at 2:10 P.M. with the Director of Nursing (DON) confirmed CNA #599 was terminated for abuse against Resident #55 effective 06/22/25 and that they did not report the incident to police per daughter's request.Review of facility policy titled, Ohio Resident Abuse, published 07/11/24, revealed abuse includes willful infliction of injury [or] intimidation. Willful means the individual must have acted deliberately.Review of the facility policy titled, Crime Reporting, revised 03/03/25 revealed individuals are required to report any reasonable suspicion of a crime against any individual who is a resident of the nursing facility. Individuals must report to the appropriate governmental agencies and to one or more law enforcement entities.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on observation, review of the medical record, review of the facility's investigation, resident interview, staff interview and review of the facility policy, the facility failed to protect Resident #68 from misappropriation of his Oxycodone (opioid) medication. This affected one Resident (#68) of three reviewed for medication administration. The facility census was 68.Findings include:Review of the medical record revealed Resident #68 was initially admitted to the facility on [DATE]. Pertinent diagnoses included: cerebrovascular disease, acute and chronic respiratory failure, Type II Diabetes, acute kidney failure with tubular necrosis and chronic pain syndrome.Review of the quarterly Minimum Data Set (MDS) Section C dated 08/06/25 indicated Resident #68 was cognitively intact.Review of the physician's order, dated 06/13/25, revealed Resident #68 had an order for one Oxycodone 5 milligrams (mg) tablet at bedtime.Review of the shift change controlled substance inventory count sheet for 07/14/25 revealed one card of thirty 5 mg tablets of Oxycodone was received by the facility and added to the medication cart for Resident #68 on that date.Review of the Medication Administration Record (MAR) for Resident #68 for July 2025 revealed one tablet was given to Resident #68 each evening from 07/14/25 to 07/20/25 for a total of seven tablets.Review of the shift change controlled substance inventory count sheet for 07/21/25 revealed one card of thirty 5 mg tablets of Oxycodone for Resident #68 was marked as removed from cart (empty) with only one nurse signature.Review of the Medication Administration Record (MAR) for Resident #68 for July 2025 revealed that on 07/21/25 and 07/23/25 the Oxycodone was not administered with a note indicating that the medication was unavailable. On 07/24/25, the medication was not administered and the note indicated that the resident took a muscle relaxer instead. On these dates, documentation indicated Resident #68 reported his pain to be zero. Review of the pharmacy electronic emergency drug administration machine documentation for Resident #68 revealed on 07/22/25 one Oxycodone 5 milligram tablet was removed for Resident #68.Interview on 09/29/25 at 2:00 P.M. with Resident #68 revealed the resident mentioned in passing during the interview that his medication was taken by a nurse but administration took care of the situation.Interview on 11/25/25 at 5:08 P.M. with Director of Nursing (DON) confirmed Resident #68 should have had a card of with 21 pills in it on 07/21/25 when the medication was documented as not available. The DON also confirmed during the interview when a narcotic card is removed from the medication cart two nurses are required to sign the shift change controlled substance inventory count sheet when the medication card is removed. She confirmed on 07/21/25 there was only signature when the Oxycontin 5 mg for Resident #68 was removed. She said that she went through the shredder bin to find the card and found the top part of the card and the medication portion was not attached.Interview on 11/25/25 at 4:10 P.M. with the DON confirmed nurses who had cared for Resident #68 were subject to drug testing and no nurses failed the drug test. DON stated the nurse who removed the Narcotic card with only one signature from the medication cart was suspended pending investigation and subsequently resigned her position at the facility. Review of the facility policy titled, Storage and Expiration Dating of Medications and Biologicals, revised 06/30/35, stated controlled medications must be counted with another designated staff member when there is an exchange of keys.Review of the facility policy titled, Missing Medication, last revised 06/04/2021 revealed if there is a discrepancy during shift count, the off-going nurse for the cart affected should not leave until the discrepancy has been explained or until the Director of Nursing instructs them to leave.Review of the facility investigation report for Self-reported investigation control number OH2611885 revealed the corrective actions the facility took in response to the identification of the missing medication.The deficient practice was corrected on 07/25/25 when the facility implemented the following corrective actions:On 07/24/25 at 3:28 P.M. the facility reported the incident to the [NAME] County Sherriff's Department.On 07/24/25 the Quality Assurance and Performance Improvement (QAPI) committee met to discuss the incident and plan approach.On 07/24/25 the DON/designee looked at all the narcotic accountability sheets that had been signed off on to ensure that there was no diversion noted. They were unable to locate the controlled substance count sheet for the Oxycodone that was removed from the medication cart and recognized that approximately 23 tablets were missing. On 07/24/25 the DON/designee interviewed the staff who worked from 07/14/25 to 07/21/25. Interviews included asking about any unusual behaviors or if they heard any complaints from the residents about medication administration.On 07/24/25 the DON notified the medical director of the investigation and the findings.On 07/24/25 human resources audited five random nursing files to ensure they were still in good standing to work at the facility.On 07/24/25 the DON interviewed residents who were able to be interviewed regarding whether they were getting their pain medication as ordered or requested.On 07/24/25 and 07/25/25, the DON reviewed with the nursing staff the missing medication policy and the correct procedure for narcotic sign in/out.On 07/24/25 and 07/25/25, four nurses who had access to Resident #68's Oxycodone were called, interviewed, and drug tested.The DON would audit random narcotic sheets weekly for four weeks and then for two additional months to ensure that there was no drug diversion or unmanaged pain.This deficiency represents non-compliance investigated under Complaint Number OH 002580250.

Based on medical record review, staff interview, review of facility investigation report, review of personnel file, and review of facility policy, the facility failed to protect Resident #55 from assault by Certified Nursing Assistant (CNA) #599. This affected one resident (#55) of four residents reviewed for facility self-reported incidents and had the potential to affect all 68 residents residing in the facility. The facility census was 68.Findings include:Resident #55 was admitted to the facility on [DATE] with diagnoses including chronic diastolic (congestive) heart failure, need for assistance with personal care, cognitive communication deficit, restlessness and agitation, Type II Diabetes Mellitus without complications, heart disease and depression. Review of quarterly Minimum Data Set (MDS) dated [DATE] for Resident #55 revealed she was severely cognitively impaired and had physical behavioral symptoms (hitting, kicking, pushing) towards others one to three days of the review period. Resident #55 required substantial/maximal assistance for toileting, showering/bathing, upper body dressing, lower body dressing and personal hygiene, rolling left to right, moving from sitting to lying and transferring to toilet. Resident #55 used a manual wheelchair and needed partial/moderate assistance for wheeling 50 feet and was dependent for wheeling 150 feet.Review of care plan entry for Resident #55 dated 04/02/24 revealed Resident #55 had behaviors towards staff and a history of refusing care. Interventions suggested included convey an attitude of acceptance towards the resident and maintain a calm environment and approach to the resident.Review of facility investigation report for Self Reported Incident (SRI) OH261885 written statement by CNA #599 dated 06/22/25 revealed CNA #599 stated she put her hand over Resident #55's mouth in response to Resident #55 spitting. In this written statement, CNA #599 said she asked the resident not to spit on her anymore.Review of the facility investigation report for SRI OH261885 written statement completed by CNA #611 dated 06/22/25 revealed CNA #611 wrote that CNA #599 had said to Resident #55 she would punch her in the face and when Resident #55 spit towards CNA #599, CNA #599 then grabbed Resident #55 by the face and said you do not spit on me. Review of the facility investigation report for SRI OH261885 undated written statement completed by the Administrator revealed there was a meeting in which the Administrator, Human Resources Staff #501, and the Director of Nursing (DON) met with CNA #599 on 06/24/25 regarding the incident. The Administrator documented CNA #599 changed how she described the incident each time they asked for more details.Review of Employee Separation Form for CNA #599 revealed CNA #599 was terminated, effective 06/22/25. The document noted the termination was involuntary and reason noted was for physical abuse to resident.Interview on 11/26/25 at 2:10 P.M. with the DON confirmed CNA #599 was terminated for due to abuse of Resident #55 and the termination was effective 06/22/25.Review of facility policy titled, Ohio Resident Abuse, published 07/11/24, revealed abuse includes willful infliction of injury [or] intimidation. Willful means the individual must have acted deliberately.This deficiency represents non-compliance investigated under Complaint Number 1293221.

Based on record review, observation, interview, policy review and review of the Center of Disease Control recommendations, the facility failed to ensure appropriate infection control procedures were followed while incontinence care was provided. This affected one (Resident #2) of one residents observed for incontinence care. Facility census was 68. Findings include: Review of the medical record revealed Resident #2 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure with hypoxia, dependence of respirator, and type 2 diabetes. The Minimum Data Set, dated dated dated [DATE] revealed Resident #2 was moderately impaired and was always incontinent of bowel and bladder. An observation on 04/21/25 at 10:00 A.M. of incontinence care by Certified Nurse Assistant (CNA) #206 for Resident #2, who was in enhanced barrier precautions (EBP), revealed CNA #206 put a gown and gloves on to provide care. Resident #2 had a small soft bowel movement. CNA #206 used wipes to remove the feces. CNA #206 did not remove gloves or perform any hand hygiene before placing a clean incontinence brief on Resident #2 and pulling the sheet up to cover Resident #2. CNA #206 verified she did not remove the gloves she was wearing when cleaning feces. CNA #206 stated she was not aware she had to change gloves when wearing the personal protective equipment (PPE) for EBP. The Centers for Disease Control (CDC) website https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html dated 02/27/24 revealed recommendations for hand hygiene for healthcare workers included hand hygiene should be performed before moving from working on a soiled body site to a clean body site on the same patient and after contact with body fluids or contaminated surfaces. The facility policy for Hand Hygiene/Handwashing revised on 02/28/25 revealed the use of gloves does not replace the need for hand cleaning by either hand rubbing or hand washing. This deficiency represents non-compliance investigated under Complaint Number OH00164491.

Based on interview and record review the facility failed to ensure fluid restrictions were followed as ordered for two residents (#20 and #34) out of three residents reviewed for conditions that required fluid restrictions. The facility census was 70. Findings include: 1. Resident #34 was admitted on [DATE] with diagnoses that included acute and chronic congestive heart failure, acute and chronic respiratory failure, dependence on respirator [ventilator], fluid overload, hypothyroidism, anxiety disorder, major depressive disorder, chronic catheter for diuresis, dependence on supplemental oxygen, chronic pain syndrome, cognitive communication deficit, chronic kidney disease, depression, hypertension, obstructive sleep apnea, congenital central alveolar hypoventilation syndrome, and heart failure. Review of the minimum data set (MDS) 3.0 dated 01/24/25 revealed Resident #34 was cognitively intact with moderately severe depression and a numeric pain level of six on a scale of 0-10. Resident #34 received anticoagulant, antidepressant, and diuretic medication with indications present. Resident #34 was on a non-invasive mechanical ventilator at night and received oxygen therapy. Review of physician's orders for Resident #34 revealed an order for fluid restriction of 2,000 milliliters (ml) in 24 hours. Fluid restriction for dietary was a total of 1,560 ml per day (breakfast 600 ml, lunch 480 ml, and dinner 480 ml). Nursing to give up to 440 ml per 24 hours broke down into first shift 240 ml and second shift 200 ml per shift. Review of the medication administration record (MAR) for March 2025 revealed Resident #34 received more than 440 ml in 24 hours on 03/03/25, 03/04/25, 03/05/25, 03/06/25, 03/09/25, 3/10/25, 03/11/25, 03/12/25, 03/13/25, 03/17/25, 3/18/25, and 03/19/25 from the nursing. Review of the diet intake records for Resident #34 revealed more than 1,560 ml in 24 hours on 03/03/25, 03/06/25, 03/12/25, 03/13/25, and 03/17/25. Review of total fluid intakes in March 2025 for Resident #34 revealed more than 2,000 ml in 24 hours on 03/03/25, 03/04/25, 03/06/25, 03/12/25, 03/13/25, 03/17/25, and 03/19/25. Review of the Plan of Care dated 01/27/25 for Resident #34 revealed Resident #34 was non-compliant with fluid restrictions and has a history of drinking excessive amounts of fluid. Resident #34 has family bring in fluids from outside sources. Interventions included educating Resident #34 and her family about the need to follow fluid restrictions and the health dangers if fluid restrictions are not followed. Interview on 03/20/25 at 09:39 A.M. with the director of nursing (DON) confirmed the resident had multiple days where the fluid restriction was exceeded. 43064 2. Review of Resident #20's medical record revealed an admitted [DATE] with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's plan of care dated 02/21/25 revealed the resident had increased nutrition and hydration risk related to her diagnoses. It was indicated that a 32-ounce (960 ml) fluid restriction was in place. Interventions included providing fluids as ordered. Review of Resident #20's physician order dated 04/29/24 revealed an order for a fluid restriction 1000 ml a day. Dietary to give 700 ml, nursing to give up to 300 ml in 24 hours, morning shift was to give 120 ml, afternoon shift was 120 ml, and evening shift was 60 ml. Review of Resident #20's Medication Administration Record (MAR) for February and March 2025 revealed nursing had exceeded their allotted fluids. On 2/19/25 they provided 390 milliliters (ml), on 02/20/25 they provided 560 ml, on 02/21/25 they provided 380 ml, on 02/22/25 they provided 320 ml, on 02/24/25 they provided 600 ml, on 02/25/25 they provided 600 ml, on 02/26/25 they provided 390 ml, on 02/27/25 they provided 390 ml, on 03/01/25 they provided 480 ml, on 03/02/25 they provided 600 ml, on 03/03/25 they provided 540 ml, on 03/04/25 they provided 360 ml, on 03/05/25 they provided 340 ml, on 03/06/25 they provided 780 ml, on 03/07/25 they provided 600 ml, on 03/08/25 they provided 480 ml, on 03/09/25 they provided 360 ml, on 03/10/25 they provided 830 ml, on 03/11/25 they provided 540 ml, on 03/12/25 they provided 900 ml, on 03/13/25 they provided 360 ml, on 03/15/25 they provided 720 ml, and on 03/16/25 they provided 600 ml. Review of Resident #20's additional fluid documentation revealed the nurse aides exceeded the allotted fluids. On 02/19/25 she was provided 960 ml (1350 ml total for the day) , on 02/20/25 she was provided 1040 ml (1600 ml total for the day), on 02/21/25 she was provided 1580 ml (1960 ml total for the day), on 02/22/25 she was provided 940 ml (1260 ml total for the day), on 02/24/25 she was provided 1100 ml (1700 ml total for the day), on 02/25/25 she was provided 1080 ml (1680 ml total for the day), on 02/26/25 she was provided 1150 ml (1540 ml total for the day), on 02/2725 she was provided 1350 ml (1740 ml total for the day), on 02/28/25 she was provided 1190 ml (1400 ml total for the day), on 03/01/25 she was provided 1080 ml (1560 ml total for the day), on 03/02/25 she was provided 1320 ml (1920 ml total for the day), on 03/03/25 she was provided 740 ml (1280 ml total for the day), on 03/0425 she was provided 1660 ml (2020 ml total for the day), on 03/05/25 she was provided 1590 ml (1930 ml total for the day), on 03/06/25 she was provided 1210 ml (1990 ml total for the day), on 03/07/25 she was provided 2160 (2760 ml total for the day), on 03/08/25 she was provided 980 ml (1460 ml total for the day), on 03/09/25 she was provided 820 ml (1180 ml total for the day), on 03/10/25 she was provided 960 ml (1790 total for the day), on 03/11/25 she was provided 1430 ml (1970 total for the day), on 03/12/25 she was provided 1860 ml (2760 total for the day), on 03/13/25 she was provided 940 ml (1300 ml total for the day), on 03/14/25 she was provided 1100 ml (1310 ml total for the day), on 03/15/25 she was provided 1680 ml (2400 ml total for the day), on 03/16/25 she was provided 1560 ml (2160 ml total for the day). Review of Resident #20's medical record from 02/19/25 to 03/16/25 revealed no documentation present that she was noncompliant with her fluid restriction. Interview on 03/19/25 at 3:18 P.M. with Licensed Practical Nurse (LPN) #96 revealed the documentation on the MAR was the fluids the nurses provide the resident and the additional fluid documentation is what the aides provided. Interview on 03/19/25 at 4:16 P.M. with the Director of Nursing (DON) verified Resident #20's fluid restriction was not followed by nursing staff. She reported the kitchen had not been aware of the fluid restriction and had been providing more than their allotted fluids.

Based on interview and record review the facility failed to ensure Resident #20's medication was held as ordered by the physician This affected one resident (#20) of five residents reviewed for unnecessary medications. The facility census was 70. Findings include: Review of Resident #20's medical record revealed an admitted [DATE] with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's physician order dated 01/03/25 revealed an order for Enulose (Lactulose) (osmotic laxative) 30 milliliters (ml) three times a day. Review of Resident #20's physician order dated 03/30/24 revealed an order for Metoprolol tartrate (relaxes blood vessels to slow heart rate and decrease blood pressure) 25 mg one tablet twice a day. Hold for systolic blood pressure below 110 mmHg (millimeters of mercury) for heart rate below 60 beats per minute. Review of Resident #20's physician order dated 03/06/25 revealed an order to hold the morning dose of Lactulose and metoprolol on dialysis days. Review of Resident #20's Medication Administration Record (MAR) from 03/01/25 to 03/17/25 revealed Enulose was not held prior to dialysis on 03/10/25, 03/14/25, or 03/17/25. Metoprolol was not held prior to dialysis on 03/10/25 and 03/14/25. Interview on 03/20/25 at 9:47 A.M. with the Director of Nursing (DON) verified her medication was not held according to the physician orders.

Based on interview and record review the facility failed to ensure pre and post dialysis assessments were completed for Resident #20. This affected one resident (#20) of one resident reviewed for dialysis. The facility census was 70. Findings include: Review of Resident #20's medical record revealed an admitted [DATE] with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's plan of care dated 02/21/25 revealed the resident required dialysis three times a week and the facility provided transportation. Her chair time and location for dialysis were provided. Interventions included noon meal provided by facility prior to dialysis, assessing for fluid excess, assuring medications are administered before and after dialysis as ordered, diet as ordered, monitor intake and output, monitor laboratory work, monitor weight, notify physician of weight changes or fluid volume excess, and report changes in neurological status. Review of Resident #20's physician orders revealed an order dated 01/16/25 indicating she was to go to dialysis on Monday, Wednesday, and Friday's. Review of Resident #20's pre and post dialysis assessments from 02/03/25 to 03/14/25 revealed on 02/03/25 the pre assessment was not fully completed, on 02/05/25 the facility did not complete a pre-assessment, on 02/07/25 and 02/10/25 the pre assessment was not fully completed, on 02/12/25 neither pre or post assessment was completed, on 02/17/25 the pre assessment was not fully completed and dialysis did not complete the post assessment, on 02/19/25 and 02/24/25 the pre assessment was not fully completed, on 02/26/25 the pre assessment was not fully completed and dialysis did not complete a post assessment, on 02/28/25 the pre assessment was not fully completed, on 03/05/25 neither the pre or post assessment was completed, on 03/07/25 and 03/10/25 the pre assessment was not fully completed, on 03/12/25 neither the pre or post assessment was completed, on 03/14/25 the pre assessment was not fully completed and the post assessment was not completed by dialysis. Interview on 03/19/25 at 9:22 A.M. with the Director of Nursing (DON) verified pre and post dialysis assessments were not being completed with every dialysis treatment.

Based on record review, resident interview, and staff interview, the facility failed to maintain availability of ordered pain management medications for one resident (Resident #33) out of two residents reviewed for pain management. The facility census was 70. Findings include: 1. Resident #33 was admitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia, cellulitis of right lower limb, dysphagia, tracheostomy, acute pancreatitis, acute myocardial infarction, depression, squamous cell carcinoma of skin, anxiety disorder, obstructive sleep apnea, hypertension, atrial fibrillation, and chronic congestive heart failure. Review of the minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 was cognitively intact with mild depression. Resident #33 received antianxiety, antidepressant, anticoagulant, diuretic, and opioid medications with indications noted. Review of physician's orders revealed Resident #33 had an order for a Fentanyl patch (opioid) 100 micrograms (mcg) per hour to be changed every 72 hours. Patch placement to be monitored every shift. Resident #33 also had an order for Oxycodone (opioid) 5 mg every four hours as needed for pain. Interview on 03/17/25 at 9:54 A.M. with Resident #33 revealed the resident had some level of pain all the time. Resident #33 stated he has a Fentanyl patch that is changed every three days. Resident #33 stated he recently went 10 - 12 days without the patch because there was a problem getting the prescription refilled. Review of the March 2025 medication administration record (MAR) revealed Resident #33 was without a Fentanyl patch from 03/09/25 until 03/14/25. Progress note dated 03/06/25 at 12:58 P.M. Registered Nurse (RN) #47 documented this nurse called the pharmacy for a refill on resident's Fentanyl 100 mcg/hr patch. Per the pharmacy, we need a new prescription to fill this medication. Physician was documented as being called and a new prescription was requested to be sent to the pharmacy so the medication could be refilled. Progress note dated 03/14/25 at 10:22 A.M. RN #30 documented Fentanyl patch was delivered the pervious shift, this nurse placed patch on this morning on left upper extremity. Interview on 03/19/25 at 7:37 A.M. with RN #47 confirmed when the last Fentanyl patch in stock was placed on 03/06/25, RN #47 placed a call to the pharmacy to reorder the medication for Resident #33. The pharmacy informed RN #47 there were no more refills on the prescription and a new prescription was required to refill the medication. RN #47 then placed a request on the physician's medication refill voice mail requesting a new prescription be sent to the pharmacy for Resident #33. Interview on 03/19/25 at 12:20 P.M. with Director of Nursing (DON) confirmed there was no Fentanyl patch placed on Resident #33 as the facility did not obtain a current order from the physician from 03/09/25 until the morning of 03/14/25.

Based on interview, medical record review, and facility policy review the facility failed to ensure an indwelling foley catheter was inserted correctly and monitored after insertion. This had the potential to affect one (#24) of two reviewed for catheter care. The census was 70. Findings include: Review of the medical record for Resident #24 revealed an admitted [DATE] with sever cognitive deficits. Diagnoses included hypertensive chronic kidney disease, depression, overactive bladder, neuromuscular dysfunction of bladder and anxiety. Review of Resident #24 nurses progress notes revealed on 10/22/24 at 6:41 P.M. the nurse changed her catheter with 22 french (FR) 10 cc balloon, because the resident was found playing in her stool, pulling her catheter, and having spasms. The nurse followed the sterile technique protocol. When the procedure was completed Resident #24 was resting in her bed. Review of Resident #24 progress notes on 10/23/24 at 10:11 A.M. the nurse was notified by the Certified Nursing Assistant (CNA) that the resident did not have any urine output overnight. Resident #24 was examined, and it was determined her catheter was inserted in the incorrect area. A new 22 FR 10 cc balloon catheter was inserted with urine coming present after insertion. Review of Resident #24's documentation of urine out put from 10/22/24 at 6:41 P.M. to 10/23/24 at 10:11 A.M. revealed no documentation indicating she had any urine output for sixteen hours. An interview on 03/18/25 at 11:30 A.M. with CNA #93 confirmed they are to monitor residents' urine output when they have an indwelling catheter inserted, if they have any problems, they are to report them to the nurse taking care of the resident. Interview on 03/19/24 at 3:00 P.M. with the Director of Nursing (DON) it was confirmed standard nursing practice was to record resident urine out put at least every eight hours. DON verified Resident #24's catheter was not monitored or changed in the sixteen hours when the catheter was inserted incorrectly into Resident #24 on 10/22/24. Review of the Facility's ,Urinary Catheterization and Removal Procedure, (Female) dated 04/24/07 and last revised on 11/06/24 revealed: If a catheter is mistakenly placed in the vagina repeat the entire procedure with another sterile catheter. Pinch catheter when flow of urine ceases (do not remove more than 1000 ml at once) hold catheter in place. The catheter is to remain in place to measure the total amount of urine.

Based on observation, interview, medical record review, and facility policy review, the facility failed to ensure fall interventions were in place and falls were documented for one (#11) of two residents reviewed for falls. The facility census was 70. Findings include: Review of Resident #11's medical record revealed an admitted [DATE], diagnoses included dementia, major depressive disorder, epilepsy, other chronic pain, paroxysmal atrial fibrillation, fracture of one rib on left side (12/03/24), and glaucoma. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of Resident #11's plan of care dated 02/14/25 revealed she was at risk for falls related to her diagnoses, history of falls, lack of coordination, and impaired mobility. Interventions included but were not limited to removing regular socks from her room and providing non-skid socks, maintaining the call light in reach, and nonskid socks. Review of Resident #11's medical record revealed no documentation related to a fall which occurred on 03/16/25. Review of the post huddle form dated 03/16/25 revealed Resident #11 had been found sitting in the door way of her bedroom with her walker back beside her recliner. Observation on 03/17/25 at 9:20 A.M. and 11:05 A.M. revealed Resident #11 was wearing regular socks, not non-skid socks. Observation on 03/19/25 at 8:45 A.M. and 9:40 A.M. revealed Resident #11 lying in bed. Her call light was out of reach, it was laced through her bedside table drawer and hanging out the far side of the drawer. Interview on 03/19/25 at 9:40 A.M. with Licensed Practical Nurse (LPN) #96 verified Resident #11's call light was out of reach. Resident #11 would have to sit up on the side of the bed to get to the call light. LPN #96 reported the resident had a fall on 03/16/25 Interview on 03/19/25 at 10:25 A.M. with the Director of Nursing (DON) verified the fall on 03/16/25 had not been documented in the progress notes. A post fall huddle form had been completed that was not part of the medical record. Review of the policy titled Fall Prevention and Management Policy dated 12/09/19 and last revised on 08/06/24 reveaeld: Residents will be assessed for fall risk[s] on admission, quarterly, and as needed. If risks are identified, preventive measures will be put in place and care planned. All falls will be reviewed and investigated. Individualized interventions will be implemented based on this assessment and care planned accordingly.

Based on observation, interview, and record review, the facility failed to monitor Resident #4 and Resident #20's use of a splint. This affected two residents (#4 and #20) of two residents reviewed for limited range of motion. The facility census was 70. Findings include: 1. Observation on 03/17/25 at 12:01 P.M. revealed a splint in Resident #4's room. Review of Resident #4's medical record revealed an admitted [DATE] with diagnoses including transient cerebral ischemic attack, contracture of left elbow, neoplasm of brain, heart failure, type two diabetes mellitus, dysphagia, depression, unspecified convulsions. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. Review of Resident #4's occupational therapy discharge evaluation dated 02/28/25 revealed a discharge recommendation to tolerate a left elbow splint for six hour intervals. Review of Resident #4's medical record from 02/28/25 to 03/16/25 revealed no indication resident #4 was using a splint. Review of Resident #4's physician order dated 03/17/25 revealed an order to wear a left elbow brace for four to six hours a day as tolerated. Interview on 03/20/25 at 9:47 A.M. with the Director of Nursing (DON) verified there was no tracking or monitoring for Resident #4's splint in the medical record. 2. Review of Resident #20's medical record revealed an admitted [DATE] with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's physician order dated 10/30/24 revealed the resident was to wear left resting hand splint six hours as tolerated at bedtime with hygiene and skin check prior to donning. Review of Resident #20's medical record from 10/30/24 to 03/18/25 revealed no indication that the left resting hand splint was being applied. Observation on 03/18/25 at 8:25 A.M. revealed Resident #20's left hand was contracted into a tight fist. Interview on 03/18/25 at 8:25 A.M. with Resident #20 revealed she had a splint for her left hand she was supposed to wear daily but staff did not always provide it. Interview on 03/18/25 at 9:47 A.M. with the DON she verified they had not been tracking or monitoring when Resident #20 was using her splint. She reported the resident was noncompliant, but verified there was no evidence of this.

Based on record review, interview, and facility policy review, the facility failed to ensure physician orders were present for therapy services prior to delivering services to one (#42) of one reviewed for hospice services, and the facility failed to follow practitioner recommendation for vascular surgery consult for one (#35) of one reviewed for non pressure skin condition. The census was 70. Findings Include: 1. Review of the medical record for Resident #42 revealed an admitted [DATE], diagnoses included Alzheimer's Disease, dementia, anxiety, bi-polar disorder and a history of falling. Resident #42 admitted to hospice services on 10/31/23 and was a Do Not Resuscitate Comfort Care (DNR-CC). Observation on 03/18/25 at 11:30 A.M. revealed Resident #42 was in bed, and Certified Occupational Therapist Aide (COTA) #102 was present and revealed she had just finished working with Resident #42 to improve her sitting position in her wheelchair. Resident #42 appeared to be very restless with involuntary head and hand control, COTA #42 explained the sessions are about forty minutes long and she has seen little improvement. Review of the Hospice Interdisciplinary Team (IDT) Comprehensive Assessment and Plan of Care Update Report from 01/17/25 to 03/17/25 revealed Resident #42's health had declined in the last two weeks cognitively and physically. Morphine (opioid) for pain had increased from two times a day to three times a day, involuntary head and hand movement continues. Resident #42 sleeps 20 to 24 hours a day and requires total care for activities of daily living, bed baths are provided due to poor trunk control. The plan did not include orders for any type of rehabilitation services. Review of the Occupational Therapy notes from 03/04/25 to 03/18/25 revealed Resident #42 received a total of eight therapy sessions. Review of the Hospice Physician Order Report from 01/17/25 to 03/19/25 revealed there was no order for physical or occupational therapy to evaluate or treat. Review of Resident #42's physician notes from 01/01/25 to 03/19/25 revealed there was no physician order for occupational therapy to treat Resident #42 for increased trunk control to utilize a wheel chair while out of bed. Review of the Resident #42 plan of care dated 12/23/24 did not include occupational or physical therapy services as being included in the care of Resident #42. Review of Resident #42 nurses progress notes from 2/2/25 to 3/10/25 revealed no indication the medical director and or the hospice physician were notified to obtain an order for Resident's #42 to receive occupational therapy. Interview with the Director of Nursing (DON) on 03/19/25 at 8:47 A.M. confirmed she was unaware that Occupational Therapist/Aide had been seeing the resident for chair positioning. Interview with the Director of Nursing and the Rehab Director #107 on 03/19/25 at 1:30 P.M. confirmed Resident #42 had been evaluated and treated by the occupational therapist with no physician order from hospice or her primary care physician. The DON verified the hospice agency Registered Nurse or physician should have been notified to obtain therapy orders for Resident #42. Review of the facility Hospice Care Policy , dated 05/24/23 revealed the hospice assumes responsibility for determining the appropriate course for hospice care, including the determination to change the level of care services provided. 43064 2. Review of Resident #35's medical record revealed an admitted [DATE] with diagnoses including depression, dysphagia, peripheral vascular disease (PVD), type two diabetes mellitus, hemiplegia, chronic diastolic heart failure, gastric ulcer, and atherosclerosis of native arteries of bilateral legs. Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had moderately impaired cognition. Review of Resident #35's physician note dated 12/12/24 revealed a recommendation to follow up with vascular surgery related to Peripheral Vascular Disease (PVD). Review of Resident #35's Certified Nurse Practitioner (CNP) notes dated 12/18/24, 12/26/24, 01/22/25, 02/04/25, 02/11/25, and 02/19/25 revealed a recommendation to follow up with vascular surgery related to PVD. Review of Resident #35's physician note dated 03/13/25 revealed a recommendation to follow up with vascular surgery related to PVD. Observation on 03/17/25 at 9:08 A.M. of Resident #35 revealed both of his feet were a dark purple color. Interview on 03/17/25 at 9:08 A.M. with Resident #35 revealed the hospital had wanted him to see a vascular doctor but that had not happened yet. Interview on 03/18/25 at 2:10 P.M., 2:14 P.M. and 5:05 P.M. with the Director of Nursing (DON) verified the physician and CNP notes had indicated follow up with vascular surgery but that had not occurred. She reported his hospital notes indicated he was not appropriate for vascular surgery and she would follow up with the CNP to ensure they were aware. She verified they had been documenting this for months and it had gone unaddressed.

Based on observation, interview and record review the facility failed to ensure Resident #4's nails were maintained in a clean manner and at a good length. This affected one resident (#4) of three residents reviewed for activities of daily living (ADL). The facility census was 70. Findings include: Review of Resident #4's medical record revealed an admitted [DATE] with diagnoses including transient cerebral ischemic attack, contracture of left elbow, neoplasm of brain, heart failure, type two diabetes mellitus, dysphagia, depression, and unspecified convulsions. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. She was dependent for personal hygiene. Review of Resident #4's plan of care dated 03/11/25 revealed she had a self care deficit related to ADL limitation, restlessness and agitation, and her diagnoses. Interventions included monitoring toenails and fingernails with ADL care daily for need of trimming or additional services, and assistance of one staff for personal hygiene. Observation on 03/17/25 at 9:24 A.M. and on 03/20/25 at 11:59 A.M. of Resident #4 revealed the resident had long curved nails that appeared dirty underneath. Interview on 03/20/25 at 11:59 A.M. with Certified Nursing Assistant (CNA) #21 verified the observation. CNA # 21 reported she would ask hospice to cut them when they came in to do her bed bath later.

Based on medical record review, interview, and facility policy review the facility failed to obtain a discharge physician order when residents were being discharged from the facility. This affected three (#69, #174, and #175) of four residents reviewed for discharge. The census was 70. Findings include: 1. Review of Resident #69's medical record revealed an admission date of 12/17/24 and a discharge date of 12/20/24, diagnoses included cirrhosis of the liver, cognitive communication deficit, chronic kidney disease, diastolic heart failure, and type two diabetes mellitus. Review of Resident #69's discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive deficits. Review of Resident #69's progress note dated 12/20/24 revealed the resident moved out of the facility when the family came in around 2:15 P.M. to take her home. Discharge summary and a copy of the medication list were provided to the resident. Review of Resident #69's physician orders from 12/01/24 through 12/20/24 revealed there was no discharge order included in the medical record. 2. Review of Resident #174's medical record revealed an admission date of 08/05/24 and a discharge date of 10/02/24, diagnoses included cognitive communication deficit, malignant neoplasm of unspecified part of bronchus or lung, candida sepsis, type two diabetes mellitus, and peripheral vascular disease. Review of Resident #174's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed no cognitive deficits. Review of Resident #174's progress note dated 10/01/24 revealed she was alert and oriented and was discharging home on [DATE]. The nurse went over the medications with the resident and their power of attorney. Review of Resident #174's physician orders from 09/01/24 through 10/02/24 revealed there was no discharge order included in the medical record. 3. Review of Resident #175's medical record revealed an admission date of 09/03/24 and a discharge date of 09/21/24, diagnoses included portal vein thrombosis, major depressive disorder, anxiety disorder, type two diabetes mellitus, cognitive communication deficit, and hypertension. Review of Resident #175's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #175's progress note dated 09/21/24 revealed the resident was discharged at 2:20 P.M. after reviewing the current medication list and discharge paperwork with the resident and her mother. Review of Resident #175's physician orders from 09/01/24 through 10/02/24 revealed there was no discharge order included in the medical record. Interview with the Social Service Designee #42 and Minimum Data Set Coordinator #19 on 3/19/25 at 2:30 P.M. confirmed there was no discharge order obtained when Residents #69 , #174 and #175 were discharged home. Interview on 03/19/25 at 3:07 P.M. interview with the DON confirmed there were no physician orders to discharge residents #69, #174, and #175. Review of the Facility's, Discharge Planning Policy, dated 09/24/2020 revealed a physician order is needed when a resident is discharged and or transferred from the facility.

Based on interview and record review the facility failed to timely complete and submit a discharge Minimum Data Set (MDS) 3.0 assessment for Resident #53. This affected one resident of six closed records reviewed. The facility census was 70. Findings include: Review of Resident #53's medical record revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses including spinal stenosis, chronic heart failure, adjustment disorder, generalized anxiety disorder, and functional quadriplegia. Review of Resident #53's discharge MDS assessment dated [DATE] revealed it was finalized but not submitted. Review of section 'Z Assessment Administration' revealed all sections of the assessment had been completed on 03/12/25. Review of Resident #53's progress note dated 12/27/25 revealed they had returned from a leave of absence that began on 12/23/25 and reported they were not returning to the facility. Interview on 03/19/25 at 2:05 P.M. with the Director of Nursing (DON) verified the MDS assessment got missed and had not been completed until 03/12/25.

Based on interview and record review the facility failed to follow medication parameters for one (#20) of five reviewed for unnecessary medication. The facility census was 70. Findings include: Review of Resident #20's medical record revealed an admitted [DATE] with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's physician order dated 03/30/24 revealed an order for Metoprolol tartrate (relaxes blood vessels to slow heart rate and decrease blood pressure) 25 mg one tablet twice a day. Hold for systolic blood pressure below 110 mmHg (millimeters of mercury) or heart rate below 60 beats per minute. Review of Resident #20's Medication Administration Record (MAR) from 03/01/25 to 03/17/25 revealed Metoprolol was not held for a systolic blood pressure below 110 mmHg on 03/10/25 when her blood pressure was 106 over 67 mmHg. Interview on 03/20/25 at 9:47 A.M. with the Director of Nursing (DON) verified her Metoprolol was not held according to the orders/parameters.

Based on interviews and medical record reviews the facility failed to notify the Ombudsman when residents were transferred or discharged from the facility. This affected three (#69, #174 and #175) of four reviewed for discharge. The total facility census was 70. Findings Include: 1. Review of Resident #69's medical record revealed an admission date of 12/17/24 and a discharge date of 12/20/24, her diagnoses included cirrhosis of liver, cognitive communication deficit, chronic kidney disease, diastolic heart failure, and type two diabetes mellitus. 2. Review of Resident #174's medical record revealed an admission date of 08/05/24 and a discharge date of 10/02/24 with diagnoses including cognitive communication deficit, malignant neoplasm of unspecified part of bronchus or lung, candida sepsis, type two diabetes mellitus, and peripheral vascular disease. 3. Review of Resident #175's medical record revealed an admission date of 09/03/24 and a discharge date of 09/21/24. Diagnoses included portal vein thrombosis, major depressive disorder, anxiety disorder, type two diabetes mellitus, cognitive communication deficit, and hypertension. Review of the facility's list of discharged residents' names reported to the Ombudsman for the months of 09/2024,10/2024, 12/2024, 01/2025 and 02/2025 revealed Residents #69 and #175 were not reported as being discharged from the facility. Interview and observation on 03/19/25 at 3:07 P.M. with the Director of Nursing (DON) confirmed Residents #69, #174 and #175 date of discharge was not reported to the Ombudsman. The facility denied having a notification to Ombudsman policy for review.

Based on interview, record review, and review of facility policy the facility failed to notify the physician of a change in Resident #71's skin condition. This affected one resident (#71) of two residents reviewed for pressure ulcers. The facility census was 70. Findings include: Review of Resident #71's medical record revealed an admitted [DATE] with a discharge date of [DATE], diagnoses included acute respiratory failure, discitis, osteomyelitis of vertebra, encephalopathy, dysphagia, and ileus. Review of Resident #71's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had intact cognition. He had three stage two pressure ulcers upon admission. Review of Resident #71's skin observation dated 01/30/25 revealed the resident had shearing to the right and left gluteal fold. Review of Resident #71's progress notes from 01/30/25 to 02/07/25 revealed no evidence the physician was notified of the residents' change in skin condition. Review of Resident #71's skin observation dated 02/08/25 revealed the resident had developed shearing to his coccyx. Review of Resident #71's progress notes from 02/08/25 to 02/10/25 revealed no evidence the physician was notified of the resident's change in skin condition. Review of the policy 'Resident Change in Condition Policy' dated 06/27/24, revealed the licensed nurse would recognize and intervene in the event of a change in condition. The physician will be notified as soon as the nurse has identified the change in condition and the resident is stable. A significant change of condition was a decline or improvement in the residents status that will not normally resolve itself without intervention by staff or implementing standard disease- related clinical intervention, impacts more than one area of the resident's health status, and/or requires interdisciplinary review or revision to the care plan.

Based on medical record review, observation, staff interview and review of facility policy, the facility failed to ensure fall interventions were in place for a resident with a history of falls and failed to have complete fall investigations. This affected one of one resident reviewed for accidents (Resident #20). The facility census was 37. Harm occurred when Resident #20 fell without having a fall interventions in place as ordered and sustained a facial fracture. Findings include: Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a history of [REDACTED]. Review of the quarterly MDS dated [DATE] revealed the resident had moderate cognitive impairments, required limited assistance with one person physical assistance with bed mobility and transfers and required extensive assistance with one person physical assistance with dressing. Review of the fall risk evaluations dated 07/07/15 and 12/07/15 for the resident revealed he was assessed at a high fall risk. Review of the fall plan of care revealed the resident was at risk for falls characterized by history of falls with injury and /or multiple risk factors related to use of psychotropic medication use, pain, visual deficit, poor decision making skills, dementia, functional problem, impaired cognition, impaired vision, and [DIAGNOSES REDACTED]. Fall interventions for the resident included to wear non skid socks on at all times and fall mat to floor beside bed while the resident was in bed. Review of the physician orders were for the resident to wear non skid socks on at all times dated 06/04/15 and for a mat beside of bed dated 12/07/15. Further review of the medical record review revealed the resident fell eight times from July 2015 through 12/08/15. On 07/07/15, 07/16/15, 08/31/15, 09/22/15, 10/21/15, 11/30/15, 12/06/15 and 12/07/15. On 08/31/15, the resident sustained [REDACTED]. On 11/30/15, the resident was found in his room on the floor face down partially on the mat wearing tube socks, sweat pants that were soiled with urine and a T-shirt with blood visible on the floor next to the resident's left side from his head to abdomen. The resident was not responding to the nurse kneeling down beside him. Staff were able to turn him over to his back and found his nose bleeding and a cut above his left eye. His eyes were open and he looked at the nurse with his eyes glazed and then his eyes rolled back on his head. The physician was notified and the resident was sent to the emergency room . Review of the discharge hospital summary dated 12/03/15 revealed the resident's hospitalization was four days from 11/30/15 to 12/03/15. The resident's [DIAGNOSES REDACTED]. Review of the nurse's progress note dated 12/03/15 revealed the resident had bilateral black eyes, immeasurable bruising on the left check, and a cut above his left eye measuring 0.8 centimeter (cm.) in length, 0.3 cm. wide, and less than 0.1 centimeter deep. Observation with the Director of Nursing (DON) on 12/10/15 at 12:56 P.M. revealed Resident #20 was lying in a low bed, his head was covered in his comforter and there was no mat to the floor. The resident had a bedside table by the foot of the bed with a meal tray on it. The DON verified the mat was not beside his bed and it was folded up, standing up and in between the wall and the head of the bed. The DON verified the mat to the floor was a fall intervention for the resident. The resident did remove his head from underneath the comforter during the observation with the DON and revealed his left side of his face had black and blue discoloration resembling bruising. Interview with the DON on 12/10/15 at 1:45 P.M. confirmed the resident was wearing tube socks and not non skid socks at the time of the fall on 11/30/15. The DON confirmed the fall plan of care and physician orders directed the resident should wear non skid at all times. The DON confirmed there was no physician order nor was it care planned for the resident to be in a low bed. The DON confirmed the investigation did not include a witness statement from the nurse for the fall. The DON also confirmed the facility's policy was to obtain witness statements for each accident/fall. The DON confirmed the fall investigation for 10/22/15 did not identify if the resident was wearing proper footwear or not at the time of the fall and did not include witness statements. Review of the facility's policy on Incident/Accident Report dated 07/27/11 revised January 2013 revealed it was the fancily's policy that an incident/accident is any occurrence which is not consistent with the routine care of a particular resident. An accident/incident can occur anywhere and be discovered by anyone (resident, visitor, employee or volunteer). All incident/accidents involving residents will be analyzed and reported. The procedure included for the nurse to immediately begin obtaining witness statements from any staff member that had possible contact with the the resident in a 72 hours period prior to the incident/accident. The DON will review all witness statements and obtain any additional statements (as applicable). This deficiency is an example of continued noncompliance from the complaint survey of 12/01/15.

Based on medical record review and staff interview it was determined the facility failed to provide a resident, assessed as high risk for falls, assessed interventions to decrease the resident's risk of falls. This affected one of three sampled residents (Resident #37) reviewed for falls. The facility census was 35. Harm occurred to Resident #37, who was assessed as high risk for falls, with a history of falls, when the facility staff failed to place non skid footwear on the resident resulting in the resident getting up and falling resulting in a fractured hip requiring surgical intervention. Findings Include: A review of Resident #37's closed record revealed the resident was admitted to the facility on [DATE] and was discharged to another facility on 09/02/15. The resident had medical [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) 3.0 dated 07/08/15 revealed a Brief Interview of Mental Status (BIMS) was 12 which means mild cognitive impairment. The MDS further revealed the resident required extensive assistance with dressing. A review of the fall risk assessment completed on 01/24/15 revealed the resident's fall risk score was a 20. The assessment stated if the score was above 10 the resident was at risk for falls. A review of a fall investigation completed on 02/20/15 revealed the resident had a fall in the room that did not result in injury. The investigation further revealed interventions in place at the time were non skid footwear. A review of the fall risk assessment completed on 02/20/15 revealed the residents fall risk score was a 20. A review of the resident's re-admission care plan dated 01/16/15 revealed the resident was a fall risk and interventions were put in place to prevent falls. The interventions were proper footwear, maintain safe environment and instruct on appropriate safety measures. A review of the fall investigation completed on 05/10/15 revealed the resident was in her/his room and got up to go to the bathroom. The resident was not wearing non skid footwear. The resident fell in room and was found by staff on the floor. The resident was assessed and it was determined the resident required evaluation by the local hospital. The resident was diagnosed at the hospital with a fractured right hip. The resident required surgical intervention but returned to the facility on [DATE]. A review of the fall investigation completed on 05/10/15 reveled the residents fall risk score was a 22. Resident #37 returned to the facility on [DATE]. A review of the fall intervention request sent to Resident #37's physician on 05/10/15 at 1:31 A.M. revealed a contributing factor to Resident #37's fall on 05/10/15 was improper footwear being worn by Resident #37. An interview on 12/01/15 at 2:53 P.M. with Licensed Practical Nurse (LPN) #86 revealed the resident was assessed as a fall risk. LPN #86 stated the resident would get up and walk to the bathroom unattended. LPN #86 further stated any resident that was assessed as a fall risk on admission would be placed in a low bed and would be assisted to wear non skid socks. An interview on 12/01/15 at 4:30 P.M. with the Director of Nursing (DON) confirmed the resident was assessed as a fall risk on re-admission to the facility on [DATE]. Interventions put in place at that time would be for the resident to wear proper footwear that would include non skid socks. This is an incidental finding to complaint OH 551

Based on observation, record review and interview, the facility failed to ensure Resident #2 received the necessary care, treatment and comprehensive monitoring to promote healing of a pressure ulcer to the back of the resident's neck caused by [MEDICAL CONDITION] ties. This resulted in actual harm to Resident #2, who was at mild risk for skin breakdown, when additional pressure ulcers developed to the back of the resident's neck, unknown to staff and one of the ulcers deteriorated to an unstageable pressure ulcer. This affected one resident (Resident #2) of one resident reviewed for pressure ulcer development and treatment. Findings include: Review of Resident #2's medical record revealed the resident was admitted to the facility on 01/02/12 and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident had a [MEDICAL CONDITION] in place. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. The assessment revealed the required extensive assistance of two or more staff for bed mobility and to transferring. The assessment revealed the resident had no pressure ulcers present. Review of Resident #2's current plan of care revealed the resident was at risk for impaired skin integrity related to incontinence, immobility, obesity and history of pressure ulcers. The interventions included to provide treatments as ordered, skin assessments per routine, reposition as needed with pillows for comfort, and an alternate air pressure mattress setting on the max firm. The care plan also included to educate the resident on complications to tightening [MEDICAL CONDITION] (trach) ties [MEDICAL CONDITION]. Record review revealed a physician order, dated 01/01/14 for a foam dressing to be placed under the ties of the tracheotomy. A skin risk assessment, dated 06/13/14 revealed the resident was at mild risk for pressure ulcer development. This resident had an order for [REDACTED]. Review of the nursing progress notes revealed on 11/02/13 the resident was assessed to have a four inch by two inch open area on his neck with greenish brown drainage. The resident was sent out the hospital on [DATE]. On 11/12/13 the resident was readmitted to the facility. A note, authored by licensed practical nurse (LPN) #16 revealed an open area to the back of the resident's neck that measured 11 centimeters (cm) in length by 15 cm width with no depth noted. The open area was measured again on 11/29/13 and noted to be 6.4 cm in length by 1.3 cm width with no depth noted. The treatment ordered at that time was to cleanse with wound cleaner and apply topical antibiotic ointment, cover with a non stick pad and foam dressing daily. Record review revealed the open area was not measured or assessed again until 12/19/13 at which time the note reflected the area had deteriorated. The area was noted to measure 8.6 cm in length by 3.2 cm width. On 01/01/14 the wound on the back of Resident #2's neck was assessed to be a pressure ulcer measuring 6.4 cm in length by 0.9 cm width with 1.2 cm depth. No staging of the pressure ulcer was completed at that time. On 01/22/14 the pressure ulcer was assessed to measure 3.4 cm in length by 0.8 cm width with one cm depth. The treatment orders were changed at that time. The new order obtained was to clean with wound cleanser, pat dry, apply calcium alginate and cover with a foam dressing daily. On 04/09/14 the pressure ulcer to the resident's neck was assessed to be a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) pressure ulcer measuring seven cm in length by 2.4 cm width with no depth noted. A new treatment order was obtained at this time and included to cleanse with normal saline, pat dry apply collagen and cover with a foam dressing daily. On 08/06/14 the pressure ulcer continued to be assessed as a Stage III pressure ulcer measuring two cm in length by one cm width with no depth noted. The ulcer was noted to have 100% [MEDICATION NAME] tissue and the dressing was changed to a moistened [MEDICATION NAME] dressing, cover with foam and change daily. On 08/20/14 at 3:05 P.M. registered nurse (RN) #10 and RN #62 were observed completing the treatment to the pressure ulcer to the back of Resident #2's neck. After removing the dressing that was in place, the resident was observed to have four distinct pressure ulcers to his neck. An area to the left side of his neck which measured one cm in length by one cm width with superficial depth, an area to the center of the neck which measured 2.5 cm in length by two cm width with 0.02 cm depth noted, an area to the right side of the neck which measured one cm in length by two cm width with superficial depth and a fourth area to the far right of the neck that was observed to have a scabbed appearance (black in color). The center area was observed to have hair and dried blood in it. During the observation, RN #10 was asked about the presence of four pressure ulcers to the resident's neck area, including an area observed to be unstageable. The RN did not reply. Additionally, the documentation provided to the surveyor included only the measurements for one pressure ulcer. When asked about this, RN #10 again did not reply. When asked about the development of the pressure ulcers, the RN indicated the resident would pull on the ties of his tracheotomy and that applied pressure to his neck. The RN stated the only pressure relief in place to the area was foam padding that had been applied to the back of his neck. Additional record review of the wound evaluation flow sheets with RN #62 revealed the resident's pressure ulcers were not being assessed or monitored at least once a week per the facility skin/wound protocol. The sheets reflected one pressure ulcer that was measured three times in January 2014, on 01/01/14, 01/08/14 and 01/22/14; one time in February 2014, on 02/02/14; weekly in March 2014; twice in April 2014, on 04/09/14 and 04/23/14; three times in May 2014, on 05/07/14, 05/15/14 and 05/21/14; twice in June 2014, on 06/11/14 and 06/24/14; once in July 2014, on 07/02/14; and twice in August 2014, on 08/06/14 and 08/13/14. Additionally, the ulcer was not staged until the assessment completed on 04/09/14, when it was assessed as a Stage III pressure ulcer.

Based on observation, record review and interview the facility failed to ensure Resident #10 received the recommended adaptive equipment for dining to prevent a decline in range of motion and increased pain. Harm occurred when Resident #10 exhibited pain while using regular silverware to eat as opposed to the built-up silverware recommended upon the resident's discharge from occupational therapy. This affected one resident (Resident #10) of three residents reviewed for range of motion. Findings include: Review of the clinical record for Resident #10 revealed the resident was initially admitted on [DATE] and most recently re-admitted on [DATE]. Resident #10 had [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 01/02/14 revealed Resident #10 was moderately cognitively impaired, exhibited disorganized thinking, physical and verbal behaviors directed towards others, and no rejection of care. Resident #10 was assessed as requiring supervision and set up help with eating. Review of the occupational therapy evaluation and plan of treatment, dated 04/01/14, revealed Resident #10 was to be assessed for use of adaptive utensils to increase grasp patterns to increase activities of daily living. A long term goal of decreased pain in both hands was noted on the plan of treatment form. Resident #10 presented to occupational therapy with [MEDICAL CONDITION] arthritis, pain and decreased range of motion in both hands. Review of the occupational therapy discharge summary, dated 04/14/14 revealed Resident #10 was discharged with recommendations for a functional maintenance program and restorative nursing program. Built-up utensils were to be used to decrease pain associated with arthritis during feeding. Both hands were noted to be contracted; the left at 90 degrees and the right at 120 degrees. No evidence of a restorative nursing program was in the clinical record or provided when requested during the survey. Review of the care plan related to activities of daily living, dated 01/26/13 and last reviewed 08/01/14 revealed Resident #10 had contractures of the left fingers and hand. There was no reference to the resident's needs related to eating or dining as it related to the presence of the contractures noted in the plan of care. Review of the care plan related to nutrition, dated 08/12/14 revealed a nutritional risk related to [MEDICAL CONDITION] arthritis. There was no reference to the resident's needs related to eating or dining as it related to the presence of the contractures noted in the plan of care. Review of the care plan related to pain, dated 02/18/13 and last reviewed 08/1/14 revealed the resident had pain related to arthritis. Interventions included therapy referral as needed for pain management. There was no reference to the resident's needs related to eating or dining as it related to the presence of the contractures noted in the plan of care. Review of the diet order and communication form for Resident #10, dated 08/01/14, revealed no indication the resident was to receive adaptive equipment. On 08/22/14 at 5:30 P.M. an observation of Resident #10 eating dinner revealed the resident was provided a regular fork, spoon, and knife. The resident was observed to have difficulty grasping the utensils, taking only a bite and putting the utensil back down. The resident was observed to have on and off facial grimacing indicative of pain during the observation. During an interview with Resident #10 at that time, she revealed she did have other utensils at one point but had not for some time. The resident confirmed she was having pain while using regular utensils to eat and thought the other utensils were better for her and caused less pain. On 08/22/14 at 5:34 P.M., an interview with the administrator confirmed Resident #10 was using regular utensils. The administrator stated she would have to check if the facility owned built-up utensils. A follow-up interview at 5:40 P.M. revealed the facility did own built-up silverware but had not provided Resident #10 with the special silverware. On 08/22/14 at 5:54 P.M. interview with licensed practical nurse (LPN) #16 revealed Resident #10 did not have any dining-specific interventions on her care plans, including restorative therapy or the use of built-up utensils as noted following the resident's discharge from occupational therapy with recommendations for such.

Based on observation, medical record review, review of the facility's investigation, resident interview and staff interview, the facility failed to provide treatment to a pressure ulcer as per the physician's orders [REDACTED]. This affected one (Resident #19) of two residents who was reviewed for pressure ulcers (Resident #19). The facility identified three residents in the facility with a pressure ulcer. The census was 42. Harm occurred when Resident #19's existing Stage II (partial thickness superficial skin break) pressure ulcer deteriorated to an unstageable pressure ulcer and increased in size on 08/31/11. Findings include: Review of Resident #19's medical record revealed he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Wound evaluation flow sheets reviewed from the time of admission indicated the wound to the coccyx/sacrum healed on 03/11/11. The resident developed another pressure ulcer to the coccyx on 06/30/11. The pressure ulcer was said to be present when the resident was readmitted to the facility on that date. The wound was not staged on the wound evaluation flow sheet but included measurements of 2.5 centimeters (cm) length (l) by 3.0 cm width (w) x 0.1 cm depth (d). The wound was healed on 07/13/11. A wound evaluation flow sheet dated 08/07/11 revealed an open area was noted to the coccyx and indicated the wound to be moisture associated skin damage. The wound evaluation flow sheet had a place at the top of the right side of the form where staff was to mark as a pressure ulcer or an other type of wound. The form had identified the area as being an other wound and not pressure. The measurements recorded was 1.0 cm l x 0.8 cm w x 0.3 cm d. The wound measurements were slightly larger over the following two weeks with a measurement on 08/21/11 as being 1.8 cm l x 1.0 cm w x 0.2 cm d. A Hospice nursing clinical note and wound assessment dated [DATE] revealed the area to the coccyx was a Stage II (partial thickness superficial skin break) pressure ulcer with measurements of 1.8 cm l x 1.0 cm w x 0.2 cm d. The appearance of the wound was healthy, pink granulation tissue with no drainage and the surrounding skin to be healthy and intact. A Hospice nursing clinical note dated 08/25/11 revealed the resident's coccyx wound dressing was intact but the resident refused to have the dressing changed by Hospice. A Hospice nursing clinical note dated 08/31/11 revealed the wound to the coccyx had deteriorated as evidenced by an increase in size measuring 3.0 cm l x 3.0 cm w with a depth unknown. The wound was noted to have bloody drainage and was not noted to have any odor. The Hospice note indicated the Hospice nurse spoke with the facility's Director of Nursing (DON) regarding the wound deterioration. The DON refused to have the facility's wound nurse evaluate the wound. A wound evaluation flow sheet completed by the facility on 09/01/11 noted the same measurements as obtained by the Hospice nurse but also indicated the area was unable to be staged. The wound evaluation dated 09/01/11 also indicated the area had a moderate amount of exudate dark in color with a consistency documented as being bloody drainage. The wound bed was noted to have granulation and some slough. The surrounding tissue was pink. A Hospice nursing clinical note dated 09/09/11 revealed the wound continued to deteriorate. Measurements collected at that time indicated the area was 4.0 cm l x 3.0 cm w x 0.5 cm d. The facility's wound evaluation flow sheet dated 09/09/11 included the same measurements and indicated the wound could not be staged. It was described as having a black and gray, necrotic wound bed with a scant amount of black exudate. A wound evaluation flow sheet dated 09/16/11 revealed the wound increased in size from the previous week measuring 5.0 cm l x 1.2 cm w x 0.1 cm d. The wound evaluation flow sheets after 09/16/11 revealed the wound slowly improved as evidenced by a decrease in size to it's most recent measurement of 1.0 cm l x 0.5 cm w x 0.2 cm d on 11/30/11. Observations on 12/07/11 and 12/08/11 noted Resident #19 lying in a bariatric bed in a supine position with the head of bed in the up position. The bed was equipped with a specialty air flow mattress. The resident was obese and was receiving oxygen via a [MEDICAL CONDITION] collar. He was not observed to be in any position other than a supine position. Interview with Resident #19 on 12/08/11 at 9:40 A.M. revealed he had a pressure ulcer on his buttocks. He stated his dressing was supposed to be changed every day. He reported there was times when the dressing did not get changed on a daily basis. He revealed the dressing sometimes was not changed for two days or so. He recalled one time in the past when it went as long as three or four days without being changed. He could not recall when it was exactly but thought it may have been a couple months ago. Interview with Hospice Nurse #10 on 12/08/11 at 9:50 A.M. revealed Resident #19 had been under the care of Hospice since 08/10/11. She stated the wound management was a collaborated effort between the facility and Hospice services. She revealed she was not required to do the dressing changes but it was more of a courtesy for her to do so. She reported she talked with the facility nurse when she visited one to two times a week to see if the dressing needed changed or to let them know she changed it during her visit. She also indicated they shared wound measurements depending on who assessed the wound when the treatment was provided. She confirmed the documentation of the measurements obtained on 08/17/11, the Hospice note on 08/25/11 and the measurements obtained on 08/31/11 was her documentation. She acknowledged the wound showed evidence of deterioration during that time. When asked if she was aware of or had any concerns regarding treatment being provided to the coccyx wound, she stated she was able to recall one instance where she had concern. She could not recall the exact date but remembered being upset because the wound had deteriorated and she did not think the dressing changes were being provided as ordered. She stated she informed the DON of her concern and thought the nurse involved had been terminated. She could not recall what date was on the old dressing or how many days it was in place when she found it on 08/31/11. She thought it may have only been a few days since it had last been changed but was not certain. She confirmed the dressing was to be changed daily on the night shift. Interview with the Administrator on 12/08/11 at 2:20 P.M. revealed she was aware of an investigation that was conducted regarding Resident #19's pressure ulcer and treatment. She stated there was concern that the dressing to the resident's coccyx wound was not being provided by the nurse on night shift as ordered. She reported the facility completed an investigation on the concern when it was brought to their attention by a day shift nurse. The investigation concluded that a day shift nurse had noted on 08/31/11 that the resident's coccyx wound had a dressing dated which indicated it had not been changed for a week. Review of the treatment records showed the nurse falsified the record by signing that the dressing change was completed on 08/19/11, 08/20/11 and 08/24/11. On 08/25/11, 08/27/11 and 08/30/11, it was noted that the TAR was unsigned and the treatment was omitted by the nurse. As a result of the investigation outcome, the nurse involved who failed to provide the treatment as ordered was terminated for failure to follow the facility's policy and failure to follow acceptable standards of care. The nurse's failure to follow policy and standards of care resulted in a negative outcome for the resident. Interview with Wound Consultant #11 on 12/08/11 at 3:42 P.M., revealed she was the facility's consulting wound nurse but was not overseeing the wound care for Resident #19. She stated, with the resident being on Hospice, she was not permitted to be consulted in his care. After reviewing his wound evaluation flow sheets she confirmed Resident #19's pressure ulcer to his coccyx had shown a deterioration between 08/21/11 and 09/01/11. She stated based on the information provided on the assessment forms the pressure ulcer went from a Stage II pressure ulcer on 08/21/11 to a Stage III pressure ulcer on 09/01/11. She indicated the assessment completed on 09/01/11, which identified the wound as not able to be staged was not accurate. She reported with the documentation of some slough being present it should have been concluded that the pressure ulcer to the coccyx was a Stage III. She verbalized concern that the assessments completed by the facility's nurses did not include enough information to effectively monitor the wound and it's healing. This deficiency substantiates allegations contained in Master Complaint Number OH 343.