Every finding on record at Columbus Healthcare Center

Based on record review, observation, resident and staff interviews, and facility policy review, the facility failed to implement new safety interventions after a resident fall. This affected one resident (#42) of four residents reviewed. The facility census was 88.Findings include:Review of the medical record for Resident #42 revealed the resident was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, chronic congestive heart failure, retention of urine, need for assistance with personal care, and unsteadiness on feet.Review of the most recent quarterly Minimum Data Set 04/23/26 revealed Resident #42 was assessed as being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Resident #42's required at least partial assistance with transferring on and off the commode.Review of Resident #42's task documentation dated 06/14/26 revealed the resident required maximal assistance on this day. Review of Resident #42's care plan report revealed the resident was noted to be noncompliant with asking for assistance with transfers, though there were no interventions in place to directly respond to the resident's known non-compliance with using their call light. Review of interventions revealed common fall interventions such as educating the resident or their representative, ensuring the room is free of hazards, completing fall risk assessments, physical and occupational therapy to evaluate/treat, and ensuring that bed locks are engaged.Observation on 06/23/26 at approximately 12:00 P.M. revealed Resident #42 had significant bruising in a deep purple color, to the left side of their face and along their left forearm.Interview on 06/23/26 at 12:02 P.M. with Resident #42 revealed they had fallen a little over a week prior, and they fell to the floor after slipping on liquid that was on the floor in their restroom when they were trying to help themselves up from the toilet to their wheelchair. Resident #42 stated they had used their call light and kept waiting for staff, kept waiting and waiting and then tried to transfer themself from the toilet to their wheelchair alone when no staff responded to the call light. Resident #42 stated that they slipped and fell on either water or urine that was on the floor, and the fall led to them hitting their head along the left side of their face, hitting their left arm, and bruising the great toe of their left foot. Observations on 06/24/26 at 10:12 A.M. and 11:20 A.M. revealed repeated instances where Resident #42 was observed to have transferred to the bathroom on their own by self-propelling in their wheelchair, and shortly after entering the bathroom, the call light outside the room would come on before nearby staff would notice and CNA #163 would enter to assist the resident with transfer off of the commode.Interview on 06/24/26 at 10:49 A.M. with Certified Nursing Assistant (CNA) #163 revealed Resident #42 will often use his call light once he has gotten to the bathroom and needs to get off of the commode, he often does not use the call light to notify us that he needs to go to the bathroom. Further interview with CNA #163 stated ideally, staff would be alerted of when the resident needed to go to the bathroom, so that they could assist the resident to the bathroom, help them get on the commode, and then staff would be aware that the resident was using the commode so that they would anticipate him needing to come off of the commode. CNA #163 stated Resident #42 should be using the call light to notify us that he needs to go to the bathroom, but it is known that he often doesn't use the call light until he has already arrived at the commode.Interview on 06/24/26 at 12:10 P.M. with CNA #163 revealed not all residents on the hall with Resident #42 are automatically considered an every two-hour check and change, rather that each resident has different and unique needs. CNA #163 stated Resident #42 is not someone that is designated to be checked, reminded, or prompted for toileting.Review of a nursing progress note dated 06/14/26 at 11:20 P.M. revealed the resident was found on the bathroom floor with noted bleeding and swelling under their left eye after the resident called for help when the fall occurred. Further review of this progress note revealed the resident was sent to the hospital for further evaluation.Review of the fall investigation/incident form for Resident #42's fall that occurred on 06/14/26 revealed Resident #42's call light was on at the time of the fall, but the resident was using the bathroom unassisted when they slipped and fell, which led to them striking their head. Further review of the fall investigation form revealed upon return from the hospital resident was reminded to call for assistance with toileting and resident voiced understanding. The fall investigation/incident form revealed the facility documented not applicable to care plan updated related to the fall. Review of Residnet #42's care plan revealed the care plan was not updated after the fall on 06/14/26 with new intervention to protect the resident from additional falls. Interview on 06/24/26 at 4:06 P.M. with Regional Registered Nurse (RN) #300 revealed typically it is the facility's process to update the resident's care plan after a fall occurs, to ensure that all necessary safety interventions are in place to meet the needs of the resident and prevent subsequent falls. Regional RN #300 stated Resident #42 was hell bent on assisting himself to the restroom under the belief that he had been cleared by physical therapy staff to do so, even though he was not. Regional RN #300 confirmed Resident #42 is known to be noncompliant with using their call light for assistance to the bathroom, and speaking of Resident #42, Regional RN #300 stated We can't force him to do what he doesn't want to do. He makes his own decisions. Regional RN #300 believed Resident #42 was fully continent, even after verifying that the resident was identified as incontinent of bowel on their most recent care plan. When asked if any other fall prevention interventions were added to Resident #42's care plan after their fall that occurred on 06/14/26 to prevent future falls, Regional RN #300 stated do you want my opinion, or do you want what's in the record? Regional RN #300 verified no new fall interventions were implemented or added to Resident #42's plan of care to prevent subsequent falls as a result of the fall on 06/14/26, stating no new interventions were done besides continued re-educating the resident.Review of the facility policy titled Plan of Care Overview (no date) revealed it is facility policy to provide resident-centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Further review of this policy revealed safety is a primary concern for residents at the facility. Additional review of this policy revealed that resident care plans should be reviewed as indicated after a significant change occurs, and that care plan documents should be resident specific or resident focused, and reflect the resident's opportunities for participation and preferences regarding their care.This deficiency represents an incidental finding discovered while investigating complaints #3051421, #3046019, #3027695, #3026786, #3025754, #3016703, and #3015583.

Based on record review, and staff interviews the facility failed to ensure medications were obtained in a timely manner and were administered as per orders. This affected one resident (#89) out of three residents reviewed for medications administered. The facility census was 88.Findings include:Review of Resident #89's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, borderline personality disorder, bipolar disorder, postural orthostatic tachycardia syndrome, and suicidal ideations.Review of the comprehensive Minimum Data Set, dated [DATE] revealed Resident #89 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15.Review of physician orders contained in Resident #89's medical record revealed orders for the following medications: Enoxaparin Sodium solution (a blood thinning medication) 40 milligrams (mg) injected subcutaneously two times a day dated 04/16/26, Vancomycin (antibiotic) 1500 mg given intravenously (IV) every eight hours for sepsis dated 04/16/26, Mupirocin external ointment (anti-infective) applied around the resident's J tube site (an opening in the abdomen) two times daily for seven days dated 05/01/26, and Nystatin (antifungal) powder applied topically to the groin every morning and at bedtime dated 05/05/26.Review of Resident #89's medication administration record (MAR) for April 2026 revealed there was no documentation the Enoxaparin injection was administered on 04/16/26 or 04/17/26, or the IV Vancomycin was administered on 04/16/26 as ordered.Review of Resident #89's MAR for May 2026 revealed there was no documentation the Mupirocin external ointment being administered on 05/06/26, and there was no documentation the Nystatin powder was administered on 05/06/25 as ordered.Interview on 06/25/26 at 4:34 P.M. with the Director of Nursing (DON) verified there was no documentation in Resident #89's MAR or throughout their medical record to indicate the following medications were administered as ordered: Mupirocin external ointment on 05/06/26, Nystatin powder on 05/06/26, Enoxaparin injections on 04/16/26 or 04/17/26, and IV Vancomycin was administered on 04/16/26. Further interview with the DON at this time revealed that although the vancomycin was ordered at 4:00 P.M. on 04/16/26, the expectation was that the medication would either be available or delivered in time to administer the medication as per physician orders, or there would be documentation indicating why the medication was not administered. The DON confirmed there was not documentation to support why the MAR IV vancomycin was not administered as ordered.This deficiency represents non-compliance investigated under Complaint Numbers 3051421, 3025754, 3016703, and 3015583.

Based on observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure call lights were kept within resident's reach. This affected one resident (#2) out of three residents reviewed for call lights. The facility census was 88. Findings include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia and paroxysmal atrial fibrillation.Review of Resident #2's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was assessed as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. Resident #2's required partial or moderate assistance with sit to stand transfers, such as standing up from a seated position on the bed.Interview on 06/23/26 at 11:26 A.M. with Resident #2 revealed the resident believed their call light was on the floor just next to his bed, so that his arm could reach down to the floor and reach the call light if he needed to use it. The resident was then observed to reached over the side of his bed, to find that the call light was not where he thought it was, Resident #2 could not reach the call light and stated he did not know where it was.Observation on 06/23/26 at 11:28 A.M. revealed Housekeeper #212 entered Resident #2's room and immediately located the call light behind the head of the bed, near the wall. Housekeeper #212 was observed to picked up the call light from behind the bed and placed it next to Resident #2.Interview on 06/23/26 at approximately 11:30 A.M. with Housekeeper #212 revealed they had deep cleaned Resident #2's room around 9:00 A.M. that morning, and they thought they remembered seeing Resident #2's call light on the floor while cleaning the room. Housekeeper #212 revealed they could estimate how long Resident #2's call light might have been out of reach of the resident.Review of the facility policy titled Resident Rights (no date) revealed residents will be treated with dignity and respect including but not limited to having a method to communicate needs to staff such as a call light or bell access kept within reach of the resident as one method to communicate needs to staff.This deficiency represents non-compliance investigated under Complaint Number 3051421 and 3015583.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure non-pharmacological interventions were utilized and adequate assessments of pain were completed prior to administering as needed pain medications. This affected one (Resident #94) of three residents reviewed for pain management. The census was 93.Findings Include:Review of the medical record revealed Resident #94 was admitted to the facility on [DATE]. Diagnoses included alcoholic cirrhosis of the liver with ascites, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, other chronic pain, polyneuropathy, hyperlipidemia, hypertension, alcohol dependence, morbid obesity, insomnia, restlessness and agitation, mood disorder, vitamin D deficiency, and unspecified convulsions. Review of Resident #94's Minimum Data Set (MDS) assessment, dated 04/10/26, revealed he was cognitively intact.Review of Resident #94's current physician orders, revealed the resident was ordered as needed pain medications including the narcotic oxycodone-acetaminophen tablet 5-325 milligrams (mg) every eight hours as needed for pain, ibuprofen oral tablet 200 mg every six hours as needed for pain management, and acetaminophen oral tablet 325 mg every six hours as needed for breakthrough pain. There was no evidence to support specific parameters or instructions, related to pain levels, for when each as needed pain medication should be administered.Review of Resident #94's medication administration records (MAR), from 03/24/26 to May 2026, revealed as needed pain medications were administered for indication of a pain level of zero on a 10-point pain scale or with no documented pain level. In March 2026, oxycodone-acetaminophen 5-325 mg was administered eight times with no pain assessment completed or with a pain level of zero. In April 2026, acetaminophen 325 mg was administered five times for a pain level of zero, ibuprofen 200 mg was administered 13 times with a pain level of zero, and oxycodone-acetaminophen 5-325 mg was administered 14 times with a pain level of zero. In [NAME] 2026, acetaminophen 325 mg was administered three times for pain level of zero, ibuprofen 200 mg was administered eight times for a pain level of zero, and oxycodone-acetaminophen 5-325 mg was administered six times for a pain level of zero.Review of Resident #94's current physician orders revealed his pain level was to be assessed every shift and the facility was to document non-pharmacological pain intervention prior to as needed pain medication administration. Non-pharmacological interventions included repositioning, ice, distraction, and relaxation.Review of Resident #94's MARs and treatment administration records (TARs), dated 03/24/26 to May 2026, revealed no documented attempts for non-pharmacological interventions prior to the administration of as needed pain medications.Interview with Registered Nurse (RN) #195 on 05/13/26 at 9:03 A.M. and Licensed Practical Nurse (LPN) #178 on 05/13/26 at 9:10 A.M. confirmed they would not give as needed pain medication to residents with a pain level of zero. They also confirmed the nurses are to attempt and document the attempt and completion of non-pharmacological interventions prior to administering as needed pain medications. Both RN #195 and LPN #178 confirmed they would expect as needed pain medications to have parameters on when to give the medication, especially if a resident had multiple types of as needed pain medications ordered.Interview with [NAME] President of Clinical Services (VPCS) #403 on 05/13/26 at 12:40 P.M. confirmed there was no documentation for non-pharmacological interventions attempted for Resident #94 when administering as needed pain medications on the occasions mentioned above in March, April, and May 2026, and confirmed there should have been. VPCS #403 confirmed there should not be as needed pain medication provided to a resident with a pain level of zero, which she confirmed there was documentation for Resident #94 receiving as needed pain medication administered for pain levels of zero as mentioned above.Review of the undated facility pain management and assessment policy revealed to the extent possible and in consideration of cognitive abilities, the nurse will provide a thorough assessment by observation of activities and treatment/relief for detection of pain and to attempt to identify location and any limitations imposed by pain. Additionally, the basis for the pain management includes but was not limited to resident's needs and goals, and source, type, and intensity of pain. The facility will document medication pain relief and response, non-pharmacological measures attempted and the resident's response, and care plan updates as needed. This deficiency represents non-compliance investigated under Complaint Number 3006435 and Complaint Number 3002091.

Based on medical record review, staff interview, and review of a facility staff schedule, the facility failed to provide adequate staffing to meet the behavioral safety needs of all residents. This affected one (Resident #41) of three residents reviewed for behavior management. The census was 93.Findings Include:Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder, systemic inflammatory response syndrome, borderline personality disorder, postural orthostatic tachycardia, disorientation, mood disorder, suicidal ideations, convulsions, personal history of other mental and behavioral disorders, conversion disorder, anxiety disorder, headache, bipolar disorder, post-traumatic stress disorder, insomnia, muscle weakness, muscle wasting, dysphagia, and fibromyalgia. Review of Resident #41's Minimum Data Set (MDS) assessment, dated 04/29/26, revealed she was cognitively intact.Review of Resident #41's progress notes, dated 04/21/26, revealed she was placed on facility issued one-on-one staff supervision on 04/21/26. As of 05/13/26, there was no documentation to support Resident #41 was taken off one-on-one staff supervision. Interview with Certified Nurse Aide (CNA) #160 on 05/13/26 at 11:13 A.M. confirmed she was working in the facility on 05/01/26. CNA #160 confirmed the schedule had her listed as one-on-one staff on 05/01/26, but it did not indicate with which resident she was assigned to. CNA #160 stated the schedule also had her listed as working on the back of the 100 hall. CNA #160 stated she started in Resident #41's room as one-on-one staff, but later, a female staff person pulled her and indicated she was to be working on the back of 100 hall as the facility did not have any staff there. CNA #160 stated, about 40 to 45 minutes later, a night shift nurse supervisor came to her and stated she needed to be in Resident #41's room because that was where she was assigned. CNA #160 confirmed she was not aware of anyone being in Resident #41's room for the time she was not in there on 05/01/26 and also confirmed the night shift nurse supervisor stated no one had been in Resident #41's room.Interview with the Administrator and [NAME] President of Clinical Services (VPCS) #403 on 05/13/26 at 11:25 A.M. confirmed the staff schedule on 05/01/26 had CNA #160 listed as being one-on-one for her assignment, even though it did not indicate which resident the one-on-one supervision was for. The Administrator and VPCS #403 also confirmed CNA #160 was assigned to the back of 100 hallway on 05/01/26 as well. Review of facility staff schedule, dated 05/01/26, revealed CNA #160 was scheduled to work the back of 100 hall, but next to her name was indicated 1:1.This deficiency represents non-compliance investigated under Complaint Number 3007315.

Based on medical record review, staff interview, review of the fall investigation, review of hospital records, hospital staff interview, and review of facility policy, the facility failed to ensure that staff followed the established care plan and safety protocols for Resident #99 during the provision of care to prevent an incident/accident resulting in the resident falling from the bed to the floor sustaining serious injuries. This resulted in Actual Harm on 03/26/26 when Certified Nursing Assistant (CNA) #333 had provided perineal care independently to Resident #99 while the resident was in bed. Resident #99, who was incontinent, had a communication deficit, was unable to lay on her side without support and care planned for two staff assistance for rolling side to side, rolled sideways off the bed to the floor from approximately 30 inches high, landing with her left knee on top of the air conditioning unit and was screaming and tapping at her left knee indicating pain. Subsequently, Resident #99 was sent to the local hospital where she was diagnosed with femur fractures in both legs. The left leg was treated with a retrograde nail, and the right leg was amputated for comfort. This affected one resident (#99) of three residents reviewed for accidents. The facility census was 90. Findings include:Review of the medical record for Resident #99 revealed an admission date of 05/10/24. Diagnoses included anoxic brain damage, hypoxic ischemic encephalopathy, spastic hemiplegia affecting right dominant side, morbid (severe) obesity due to excess calories, type two diabetes mellitus without complications, unspecified convulsions, contracture, right elbow, anxiety disorder, major depressive disorder and cognitive communication deficit. The resident's contracture to the right leg was not included as a diagnosis.Review of the fall risk assessment dated [DATE] for Resident #99 revealed Resident #99 was noted to be a total mechanical lift for all transfers because she was unable to bear weight, unable or unwilling to cooperate, was limited in movement and heavy or obese. Resident #99 was noted to be non-ambulatory. Per Section E of the assessment, the resident was identified as a potential risk for falls; however, Section F asked if Section E identified the resident as at risk for falls and 'no' was selected.Review of the care plan entry revised on 07/30/24 noted Resident #99 had a communication problem due to her anoxic brain injury. It was noted she had an iPad for communication, and she was able to use it but didn't like to. The care plan entry noted that she was able to answer yes or no questions without the iPad. Interventions recommended to allow adequate time to respond, repeat as necessary, do not rush, request feedback, clarification from resident to ensure understanding, face the resident when speaking and make eye contact, turn off television/radio as needed to reduce environmental noise, ask yes/no questions if appropriate, and use simple, brief, consistent words/cues.Review of the care plan entry revised on 02/21/25 revealed Resident #99 was at risk for falls due to anoxic brain injury, spastic hemiplegia and convulsions with interventions to assess fall risk quarterly, ensure residents room was free of potential visible hazards, ensure the bed locks were engaged, place call bell within reach, and remind resident to call for assistance. The care plan also noted an activities of daily living (ADL) self-care performance deficit due to the anoxic brain injury, hemiplegia affecting the right dominant side and contractures. The care plan noted Resident #99 was resistive to care, and would yell at and hit at staff during care. The interventions section was reviewed on 02/26/26 and indicated Resident #99 was dependent on care and required assistance of two or more helpers to roll left and right.Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #99 had severe cognitive impairment and was dependent upon staff for toileting, showering, dressing and personal hygiene. Resident #99 was also dependent on staff for transfers from bed to chair, tub/shower, and rolling left and right. Per the coding description within the MDS, dependent upon staff means helper does all of the effort, the resident does none of the effort to complete the activity, or the assistance of two or more helpers was required for the resident to complete the activity.Review of Kardex GG Roll left and right documentation for Resident #99 for 03/10/26 to 03/26/26 revealed on 03/11/26 at 12:09 P.M., 03/12/26 at 2:53 A.M. and 03/26/26 at 12:22 A.M. total dependence of two [staff] was checked, meaning two staff assisted the resident in rolling left to right.Review of the progress note dated 03/26/26 at 6:35 A.M., authored by Registered Nurse (RN) #548 revealed the nurse heard Resident #99 screaming and went in the room to check and found Resident #99 on the floor. CNA #333 was in the room with the resident and had been changing the resident at the time. The nurse and other staff helped Resident #99 back to bed, notified the unidentified on-call Certified Nurse Practitioner (CNP) and obtained an order to send the resident to the emergency room for further evaluation and notified the residents family and the Director of Nursing (DON).Review of the fall investigation revealed on 03/26/26 at 6:30 A.M., Resident #99 fell while a CNA was providing care to the resident, by herself. The resident was lying on her right side in bed. The CNA had her hand on the resident's waist, the resident was [rolled] holding onto the bed frame with her left hand, the resident raised her left hand and pushed up against aide. The CNA released her hand and the resident slid out of bed. The immediate intervention was that the resident was sent to the emergency room (ER) for possible evaluation and treatment of a possible fracture. Fall interventions in place at the time of the fall included call light within reach, bolsters to air mattress in place, bed locks engaged, room free of environmental hazards and observed medication side effects for potential falls. The new intervention was for the resident to be a two person assist with bed mobility. Per Resident #99's care plan dated 02/26/26, the resident was already required to have two staff assistance with rolling from left to right. The fall investigation did not include a Root Cause Analysis for how the fall occurred, but it included a re-enactment of the fall.Review of the undated fall re-enactment of the 03/26/26 incident with Resident #99 and CNA #333 as documented by Regional Director of Clinical Operations (RDCO) #611 revealed CNA #333 introduced herself to the resident and explained what she was going to do. She demonstrated she started with the resident on her back, and she opened the brief and provided perineal care to the front of the resident. She then demonstrated she rolled the resident toward her and did perineal care to the back, tucking the old brief under the patient, and rolling the soiled draw sheet and brief underneath the resident, and a new brief was applied under her as well. She rolled the resident away from her toward the window and over the soiled linen onto her right side, and the resident was scooted down into the bed to where her waist was lateral to the opening in the perimeter mattress and patient reached over the perimeter mattress with her left arm grabbing the bed frame. She stated the bed was elevated to her waist level and she was approximately five feet tall. She stated the soiled linen was not under the patient once she rolled her to her right side as she had tucked them prior to rolling from the left side to the right. She demonstrated that her left hand was on the residents left hip and suddenly the resident removed her left hand from the bed frame and reached back and tapped on her hand that was on the patients left hip, so she removed her hand and at that time the patient slid from the bed; her left knee was bent and on top of the air conditioning unit (AC). She walked around the bed and as she was doing that, the resident pulled her knee off the AC unit and was in a sitting position with her back against the bed. She made sure the resident was in a safe position and went and got the nurse and she reported the resident was tapping at her left knee as if she was in pain.Review of the witness statement from RN #548 as transcribed by the DON dated 03/26/26 at 6:39 A.M. revealed CNA #333 was changing Resident #99 and she fell out of bed. RN #548 stated that she immediately called nine-one-one (911) due to the resident screaming and she notified telemedicine.Review of the progress note dated 03/26/26 at 6:35 A.M. for Resident #99 revealed the nurse conducted a neurological examination and checked the residents vital signs and applied an ice pack to the residents left knee.Review of the hospital notes dated 03/26/26 at 10:36 A.M. revealed Resident #99 was transferred from the initial hospital to another trauma hospital for specialized care after discovery of a left femur fracture.Review of the hospital notes dated 03/29/26 at 11:20 A.M. revealed Resident #99 endorsed that her pain was well controlled on her left lower extremity; however, she indicated persistent right lower extremity pain. The note indicated this was the site of chronic contractures however there was persistent pain and pain on palpation. An x-ray was obtained and demonstrated a right distal femur fracture.Review of the hospital X-ray report of the right femur dated 03/29/26 at 1:21 P.M. revealed the resident had an oblique fracture of the distal femur with posterior displacement of the distal fracture fragment.Review of the hospital progress note dated 04/03/26 at 2:56 P.M. revealed Resident #99 had surgery on 03/27/26 to obtain a left retrograde intramedullary nail. The note further indicated that the left and right femur fractures were pathological due to a combination of diffuse osteopenia and trauma which alone would not have resulted in a fracture. The author noted that initially the plan was for non-operative management for the right leg due to the contracture; however, Resident #99 had significant discomfort and uncontrolled pain.Review of the hospital progress note dated 04/05/26 at 12:02 P.M. revealed orthopedics evaluated the right femur fracture and initially the plan was for non-operative management, but given the residents significant discomfort, and uncontrolled pain, the plan was for a possible above the knee amputation (AKA) on 04/06/26.Review of the hospital progress note dated 04/06/26 at 10:49 A.M. revealed Resident #99 communicated by pointing and gesturing due to her anoxic brain injury. She stated her pain was a 9/10 (on a scale of zero to 10, zero being no pain and 10 being the worst pain). The resident seemed upset about her [AKA] surgery being cancelled due to pain. The writer explained that operating room availability was an issue that day and it was moved to Wednesday [04/08/26].Review of the hospital progress note dated 04/08/26 at 4:11 P.M. revealed Resident #99 had just returned from the operating room from the right AKA. She had a history of prior anoxic brain injury and was minimally ambulatory and communicative at baseline. The resident pointed to her right leg which was painful. She pointed to the 10/10 pain on the FACES pain scale (a pain scale with different faces representing someone's level of pain).Review of the hospital progress note dated 04/10/26 at 2:29 P.M. revealed Resident #99 was seen on morning rounds, was described as initially very agitated and appeared to be in pain.Review of the hospital progress note dated 04/13/26 at 12:32 P.M. revealed Resident #99's severity of pain was to be expected given the left and right femur fractures and extensive surgical intervention, and this was five days after her right AKA. The note indicated the resident pointed to her right leg, which was painful, she pointed to a 10/10 pain on the FACES pain scale.An interview on 04/23/26 at 12:43 P.M. with Psychiatric Mental Health Nurse Practitioner (PMHNP) #400 revealed Resident #99 would only let one or two people help her and it had to be a certain time of day. She was a larger person and if she was going to turn on her side, she would need assistance to stay on her side. PMHNP #400 noted that when Resident #99 was in a bad mood, her cognition was poor. PMHNP #400 said if you didn't know Resident #99 well, it would be hard to communicate with her.A telephone interview on 04/23/26 at 2:07 P.M. with CNA #333 revealed she had cared for Resident #99 before and noted Resident #99 would yell a lot. She said she had watched others do perineal care by themselves with Resident #99, but this was the first time she had done perineal care with her by herself. She said that Resident #99 would hold up one or two fingers to tell you if she wanted one or two people to change her. She noted Resident #99 was very particular about where she lay on the bed and liked to be on the edge. She would hold onto to bed with her left hand. CNA #333 said that she was done with changing Resident #99 and was smoothing everything out on the pad. She said she had her hand on Resident #99's hip and the resident let go of the bed to swat her away. She said she wouldn't ever want to keep her hands on someone who didn't want to be touched and so she removed her hand and that's when the resident slipped off the bed. She said when she demonstrated what had happened, she was told she should have rolled the resident towards her. She said how could you do that as Resident #99 was over 200 pounds. She denied resident required two-person assistance for toileting because she watched other aides change Resident #99 by themselves. She said she felt really bad about what happened though she didn't think she did anything wrong because she did what she saw others do.An interview on 04/23/26 at 2:54 P.M. with CNA #355 revealed that usually Resident #99 required one-or-two-person assistance. She said she usually had two though. She said she never had Resident #99 resist care with her, but she wasn't sure about the others. She said she looked at the care plan to know what care a resident needed.An interview on 04/23/26 at 3:21 P.M. with Crisis Nurse #622 confirmed the ADL care plan for Resident #99 indicated that Resident #99 required assistance of two or more helpers to roll left and right and confirmed that when an aide provided perineal care in the bed, it would require rolling the resident.An interview on 04/23/26 at 3:26 P.M. with RDCO #611 revealed that the care plan indicated Resident #99 required one person assistance for toileting. He provided and confirmed the aide Kardex documentation of times when aides used one person or two-person assistance with Resident #99.An interview on 04/27/26 at 9:43 A.M., with the Director of Risk #633 revealed they did not have a policy defining what parameters (such as over a certain weight or diagnosis such as spasticity) they would automatically use two aides to assist with a resident. She said they didn't have that because their care plans were individualized.An interview on 04/27/26 at 10:29 A.M. with CNA #377 revealed Resident #99 was very particular on how to handle her. If you didn't know her and how to communicate with her, it could be a problem. If you had a hard time understanding her, she would get upset and worked up and start yelling. She stated her one leg [indicating her right leg] was bent permanently. CNA #377 admitted she hadn't provided perineal care for Resident #99, but she believed her to be a two person assist because of the contracture.An interview on 04/27/26 at 11:36 A.M. with MDS Nurse #515, she stated she determined what she entered into the MDS assessment based on interviews with staff and record review. She said if there were three times during a lookback period where two staff were used [for care], then that was what she was required to say. She confirmed there were three times in the lookback period in which two aides assisted Resident #99. She said Resident #99 was very noncompliant and her moods varied. She said because she had known Resident #99 for a long time, she theoretically could change Resident #99 by herself also because she had been working in the industry for a long time; however, she wouldn't do that due to safety reasons. She said how things would go with Resident #99 would depend on whether Resident #99 was having a good day or a bad day and you wouldn't know when you walked into the room which it was going to be. She said she was very surprised to hear about the fall but was not surprised to hear about Resident #99 swatting at the aide. She said they even had Resident #99's behaviors of swatting at staff and being resistant to care in the care plan.An interview on 04/28/26 at 9:16 A.M. with RDCO #611 confirmed the most recent fall risk assessment he could find for Resident #99 prior to the one completed on 03/26/26 was dated 05/24/24. He said he would typically expect them to be done quarterly and wasn't sure why one wasn't done more recently. He noted that perhaps one hadn't been done more recently because she hadn't had a fall.An interview on 04/28/26 at 9:57 A.M. with CNA #388 revealed she had helped to change Resident #99 previously and felt she knew her well. She said Resident #99 would indicate to you where she would let you touch her. She said for safety purposes she always had two aides for perineal care. She said technically, one person might be able to do it alone but for your own safety and for the residents' safety, it would be better to have two because of the contracture. She said she was there the day the incident happened and she heard the resident screaming. She said Resident #99 was very picky with care. She said Resident #99 had never swatted at her, but she knew that was a behavior of hers.An interview on 04/28/26 at 10:06 A.M. with Licensed Practical Nurse (LPN) #526 revealed Resident #99 would scream because she wasn't able to communicate and she would indicate with hand gestures where she hurt. She said she usually saw two aides doing perineal care for Resident #99 and they would know that based on the admission assessment. She said Resident #99 never swatted at her.An interview on 04/28/26 at 10:12 A.M. with Medication Technician #537 revealed he almost always saw two people providing care for Resident #99 because one person wouldn't be able to turn her.An interview on 04/28/26 at 10:33 A.M. with Hospital RN Case Manager (RNCM) # 411 revealed Resident #99 was in an extreme amount of pain in the hospital. She said Resident #99 just kept screaming out that she needed medication. She said when they were talking about discharge planning, Resident #99 would get upset because she didn't want to leave because of the pain. She said this was after the left leg surgery and before the right leg amputation. She said she saw Resident #99 pointing to her right leg to indicate the pain. RNCM #411 said she saw Resident #99 after the amputation and that Resident #99 appeared to still have pain but wasn't as animated about the pain as she was before. She said Resident #99 was adamant about not wanting to return to the facility and would vigorously shake her head no. RNCM #411 said she was able to establish that Resident #99 wasn't afraid to go to a facility, it was specifically that she didn't want to return to the facility where she had been.An interview on 04/28/26 at 10:51 A.M. with hospital trauma service Certified Nurse Practitioner (CNP) #422 revealed they discovered Resident #99's osteopenia when they did a computed tomography (CT) scan in the hospital. She said it would be really hard for someone of Resident #99's age to break a femur and so the osteopenia was part of the reason for the fracture, but that the fall was definitely a contributing factor. She said [Resident #99] wouldn't have broken those bones from the osteopenia alone. She said it was clear that Resident #99 was in pain the way she was crying out.Interview on 04/28/26 at 1:11 P.M. with RDCO #611 revealed the care plan entry regarding Resident #99 requiring two people for rolling left and right was originally initiated on 08/18/25 and was reviewed on 02/26/26. He said there was nothing that was changed related to this on the 02/26/26 date. He confirmed the last known weight they had for Resident #99 was 246.8 pounds on 06/01/24; however, he thought she weighed less because she had been on Trulicity for approximately six months and she had lost weight from that. He stated the 2024 weight was the last weight as the resident had since refused to be weighed.Review of the undated Fall Prevention and Management policy revealed a Fall Risk Assessment should be completed upon admission, quarterly and with any significant change of condition. Information about resident should be obtained from many different sources. Other factors should include the environment, medications, physical and mental diagnosis as well as the residents' current ADL status. If the resident is identified to be at risk for falls, a care plan should be initiated that includes a plan to potentially diminish the risk for falls. The care plan can include interventions that address environmental factors, ADL factors, risk factors that result from dementia and other mental diagnosis, and medical diagnosis that put the resident at higher risk. Issues such as toileting, eating, transferring and impulsiveness should be considered. The policy suggested once the resident was safe, a fall investigation should begin. The policy suggested to ask the resident what they were doing when they fell, identify if there were any witnesses to the fall. Ask them what they saw and have them write a statement if possible. The policy noted immediately written statements would provide more detail than asking later. The policy suggested attempting to put an intervention in place that could prevent further falls, such as, if the resident was going to the bathroom, assist them to the toilet. If the resident was getting a drink and overreaching, place the drink within range. It stated to attempt to identify why the resident fell and put an immediate intervention in place.This deficiency represents an example of continued non-compliance investigated under Complaint Number 2984816.

Based on observation, interview, and facility policy review, the facility failed to store food in a safe and sanity manner. This had the potential to affect all 95 residents admitted to the facility. The facility census was 95.Findings include: Observation of the kitchen dry storage on 03/16/26 at 9:19 A.M. revealed about four bags of unnamed/unlabeled breadsticks on top of the dry storage shelving unit. Further observed revealed some of the breadsticks were observed to have a blueish-green spots on the bread. Observation of the stand-alone fridge on 03/16/26 at 9:30 A.M. revealed a tray of about ten cups of juice; two of the cups were not covered and none of the ten cups were dated. Interview with Kitchen Manager #367 on 03/16/26 at 9:20 A.M. confirmed the breadsticks were not stored in the proper location and removed them from the dry storage area and disposed of them. Additional interview with District Manager #374 confirmed the cups in the fridge should all have covers on them and confirmed items in the kitchen should all have dates on them. Review of the facility's Food Storage policy, revised 02/2023, revealed storage areas will be neat, arranged for easy identification, and date marked as appropriate, and all food items will be kept clean, dry, and properly sealed.

Based on interview and document review the facility failed to ensure kitchen equipment was maintained in safe operating condition. This had the potential to affect all 95 residents residing within the facility. The facility census was 95.Findings include: Interview with District Manager (DM) #374 on 03/17/26 at 8:40 A.M. revealed one of the ovens is under cooking, the second over is over cooking, and the steamer is not fully functional. DM #374 reported the equipment has been in this condition for at least three weeks, and due to this the facility has been using emergency menus. DM #374 confirmed the equipment not being in working condition has been reported to maintenance and the administrator. Interview with the administrator on 03/17/26 at 8:50 A.M. confirmed the ovens were not working properly and was not aware of the issue with the steamer. The administrator reported new parts were ordered and scheduled to be delivered over the weekend. The administrator was unable to confirm when the equipment stopped functioning properly. Additional interview with the administrator on 03/17/26 at 10:02 A.M. revealed the administrator planned to contact someone about the steamer to address the report of it not functioning properly. The administrator further revealed a company came to service the oven in January of 2026 and confirmed the ovens were functional. Additional issues with the oven were identified in February 2026 which resulted in a quote being requested for a new oven range on 02/17/26, and a quote was received the same day. The administrator confirmed the oven was paid for and was supposed to be delivered on 03/13/26 but it did not arrive. The administrator reported he had not yet followed up with the company to inquire about the oven. Interview with Dietitian #370 on 03/17/26 at 11:23 A.M. revealed the kitchen oven had been having issues since November. Dietitian #370 reported she had notified the facility monthly since November about the concerns with broken equipment and stated she had concerns with equipment in the kitchen not being fixed within a timely manner. Dietitian #370 revealed the equipment fix for the oven in January did not last for more than a week and this was when she put her foot down about the facility addressing the need for the oven range to be replaced. Follow-up interview with the Administrator on 03/17/26 at 2:40 P.M. revealed the oven was now scheduled to be delivered on 03/20/26. Interview with Account Manager (AM) #398 on 03/17/26 at 4:30 P.M. revealed the facility did not identify the purchase of the oven range as being an emergency or needing it urgently. AM #398 revealed the item being identified as emergent would not necessarily result in the items being delivered sooner. AM #398 confirmed the oven was purchased and was scheduled for delivery. Review of the Quality Assurance Evaluations on 03/17/26 from November 2025 to March 2026 revealed the following:-11/10/25 - Under essential equipment it is noted the oven does not work well/pilot light issues-12/08/25 - Under essential equipment it is noted the oven was not working properly-01/14/26 - Under essential equipment it is noted the oven was not working, in process of getting it fixed-02/16/26 - Under essential equipment it is noted the oven was not working properly, pellet warmer broken-03/16/26 - Under nutrition/hydration status it is noted an emergency menu was in place due to the oven broken, and under essential equipment it is noted a new oven was ordered and the pellet warmer was broken. Review of work orders on 03/17/26 revealed the following work orders for the kitchen:-12/08/25 - 12/09/25 Pellet warmer does not drain properly-12/08/25 - 01/19/26 Oven does not work well/pilot light issues-01/26/26 - 02/02/26 Oven issues with the comments of the oven and flat top are not heated to the correct temperature and the pilot light was out.-01/26/26 - 01/29/29 Pellet warmer with comments of the pellet warmer was not working-02/04/26 - 02/05/26 The induction plate warmer does not heat-02/04/26 left side of the oven is not working-02/16/26 - 02/19/26 The oven was identified as not working well and/or having pilot light issues Review of invoice #2198351 dated 01/20/26, on 03/17/26, revealed the oven was serviced on 01/14/26 and the range was noted to not be operating. The invoiced revealed the right side was noted to have stopped worked last week while the left side had been intermittent for some time but noted the range had not been serviced in several years. The invoice identified both thermocouples would first be replaced due to it being the most cost-effective solution, both ovens were down and would need repair as soon as parts arrived. The invoice note dated 01/16/26 revealed both thermocouples in the oven range were replaced and both ovens were now functional. Review of quote documentation dated 02/17/26, on 03/17/26, confirmed a quote was received on 02/17/26 for a new oven range. Review of requisition information dated 02/23/26, on 03/17/26, revealed an order for a new oven range was placed. Review of the requisition information dated 03/04/26, on 03/17/26, revealed an item described as a thermal on/off switch for a kitchen plate or pallet warmer was ordered. Review of email correspondents between the administrator and supply company on 03/17/26 revealed on 03/10/26 the administrator asked for an estimated time of arrival on the oven range with a response on 03/13/26 being the scheduled delivery date. Review of an additional email correspondent between the administrator and supply company on 03/17/26, reviewed on 03/17/26, revealed the supplier updated the delivery date to 03/20/26.

Based on interview, record review, and review of facility policy, the facility failed to ensure residents had a comprehensive care plan that reflected their current status. This affected four residents (#15, #45, #75, and #96) of 29 sampled residents. The facility census was 95 residents.Findings include:1. Review of Resident 15's medical record revealed an original admission date of 04/24/25 and a readmission date of 02/08/26. Resident #15's diagnoses included limitation of activities due to disability, radiculopathy lumbar region, unspecified convulsions, syncope and collapse, muscle wasting and atrophy not elsewhere classified multiple sites, unsteadiness on feet, chronic pain, muscle weakness (generalized), and need for assistance with personal care. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #15 was cognitively intact and independent for eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Resident #15 required substantial/maximal assistance to shower/bathe self. Review of Resident #15's progress notes dated 02/26/26 at 05:43 A.M. revealed the resident was found lying on the floor. Review of Resident #15's Interdisciplinary Team (IDT) Follow Up note dated 02/27/26 at 10:49 A.M. revealed the post-fall intervention put into place was nonskid strips to the floor. Review of Resident #15's risk for falls care plan initiated 10/25/23 and revised on 06/02/25 did not reveal an intervention of nonskid strips to the floor. Interview with Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #426 on 03/18/26 at 8:49 A.M. confirmed Resident #15's risk for falls care plan did not include an intervention of nonskid strips to the floor. 2. Review of Resident #45's medical record revealed an initial admission date of 11/08/24 and a readmission date of 02/20/26. Resident #45's diagnoses included type 2 diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease unspecified, epilepsy unspecified not intractable without status epilepticus, acquired absence of right leg above knee, and generalized anxiety disorder. Review of Resident #45's Minimum Data Set (MDS) dated [DATE] revealed Resident #45 was cognitively intact. Review of Resident #45's progress note dated 03/05/26 revealed the resident had a diagnosis of other psychoactive substance abuse uncomplicated with a history of overdose leading to hospitalization in 2024. Review of Resident #45's care plan on 03/19/26 revealed there were no goals or interventions in place for substance abuse. Interview with MDS LPN #426 on 3/19/26 at 4:28 P.M. confirmed substance abuse was not included in Resident #45's care plan but should be included. 3. Review of the medical record for Resident #75 revealed an admission date of 02/02/26 with diagnoses of, but not limited to, alcohol abuse, panic disorder, bipolar disorder, depression, and Post Traumatic Stress Disorder (PTSD). Review of the resident's Brief Interview of Mental Status (BIMS) revealed a score of 14 indicating the resident was cognitively intact. Review of the care plan for Resident #75 revealed an initiated date of 02/03/26. Further review of the care plan revealed a psychosocial well-being adjustment goal which mentioned anxiety, depression, and bipolar disorder, but did not mention PTSD. The care plan revealed a focus which stated the resident had a mood problem related to panic disorder but did not mention PTSD. Further review of the care plan revealed a focus that identified Resident #75 had a diagnosis of PTSD however the interventions were not specific to the resident and did not include the triggers, if any, that the resident had nor the cause of the resident's PTSD. 4. Review of the medical record for Resident #96 revealed an initial admission date of 02/10/26 with diagnoses of, but not limited to, depression, generalized anxiety disorder, and PTSD. Review of the resident's BIMS revealed a score of 15 indicating the resident was cognitively intact. Review of Resident #96's care plan revealed focus initiated on 02/20/26 which identified the resident as having a diagnosis of PTSD related to a recent amputation. Further review revealed interventions of the resident to be assisted in identifying what triggers PTSD episode and observe for increased agitation, anxiety, and offer quiet areas and comfort items. The care plan did not have resident specific interventions to Resident #96's PTSD nor triggers. Interview with Resident #96 on 03/16/26 at 1:40 P.M. revealed the diagnosis of PTSD was partially related to trauma she experienced as a child and identified her recent amputation as not being related to her PTSD. Resident #96 reported she did not feel the facility knew or understood her triggers. Interview with Social Services on 03/19/26 at 10:25 A.M. revealed for residents with PTSD, resident specific triggers and information related to their trauma should be included in their care plan to ensure staff are informed of the residents' needs. Social Services confirmed Resident #75 and Resident #97 both had diagnoses of PTSD and did not have this information in their care plans. Review of the facility policy titled, Plan of Care Overview, not dated, revealed the facility was to provide resident centered care plans that meets the psychosocial, physical, and emotional needs of the resident.

Based on observation, interview, record review, and review of facility policy, the facility failed to have interventions in place to prevent falls for Residents #52, #15, #97, #103, and #94. Additionally, the facility failed to complete a thorough investigation following a fall for Resident #88. This affected six residents (#52, #15, #97, #88, #103, and #94) of 11 residents reviewed for falls. The facility census was 95 residents.Findings include:1.Resident #52 was admitted [DATE] and has diagnoses that include chronic obstructive pulmonary disease, severe protein-calorie malnutrition, and dysphagia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident used a wheelchair for mobility and has severe cognitive impairment. Review of the facility incident and accident log revealed Resident #52 suffered falls on 12/24/25 and 01/02/26. Review of the medical record for Resident #52 revealed an order for non-skid strips on the floor near bed for recurrent falls from bed ordered on 12/24/25. Further review of Resident #52's care plan revealed an intervention of fall mat to both sides of bed for resident at risk of falls initiated on 12/25/25 and intervention for non-skid strips to floor near bed initiated 02/24/26. Observation of the Resident #52's room was conducted on 03/17/26 at 12:49 P.M. There were no non-skid floor strips found near the resident's bed and no fall mats placed at bedside. Interview with Licensed Practical Nurse (LPN) #161 was conducted on 03/17/26 at 12:49 P.M. LPN #161 confirmed that there were no non-skid strips and no fall mats near the bed in Resident #52's room. 2. Review of Resident #15's medical record revealed an original admission date of 04/24/25 and a readmission date of 02/08/26. Resident #15's diagnoses included limitation of activities due to disability, radiculopathy lumbar region, unspecified convulsions, syncope and collapse, muscle wasting and atrophy not elsewhere classified multiple sites, unsteadiness on feet, chronic pain, muscle weakness (generalized), and need for assistance with personal care. Review of the MDS dated [DATE] revealed Resident #15 was cognitively intact and independent for eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Resident #15 required substantial/maximal assistance to shower/bathe self. Review of Resident #15's progress notes dated 02/26/26 at 05:43 A.M. revealed the resident was found lying on the floor. Review of Resident #15's Interdisciplinary Team (IDT) Follow Up note dated 02/27/26 at 10:49 A.M. revealed the post-fall intervention put into place was nonskid strips to the floor. Review of Resident #15's risk for falls care plan initiated 10/25/23 and revised on 06/02/25 did not reveal an intervention of nonskid strips to the floor. Further review of Resident #15's care plan revealed an intervention for a visual reminder to ask for assistance when getting out of bed that was initiated on 06/10/25 and revised on 03/12/26. Observation of Resident #15's room on 03/16/26 at 9:30 A.M. revealed nonskid strips were not on the floor of the resident's room and the visual reminder to ask for help was not observed in the room. Observation of Resident #15 room on 03/16/26 at 3:00 P.M. revealed nonskid strips were not on the floor of the resident's room and the visual reminder to ask for help was not observed in the room. Observation of Resident #15 on 03/17/26 at 4:05 P.M. revealed nonskid strips were not on the floor of the resident's room and the visual reminder to ask for help was not observed in the room. Interview with Registered Nurse (RN) #470 on 03/17/26 at 4:18 P.M. confirmed nonskid strips were not on the floor of Resident #15's room. Interview with LPN #422 on 03/18/26 at 7:49 A.M. revealed a visual reminder to ask for help would hang on the wall near Resident #15's bed and in the bathroom. Further interview LPN #422 confirmed that the visual reminder to ask for help was not in place for Resident #15. 3. Review of the medical record for Resident #97 revealed an admission on [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, traumatic hemorrhage of the cerebrum, heart disease and alcohol abuse. Review of the admission MDS completed on 01/04/26 revealed the resident was cognitively intact. He required one person to assist with activities of daily living. Further review of the medical record for Resident #97 revealed he was found on the floor on 02/12/26 at 2:15 P.M. A full investigation was completed, and it was determined Resident #97 was left in his room in his wheelchair after his therapy session. He was sitting in his wheelchair and slid out of it onto the floor. It was an unwitnessed fall with no injuries. The Interdisciplinary team reviewed the fall and added a preventative intervention of Dycem to his wheelchair. Observation and interview on 03/19/26 at 11:00 A.M. of Resident #97 in the therapy department confirmed he did not have Dycem on his wheelchair seat to prevent him from sliding out of it. Therapist #364 and #362 verified there was no Dycem to Resident #97's wheelchair. Interview with Therapist #362 on 03/19/26 at 11:15 A.M. confirmed she was the therapist who placed the Dycem on his wheelchair after his fall and did not know why it was not on it. 4. Review of Resident #88's medical record revealed an admission date of 09/19/24 with diagnoses including anoxic brain damage, chronic obstructive pulmonary disease, dysphagia, contractures of right and left hand, attention-deficit hyperactivity disorder, moderate protein-calorie malnutrition, psychoactive substance abuse, anxiety disorder, and cognitive communication deficit. Review of Resident #88's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. He was dependent on staff for rolling. Review of Resident #88's plan of care dated 08/21/25 revealed the resident was at risk for falls related to mobility, gait problems, and medications. Interventions included assessing risk for falls on admission, educating resident or resident representative, encouraging and assisting resident to up to chair before dinner, ensuring resident is wearing appropriate nonskid footwear, and ensure room is free from accident hazards. Review of Resident #88's plan of care revised 02/26/26 revealed a self-care performance deficit related to anoxic brain injury, contractures, fearful during care, and will grab at and hold onto staff during care. Interventions included lids on hot beverages, placing splints as ordered, the resident was dependent for toileting hygiene, bathing, personal hygiene, and rolling in bed. Review of Resident #88's progress note dated 02/27/26 at 7:07 P.M. revealed the resident was lowered to the floor during activity of daily living care by the certified nursing assistant (CNA). The resident received a skin tear to the right side of his back during this. Review of Resident #88's fall investigation dated 02/27/26 revealed the conclusion of the event was entered on 03/01/26. It was indicated that the hospice aide was providing care to Resident #88 when they fell out of bed. The resident was assisted to the floor by the CNA, the suspected root cause was the air mattress and turning the resident. The investigation did not identify why the resident needed to be lowered to the floor, who lowered them to the floor, and how he obtained a skin tear. Interview on 03/18/26 at 3:00 P.M. with the Director of Nursing (DON) revealed both a hospice aide and a facility CNA had been present for Resident #88's fall. She reported the resident was totally dependent on care and 'could' have rolled out of bed when the cloth underneath him had been pulled. She reported she had witness statements. Review of the witness statement provided on 03/19/26 revealed the statement was by Unit Manager #365. It indicated the nurse reported to them that the hospice aide was providing a bed bath and our staff was in the room when Resident #88 was being turned, staff CNA controlled a fall from the bed and the resident received a skin tear. Interview on 03/19/26 at 10:51 A.M. with the Director of Nursing (DON) revealed the staff present in the room were contradicting each other on what happened. The only witness statement she had was by Unit Manager #365. She verified it was unclear what happened and how he obtained the skin tear. The DON verified a thorough investigation was not completed. 5. Review of Resident #103's medical record revealed an admission date of 03/04/26 major depressive disorder, borderline personality disorder, unspecified mood disorder, convulsions, personal history of other mental and behavioral disorders, conversion disorder with seizures or convulsions, anxiety disorder, and fibromyalgia. Review of Resident #103's comprehensive MDS 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #103's plan of care dated 03/06/26 revealed the resident was at risk for falls related to being a new admission, potential medication side effects, and a history of seizures. Interventions included assessing risk for falls, education, ensuring the residents room is free from potential hazards, ensuring bed locks were engaged, medication review, placing call bell in reach, and added 03/09/26 fall mats. Review of Resident #103's progress note dated 03/08/26 revealed the resident fell from bed during seizures and was sent to the hospital. Review of Resident #103's interdisciplinary fall follow up dated 03/09/26 revealed on 03/08/26 at 6:55 P.M. the resident had been observed with seizure activity on the floor at bedside. The intervention was to put fall mats in place to both sides of the bed. Observation on 03/16/26 at 11:00 A.M. and on 03/19/26 at 8:40 A.M. revealed Resident #103 was in bed and fall mats were not in place. Interview on 03/19/26 at 8:40 A.M. with the Director of Nursing (DON) revealed the intervention for Resident #103's first fall was a fall mat. The DON verified Resident #103's fall mat was not in place at that time. 6. Review of the medical record for Resident #94 revealed a readmission date of 12/10/25 with diagnoses of, but not limited to, acquired absence of left leg above knee, polyneuropathy, muscle weakness, and muscle wasting atrophy. Review of Resident #94's Brief Interview of Mental Status revealed a score of 15 indicating the resident was cognitively intact. Review of the progress note dated 02/09/26 revealed the resident had gone out of the facility with a company driver to attend dialysis and while going toward the van the resident fell forward out of the wheelchair and hit his head. According to the progress note staff were reported to have gotten the resident up from the floor and transferred Resident #94 back into his wheelchair, transported him back inside the facility, and notified the nurse. The nurse was reported to have completed a body assessment, neurological checks, and range of motion to extremities. There were no noted changes in range of motion, and a small abrasion was noted to the right leg below the knee and vital signs were normal. Per the progress note the facility contacted a 24/7 clinical coverage provider and the resident was assessed via video and orders were placed for x-ray due to the resident complaining of right shoulder and cervical spine pain. Review of the Interdisciplinary Team (IDT) Fall Follow-up dated 02/10/26 revealed Resident #94 was being transferred in a wheelchair out of the facility when their right leg was caught up in the wheel and the resident fell forward. The IDT Fall Follow-up identified the cause of the fall to be the resident needed their right food pedal placed on the wheelchair and initiated a post fall intervention of the right food pedal to be put in place when the resident was being transported via wheelchair. Interview with Therapy Manager (TM) #364 on 03/18/26 at 3:45 P.M. revealed a resident with a wheelchair is always given foot pedals. TM #364 reported a resident can refuse the foot pedals but if they do their foot pedals are returned to therapy or kept in the residents' room, and the refusal would be noted in the residents' chart. TM #364 revealed Resident #94 always used foot pedals when in their wheelchair, including coming to and from therapy and when exiting the building. Interview with the Director of Nursing (DON) on 03/19/26 at 11:25 A.M. confirmed Resident #94's fall was due to his foot going underneath the wheel of the wheelchair while the dialysis company was transporting him from the facility to the van for dialysis. DON confirmed the resident did not have the right foot pedal on his wheelchair when leaving for dialysis and this was implemented as a care plan intervention post fall. Additional interview with TM #364 on 03/23/26 at 11:15 A.M. revealed the resident should have always had the foot pedals on, especially when leaving the facility for dialysis. TM #364 revealed Resident #94 could not take the pedal off themselves. TM #364 also confirmed the resident could not self-propel and therefore the pedals would not be taken off for him to do so. Review of the facility policy titled, Fall Prevention and Management, not dated, revealed the facility would identify risk factions that can minimize the potential for falls. The policy further revealed the facility would obtain information about the resident from other sources when identifying their risk for falls including but not limited to physical assessments, diagnoses, and the residents current Activities for Daily Living (ADL) status. Further review revealed a fall investigation should begin once the resident was safely transferred following a fall. The resident should be asked what they were doing when they fell, even if they have dementia, and witnesses should be identified and asked to write a written statement immediately. In order to put in a post fall intervention the facility was to attempt to identify why the resident fell. During the interdisciplinary team review the team should discuss the fall, potential causes, interventions in place, and a deep root cause investigation should be discussed. This violation represents noncompliance investigated under complaint 2647719, 2595291, and 2795028.

Based on interview, record review, and policy review, the facility failed to provide showers per resident choice. This affected one (Resident #53) of two residents reviewed for choices. The facility census was 95 residents.Findings include:Review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses that included cellulitis of the left lower limb, chronic diastolic (congestive) heart failure, other specified chronic obstructive pulmonary disease, obesity class 3, unsteadiness on feet, muscle weakness (generalized), need for assistance with personal care, and muscle wasting and atrophy not elsewhere classified multiple sites. Review of the Minimum Data Set (MDS) assessment, dated 01/05/26, revealed Resident #53 was cognitively intact and required substantial or maximal assistance for shower or bathing self. Review of Resident #53's Nursing admission Evaluation dated 12/29/25 revealed Resident #53 preferred a shower in the evening. Review of Resident #53's Activities of Daily Living (ADL) Self Care Performance care plan dated 02/15/26 did not reveal Resident #53's preference for a shower. Review of Resident #53's shower/bathe self-task documentation revealed Resident #53's last shower was 02/28/26. Resident #53 received a bed bath on 02/24/26, 03/03/26, 03/10/26, 03/13/26, 03/18/26 and 03/21/26. Interview with Resident #53 on 03/16/26 at 9:08 A.M. revealed the resident's last shower was 3 weeks ago. Resident #53 reported staff provided a basin at the bedside for the resident to bathe self. Resident #53 stated he prefers to take a shower. Interview with Risk Management #366 on 03/18/26 at 12:30 P.M. revealed that shower sheets could not be provided for Resident #53 because they were not part of the medical record and shower sheets may or may not be filled out. Interview with Unit Manager Registered Nurse (RN) #365 on 03/19/26 at 10:15 A.M. confirmed the admission assessment was used to identify resident shower or bath preference. Interview with Certified Nurse Aide (CNA) #261 on 03/23/26 at 09:46 A.M. confirmed resident should be asked preference for a shower or bath prior to providing care. Interview with RN #470 and Licensed Practical Nurse (LPN) #422 on 3/23/26 at 2:10 P.M. confirmed Resident #53's last shower was two to three weeks ago. RN #470 and LPN #422 confirmed the shower was provided to Resident #53 because Resident #53 complained of not receiving a shower. Review of the facility policy 'Resident Rights' undated revealed residents will be treated with dignity and respect. Dignity included respecting resident choice.

Based on observation, interview, and policy review, the facility failed to maintain clean and sanitary bed curtains. This affected one (Resident #45) of three residents reviewed for environment. The facility census was 95 residents.Findings include:Review of Resident #45's medical record revealed an initial admission date of 11/08/24 and a readmission date of 02/20/26. Resident #45's diagnoses included type 2 diabetes mellitus with hyperglycemia, long term (current) use of insulin, chronic obstructive pulmonary disease unspecified, moderate protein-calorie malnutrition, epilepsy unspecified not intractable without status epilepticus, presence of right artificial shoulder joint, acquired absence of right leg above knee, polyneuropathy unspecified, anemia unspecified, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #45 was cognitively intact. Observation of Resident #45's bed curtain on 03/16/26 at 10:31 A.M. revealed three dark red stains splattered on the curtain. The largest stain measured approximately one centimeter (cm). The other two stains measured approximately 0.5 cm. Further observation of Resident #45's bed curtain also revealed linear black stains. Interview with Resident #45 on 3/16/26 at 10:31 A.M. revealed the resident requested the bed curtain be cleaned, but the facility never cleaned the curtain. Interview with Certified Nurse Aide (CNA) #249 on 03/16/26 at 10:56 A.M. confirmed stains were present on Resident #45's bed curtain. Interview with Risk Management #366 on 3/23/26 at 3:28 P.M. revealed the facility does not have an environment policy. Risk Management #366 confirmed environmental concerns would be included in the facility 'Resident Rights' policy as residents have the right to a safe, clean, home-like environment. Review of the facility policy 'Resident Rights' undated revealed residents will be treated with dignity and respect. Dignity included providing safe and secure housing.This deficiency represents non-compliance investigated under Complaint Numbers 2631443 and 2795028.

Based on observation, interview, medical record review, and review of facility policy, the facility failed to provide nail care for Residents #66, and #88 who were dependent on staff for care. This affected two residents (#66 and #88) of seven residents reviewed for activities of daily living. The facility census was 95.Findings include: 1. Review of Resident #66's medical record revealed an admission date 07/25/25. Resident #66's diagnoses included chronic obstructive pulmonary disease unspecified, repeated falls, dysphagia following cerebral infarction, unspecified protein-calorie malnutrition, essential (primary) hypertension, dysphagia oropharyngeal phase, alcohol use unspecified uncomplicated, anxiety disorder unspecified, and depression unspecified. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact. Resident #66 was dependent for putting on and taking off footwear. Observation of Resident #66 on 03/16/26 at 12:22 P.M. revealed long, jagged toenails. Interview with Resident #66 on 03/16/26 at 12:22 P.M. revealed staff do not provide toenail care. Interview with Certified Nurse Aide (CNA) #116 confirmed Resident #66 toenails were long and jagged. Further interview with CNA #116 revealed the CNA was uncertain if permitted to trim toenails in the facility. Interview with Director of Social Services #129 on 03/18/26 at 12:13 P.M. revealed Resident #66 declined podiatry care on 01/23/26. Interview with Director of Nursing (DON) on 03/23/26 at 1:45 P.M. confirmed CNAs can trim toenails if the resident does not have a diagnosis of diabetes. However, further interview with the DON confirmed, since Resident #66's toenails were in such poor condition, the resident should be re-referred to podiatry for toenail care. Review of the facility job description 'Certified Nurse Aide' revealed it was the responsibility of the Certified Nurse Aide to provide personal care functions to residents. Review of facility policy 'Routine Resident Care' undated revealed routine daily care will be provided to residents. 2. Review of Resident #88's medical record revealed an admission date of 09/19/24 with diagnoses including anoxic brain damage, chronic obstructive pulmonary disease, dysphagia, contractures of right and left hand, attention-deficit hyperactivity disorder, moderate protein-calorie malnutrition, psychoactive substance abuse, anxiety disorder, and cognitive communication deficit. Review of Resident #88's comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition. He was dependent for personal hygiene and bathing. Review of Resident #88's plan of care revised 02/26/26 revealed a self-care performance deficit related to anoxic brain injury, contractures, fearful during care, and will grab at and hold onto staff during care. Interventions included lids on hot beverages, placing splints as ordered, the resident was dependent for personal hygiene. Review of Resident #88's plan of care dated 10/28/24 revealed the resident had bilateral hand contractures and impaired functional range of motion. Interventions included administering medications as ordered, monitoring for increase in pain, monitoring skin condition under splint upon removal and report any areas of concern, placing splints as ordered, therapy as ordered. Review of Resident #88's medical record revealed no documentation indicating when his nails were cleaned or cut. Observation on 03/16/26 at 10:15 A.M. and 1:45 P.M. of Resident #88 revealed his right hand was contracted with his thumb and index finger extended. The nails observed on his right hand and all the nails on his left hand were observed to be long (approximately one centimeter past his fingertips) and had a dark brown substance underneath them. Observation on 03/16/26 at 3:30 P.M. of Resident #88 revealed his fingernails remained long and dirty. He declined to open his contracted hand or have assistance opening it. Interview on 03/16/26 at 3:30 P.M. with CNA #396 verified the condition of Resident #88's nails. She reported a service came in to take care of residents nails, she then indicated she thought hospice took care of Resident #88's nails. CNA #396 went to confirm with Registered Nurse (RN) #470, who reported that she thought hospice was responsible. CNA #396 then spoke to the Director of Nursing (DON) who reported the CNAs were responsible for nail care. This deficiency represents non-compliance under Complaint Numbers 2631443 and 2579770.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure a midline dressing was changed as ordered. This affected one (Resident #53) of one resident reviewed for intravenous access line care. The facility census was 95 residents.Findings include:Review of Resident #53's medical record revealed the resident was admitted to the facility on [DATE] and had diagnoses that included cellulitis of the left lower limb, chronic diastolic (congestive) heart failure, other specified chronic obstructive pulmonary disease, and obesity class Review of the Minimum Data Set (MDS) assessment, dated 01/05/26, revealed Resident #53 was cognitively intact. Review of Resident #53's Midline Insertion Record completed 02/27/26 at 12:05 P.M. revealed a midline catheter (a vascular access device used for intravenous therapy) was placed in the left cephalic vein (a vein located in the left upper arm) on 02/27/26. Further review of Resident #53's Midline Insertion Record revealed a transparent dressing was placed over the midline catheter. Review of Resident #53's order dated 03/03/26 revealed an order to measure external catheter length with each dressing change ordered for every day shift on Fridays and to change the needleless connector with the site change every week ordered for every day shift on Fridays. Review of Resident #53's Treatment Administration Record (TAR) for March 2026 revealed the external catheter length was measured with each dressing change and the needleless connector was changed with each site change on 03/06/26 and on 03/13/26. Observation of Resident #53's midline insertion site on 03/16/26 at 9:08 A.M. revealed a dressing covering the site dated 02/27/26. Interview with Registered Nurse (RN) #470 on 03/16/26 at 9:21 A.M. confirmed the dressing covering the midline insertion site was dated 02/27/26 and should have been changed. Review of facility policy 'PSG Infusion Intravenous (IV) Access Line Maintenance Protocol' effective 04/15/23 revealed a transparent dressing covering a midline catheter should be changed 24 hours after insertion, then weekly and as needed.

Based on observation, record review, and staff and resident interviews, the facility failed to provide timely treatment to maintain Resident's #1 hearing abilities. This effected one resident (#1) of one resident reviewed for hearing issues. The facility's census was 95.Record review for Resident #1 revealed this resident was admitted to the facility on [DATE] with diagnoses including: Chronic obstructive pulmonary disease, muscle weakness, acute and chronic respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require staff supervision for mobility and self care. Review of the medical record of Resident #1 revealed on 03/09/26, he notified staff he was having trouble hearing out of one of his ears and thought something might be stuck in it.Review of the physician orders of Resident #1 revealed on 03/10/26 he was prescribed Carbamide Peroxide Solution 6.5 % ear drops, to be administered twice per day for excessive cerumen for 3 days.During an interview with Resident #1 on 3/17/26 at 10:15 A.M. he stated he was still having the same issues with his hearing and would like a doctor of examine it. He said he had advised two nurses between 03/13/26 and 03/15/26 that the ear drops had not resolved the issue, but had not had any follow-up care Observation on 03/16/26 at 11:54 AM revealed Resident #1 notified Licensed Practical Nurse (LPN) #161 his ear was continuing to bother him, so he wanted to see a specialist physician. LPN #161 said she would notify the resident's provider.During an interview on 03/17/26 at 10:15 A.M. Resident #1 verified he has not received any additional treatment for his ear.During an interview on 03/18/26 at 9:45 A.M. with Unit Manager #365 revealed she had previously been made aware of Resident #1's hearing complaints and she had spoken to Resident #1's certified nurse practitioner for an Ear, Nose and Throat, (ENT) referral.During an interview on 03/19/2026 at 9:20 A.M. with Certified Nurse Practitioner #901 revealed she denied being informed that Resident #1 was still experiencing hearing issues after he completed his ear drops on 03/13/26 until 03/18/26. She said once she was made aware of the issue, she submitted an ENT referral for the resident.

Based on staff interview, medical record review, and facility policy review, the facility failed to obtain weekly weights as ordered for Resident #52. This affected one resident (#52) of seven residents reviewed for nutritional issues. The facility census was 95.Resident #52 was admitted [DATE] and has diagnoses that include chronic obstructive pulmonary disease, severe protein-calorie malnutrition, and dysphagia. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident used a wheelchair for mobility and had severe cognitive impairment. Further review of Resident #52's medical record revealed an order for weekly weights written on 12/04/25. Further review of Resident #52's medical record demonstrated there were no recorded weights for the timeframe between 12/17/25 and 01/08/26. Additionally, there were no recorded weights in the medical record for the timeframe between 02/26/26 and 03/17/26. Dietician #370 was interviewed via telephone about 8:35 A.M. on 03/19/26. She stated that Resident #52 had significant weight loss since November 2025. Interview with Registered Nurse (RN) #453 at 1:02 P.M. on 03/19/26 confirmed there were no weights in Resident #52's medical record between 12/17/25 and 01/08/26 or between 02/26/26 and 03/17/26. Review of facility policy titled, Resident Height and Weight, (undated) stated weights will be obtained monthly or as ordered by the physician or practitioner.

Based on observation, interview, and record review, the facility failed to change oxygen tubing as required and failed to ensure the humidifier solution was not empty. This affected one resident (#1) of four residents reviewed for respiratory care. The facility's census was 95.Record review for Resident #1 revealed this resident was admitted to the facility on [DATE] with diagnoses including: Chronic obstructive pulmonary disease, muscle weakness, and acute and chronic respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 12. This resident was assessed to require staff assistance with mobility and self-care assistance. Review of the care plan dated 02/12/26 revealed Resident #1 is dependent on continuous oxygen therapy related to a medical history of shortness of breath and respiratory failure. Observation and interview on 03/16/26 at 11:15 A.M. revealed Resident #1's nasal cannula oxygen tubing on 03/16/26 revealed a date on the tubing of 03/03/26. Resident #1 verified his oxygen tubing had not been changed in two weeks and also stated his humidifier solution had been empty for over a week. Further observation revealed the humidifier solution was empty. Interview with Licensed Practical Nurse (LPN) #161 at 11:42 A.M. confirmed oxygen tubing was to be changed once every week. She confirmed Resident #1's oxygen tubing had not been changed in two weeks. She also confirmed the empty bottle of solution for the resident's humidifier. Review of the facility's policy, Supplemental Oxygen using Nasal Cannula, revealed nasal cannulas and tubing are changed weekly or when soiled or contaminated.

Based on medical record review, resident interview, and staff interview, the facility failed to provide services to treat a resident's anxiety. This affected one (#65) of one resident reviewed for behavioral health. The facility census was 95. Record review for Resident #65 revealed this resident was admitted to the facility on 01/14 26 with diagnoses including: multiple fractures of the bilateral ribs, anxiety disorder, fracture of the pelvis, fracture of the right lower leg, depression, and insomnia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require hygiene and mobility assistance from staff.Review of the care plan dated 01/14/26 revealed Resident #65 is at risk of impaired psychosocial well-being. Interventions included a psychiatric mental health consultation and counseling services.Review of the practitioner progress notes of Resident #65 revealed on 01/14/26 during his initial assessment with the physician, the resident requested Hydroxyzine to manage his anxiety, as he was previously taking prior to facility admission. The physician advised the resident this medication is not used for long-term management of anxiety. When Resident #15 persisted, the physician requested a psychiatric consultation for the resident. During an interview with Resident #65 on 03/16/26 at 12:47 P.M. he confirmed as of this date, he is still waiting to see a psychiatric provider to manage his anxiety. During an interview on 03/18/26 at 12:32 P.M. with Therapy Manager #364 she confirmed that Resident #65 has refused therapy multiple times because he was feeling anxious. During an interview on 03/17/26 at 5:20 PM with Social Worker, she confirmed Resident #65 has not had a psychiatric provider visit.

Based on interview, record review, and review of the social service director job description, the facility failed to timely arrange and follow up on guardianship for Resident #78 according to the expert evaluation. This affected one resident (#78) of one resident reviewed for guardianship. The facility census was 95.Findings include: Review of Resident #78's medical record revealed an admission date of 03/22/23 with diagnoses including chronic myeloid leukemia, chronic obstructive pulmonary disease, chronic heart failure, aphasia, dementia, epilepsy, spondylosis, gout, and depression. Review of Resident #78's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of Resident #78's hospital social work Discharge summary dated [DATE] revealed the social worker had spoke to the facility about starting guardianship and they were in agreement. Review of Resident #78's statement of expert evaluation completed 03/05/25 revealed it concluded that guardianship should be established or continued. Review of Resident #78's progress note dated 04/24/25 revealed the social worker submitted a referral to [NAME] County Probate Investigator following the completed expert evaluation. Review of Resident #78's progress note dated 07/08/25 revealed the social worker sent correspondence to [NAME] County Probate to inquire about services and the referral sent by the previous social worker. The social worker was waiting on a response and would update with facility team and discuss next steps. Review of Resident #78's medical record from 07/09/25 to 03/23/26 revealed no additional documentation about Resident #78 obtaining a guardian. Interview on 03/19/26 at 12:39 P.M. with Director of Social Services #129 revealed she believed the guardian process had been delayed because the resident had a house nobody had been aware of. She did not know if this had been followed up on since her last note on 07/08/25, and would have to check. Further interview on 03/23/26 at 9:50 A.M. revealed she had no further information. She had submitted information for guardianship but had not heard anything and had not followed up. Interview on 03/19/26 at 9:55 A.M. and 12:40 P.M. with Regional Business Office Manager #393 revealed she was unaware of any housing situation that would prevent guardianship and has asked the social worker to follow up. Review of the position description for Social Service Director, dated June 2019, revealed the position provided planning, assessing, coordinating and implementing services to enhance each residents social and psychosocial well being and assure that care standards are met. The social service director was to perform all duties involved in resident advocacy. They were to perform applications for supplementary services to be used while in the facility. This deficiency represents non-compliance under Complaint Number 2749140

Based on interview and record review, the facility failed to ensure medications were administered timely for two residents (#101 and #103) of two residents reviewed for timely administration of medications. The facility census was 95.Findings include:1.Review of Resident #103's medical record revealed an admission date of 03/04/26 with diagnoses of major depressive disorder, borderline personality disorder, disorientation, unspecified mood disorder, suicidal ideations, unspecified convulsions, personal history of other mental and behavioral disorders, conversion disorder with seizures or convulsions, anxiety disorder, dysphagia, uninhibited neuropathic bladder, and fibromyalgia. Review of Resident #103's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #103's physician orders active on 03/15/26 revealed the following orders: Aprepitant oral capsule 125 milligrams (mg) one time a day for nausea and vomiting, Cariprazine oral capsule three mg one capsule one time a day for antipsychotic, Esomeprazole Magnesium 40 mg for reflux one packet a day for Gastroesophageal reflux disease, fludrocortisone acetate 0.1 mg one time a day for hypotension, Gabapentin 600 mg two tablets two times a day for neuropathy, Linzess 290 micrograms (mcg) one capsule one time a day to promote bowel movements, Levetiracetam oral tablet 500 mg one tablet two times a day for anti-seizure, Rimegepant Sulfate oral tablet 75 mg one tablet by mouth one time a day every other day for migraine prevention, Clonazepam oral tablet one mg by mouth three times a day for anxiety, Azithromycin 250 mg one time a day for pneumonia, Amoxicillin-Pot Clavulanate extended release 1000-62.5 mg two tablets two times a day for pneumonia for five days, Amitriptyline 10 mg one tablet two times a day for depression, and melatonin five mg one tablet at bedtime for sleep aide. Review of Resident #103's medication administration audit report revealed on 03/15/26 morning medications were to be administered between 7:00 A.M. and 8:00 A.M. and were not administered until between 10:35 A.M. and 11:07 A.M. The late medications included Aprepitant, Cariprazine, Esomeprazole Magnesium, fludrocortisone acetate, Gabapentin, Linzess, Levetiracetam, Rimegepant Sulfate, Clonazepam, Azithromycin, Amoxicillin, and Amitriptyline. Evening medications were due on 03/15/26 at 9:00 P.M. and were not administered until 03/16/26 between 4:45 A.M. to 4:49 A.M. The late evening medications included Amitriptyline, Esomeprazole Magnesium, Clonazepam, Amoxicillin, gabapentin, levetiracetam, and melatonin. Interview on 03/16/26 at 11:01 A.M. with Resident #103 revealed her medications had been late on 03/15/26. Interview on 03/18/26 at 3:00 P.M. with the Director of Nursing (DON) verified Resident #103's medications were late. Medications were to be administered within the range of one hour before or one hour after the administration time. She was unable to find the cause of the late administration. 2. Review of Resident #101's medical record revealed an admission date of 03/12/26 with diagnoses including chronic obstructive pulmonary disease (COPD), other disorder of circulatory system, peripheral vascular disease, follicular lymphoma, depression, anxiety, cervicalgia, and age related osteoporosis. Review of Resident #101's physician orders active on 03/15/26 revealed the following orders: pantoprazole delayed release 20 mg two times a day for reflux, duloxetine delayed release 30 mg one time a day for depression, Amlodipine Besylate 10 mg one time a day for hypertension, Aspirin 81 mg one time a day for pain, Gabapentin 300 mg two capsules three times a day for neuropathy, Levetiracetam 500 mg one tablet twice a day for seizures, ducosate sodium 100 mg one time a day for constipation, baclofen five milligrams three times a day for muscle spasms, atorvastatin 20 mg one time a day for hyperlipidemia, MiraLax powder 17 grams by mouth one time a day for constipation, Incruse Ellipta Inhalation Aerosol Powder 62.5 micrograms per actuation one puff one time a day for COPD, and Melatonin three mg at bedtime for sleep aid. Review of Resident #101's medication administration audit report revealed on 03/15/26 morning medications were to be administered at 7:00 A.M. but were administered from 11:37 A.M. to 11:50 A.M. The late medications included pantoprazole, duloxetine, amlodipine besylate, aspirin, gabapentin, levetiracetam, ducosate sodium, baclofen, atorvastatin, MiraLax, and Incruse Ellipta. Evening medications were due on 03/15/26 at 9:00 P.M. and were administered between 11:28 PM and 11:30 P.M. The medications included Melatonin, pantoprazole, duloxetine, gabapentin, levetiracetam, and baclofen. Interview on 03/16/26 at 10:48 A.M. with Resident #101 revealed her medications had been late on 03/15/26. Interview on 03/18/26 at 3:00 P.M. with the Director of Nursing (DON) verified Resident #101's medications were late. Medications were to be administered within the range of one hour before or one hour after the administration time. She was unable to find the cause of the late administration.

Based on closed medical record review, hospital record review, staff interview and policy review, the facility failed to provide timely, necessary and adequate care and services following an acute change in condition involving Resident #88. The facility failed to ensure changes in the resident's medical condition were comprehensively assessed, that high blood glucose levels were communicated to the medical provider, and individualized interventions were implemented. This resulted in Actual Harm with subsequent hospitalization when on 06/23/25 Resident #88 had a high blood glucose reading of 471 milligrams per deciliter (mg/dL) (normal ranges from 80 to 130 mg/dL in adults with type two diabetes) requiring notification to a medical provider, which was not completed. On 06/26/25 and 06/27/25, Resident #88 presented with symptoms of hyperglycemia with changes in mental status, drowsiness, incontinence, and dietary changes. Certified Nursing Assistant (CNA) #127 and CNA #135 reported the changes to nursing staff. Certified Nurse Practitioner (CNP) #200 was informed of the blood glucose reading high (indicating a reading over 500 mg/dL) on 06/27/25 after lunch and the staff began to treat the residents blood sugar with insulin. On 06/27/25 the resident was sent to the hospital and diagnosed with diabetic ketoacidosis (DKA) (a life threatening complication of diabetes that occurs when the body does not have enough insulin), acute metabolic encephalopathy and acute kidney injury, in addition to a blood glucose reading of 1157 mg/dL. This affected one (Resident #88) of three residents reviewed for changes in condition. The facility census was 87. Findings include:Review of the medical record for Resident #88 revealed an admission date of 07/31/24 and a discharge date of 06/27/25. Diagnoses included heart disease, heart failure, muscle weakness, cognitive communication deficit, muscle wasting, hemiplegia and hemiparesis, vascular disease and type two diabetes. Review of the physician orders revealed an order dated 08/01/24 to monitor for signs and symptoms of hypo/hyper glycemia (sweating, tremor, pallor, tachycardia, palpitations, nervousness, headaches, confusion, light headedness, slurred speech, lack of concentration, irritability, and staggering gait). Review of the physician orders revealed an order dated 08/05/24 for a blood glucose check (accu-check) in the morning once weekly on Mondays for hypo/hyperglycemia monitoring. The instructions on the order were to notify the physician if the blood sugar was under 60 or over 400 mg/dL. Review of the plan of care dated 08/05/24 revealed Resident #88 had diabetes mellitus with interventions to administer medications per medical provider orders, observe for side effects and effectiveness and report abnormal findings, observe for signs and symptoms of hyperglycemia (increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (deep, rapid and labored breathing), stupor and coma) and report findings to the medical provider, report findings of hypoglycemia (sweating, tremors, increased heart rate, confusion, blurred speech, lack of coordination) to medical provider, obtain and monitor laboratory (lab) results and diagnostic studies, obtain blood sugars according to physician orders, and offer snack and provide diet as ordered. Review of Resident #88's physician orders revealed an order dated 10/22/24 for Farxiga oral tablet 10 milligrams (mg) with instructions to administer one tablet by mouth once daily for diabetes. There were no standing insulin orders. Review of the lab results dated 02/27/25 revealed Resident #88 had a blood glucose of 159 mg/dL with a reference range for non-fasting of 65-125 mg/dL and a hemoglobin A1C (a blood test that shows an average levels of blood sugar levels over a two to three month period) of 6.5 percent (with a reference range of 4.1-6.1 percent) and a mean glucose of 140 mg/dL (with a reference range of 70-120 mg/dL). Review of Resident #88's blood sugar checks from 03/03/25 to 06/16/25 revealed results from 122 to 300 mg/dL with five readings in the 100's, ten readings in the 200's and one at 300 with results trending up over the last six months. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 had intact cognition and was independent with activities of daily living (ADL). Resident #88 only required supervision/touching assistance with ambulation and bathing. The MDS assessment stated the resident was always continent of bowel and bladder and received a hypoglycemic medication but was not receiving insulin injections. Review of the lab results dated 05/27/25 revealed Resident #88 had a blood glucose of 214 mg/dL, a hemoglobin A1C of 7.9 percent, and a mean glucose of 180 mg/dL. Review of the progress note dated 05/28/25 revealed Certified Nurse Practitioner (CNP) #200 reported Resident #88 had elevated blood glucose from 120 to 300 mg/dL with a plan to add Glipizide 5 mg daily and to continue the Farxiga. The note included an addendum of further discussion with the resident and pharmacist and it was thought the increased Hemoglobin A1C from 6.5 to 7.9 percent was related to the resident's diet. CNP #200 reported a discussion with the resident who was agreeable to managing his diet instead of making medication changes. Review of the blood sugar checks on 06/23/25 revealed Resident #88 had result of 471 mg/dL. Review of the progress note date 06/23/25 revealed Resident #88 had a blood sugar result of 373 mg/dL. Review of Resident #88's progress note dated 06/27/25 at 3:41 P.M. revealed the resident was seen by CNP #200 for hyperglycemia with blood sugars reading high (over 500). The note stated per staff report, the resident had not been acting right since lunch. The bedside nurse took vital signs which were reported within normal limits, then CNP #200 instructed the registered nurse to take a blood sugar reading which resulted as high. The note stated the resident was not on insulin injections and was allergic to Metformin, only receiving Farxiga. The resident was given two units of Lispro and was re-checked 30 minutes later with the glucometer still reading high. CNP #200 instructed the bedside nurse to give an additional two units of Lispro with a plan for recheck. CNP #200 also mentioned adding a sliding scale for insulin with meals. The plan was for labs to be drawn on Monday, 06/30/25. The note revealed upon assessment, the resident had sluggish responses and was less verbal than usual. Review of Resident #88's progress note dated 06/27/25 at 3:48 P.M. revealed the nurse found the resident lethargic with slow speech, and he was not acting his normal self. He only ate 50 percent of breakfast and lunch and was able to drink all fluids. The nurse notified CNP #200 of the change in condition and vitals were taken and were within normal limits and a blood sugar was taken and read high. A new order for Lispro two units was obtained. Review of Resident #88's physician orders revealed an order dated 06/27/25 for insulin Lispro (rapid acting insulin) with instructions to inject two units (u) one time only for diabetes mellitus. This medication was ordered at 2:00 P.M. and documented as administered at 2:00 P.M. Review of Resident #88's physician orders revealed an order dated 06/27/25 for insulin Lispro with instructions to inject two units one time only for diabetes mellitus. This medication was ordered at 3:00 P.M. and documented as administered at 4:05 P.M. Review of Resident #88's progress note dated 06/27/25 at 4:43 P.M. from the on-call CNP #250 revealed the resident had a telehealth visit for blood sugar readings high. The resident had already received two units twice of insulin Lispro so far with no improvement in blood sugar readings. The note revealed the resident was symptomatic with fatigue and seen by facility provider and sliding scale coverage was ordered with a plan to recheck the blood sugar in two hours and report to the on-call provider if it was still elevated at 6:30 P.M. Review of Resident #88's progress note dated 06/27/25 at 4:51 P.M. revealed the nurse administered another one-time order for insulin Lispro two units. Later, the nurse checked the blood sugar and it had still read high. The nurse called the CNP #200 who instructed to keep the sliding scale order and recheck in two hours. Review of the physician orders revealed an order dated 06/27/25 for insulin Lispro sliding scale with instructions stating if blood sugar was from 150-200 mg/dL give 2 units; 201-250 mg/dL give 4 units; 251-300 mg/dL give 6 units; 301-350 mg/dL give 8 units; and if over 350 mg/dL give 8 units and recheck in one hour, if it remains over 350 call the physician or nurse practitioner. Lispro was ordered at 8:00 A.M., 12:00 P.M. and 5:00 P.M. and documented as administered within the 5:00 P.M. time slot. Review of progress note dated 06/27/25 at 6:20 P.M. revealed the on call CNP #250 ordered staff to administer eight units of insulin and call her back after two hours which was 6:30 P.M. The resident's' family arrived at the facility and 911 was contacted and the resident was transferred to the hospital. The note also stated a blood sugar reading of 404 mg/dL was taken just prior to the transfer to the hospital. Review of the hospital emergency room notes dated 06/27/25 revealed Resident #88 presented with altered mental status and reported high blood glucose readings of high. The note stated the resident was drowsy, but alert and made eye movements but was not speaking and movements were slow, and he did not follow commands upon arrival. Resident #88 was found to have diabetic ketoacidosis (DKA) (a life threatening complication of diabetes that occurs when the body does not have enough insulin) and acute renal failure and he would be admitted . Basic labs were completed at 8:08 P.M. with a recheck at 9:58 P.M. after treatment had been initiated for DKA. Initial lab results included a sodium of 132 milliequivalents per liter (mEq/L) (normal ranges from around 135-145 mEq/L), potassium of 6.2 millimoles per liter (mmol/L) (normal ranges from around 3.6 to 5.2 mmol/L), chloride of 97 mEq/L (normal ranges from around 96 to 106 mEq/L), glucose of 1157 mg/dL, blood urea nitrogen (BUN) of 112 mg/dL (normal ranges from around 8-24 mg/dL), and creatinine of 2.29 mg/dL (normal ranges from 0.7-1.3 mg/dL) with repeat labs showing sodium of 146 mEq/L, potassium of 5.4 mmol/L, chloride of 112 mEq/L, glucose of 799 mg/dL, BUN of 107 mg/dL, and creatinine of 2.39 mg/dL. Both glucose lab results were critical. Review of the hospital history and physical dated 06/28/25 at 12:12 A.M. revealed Resident #88 had DKA with type two diabetes with acute metabolic encephalopathy and acute kidney injury with hyperkalemia with instructions to continue intravenous (IV) maintenance fluids and insulin per the hospital's DKA protocols. The note also reported the resident was diagnosed with polycythemia due to severe dehydration. Review of Resident #88's hospital nephrology consult note dated 06/28/25 revealed the resident informed the hospital medical team he still felt very bad and had felt bad for several days prior to the hospital admission and reported he was not eating well. The note stated upon hospital admission the resident had received fluids, two ampules of sodium bicarbonate (a medication used to buffer severe metabolic acidosis) and insulin. Review of Resident #88's hospital endocrinology note dated 06/28/25 revealed the resident was in a hyperglycemic hyperosmolar state (HHS) (a life-threatening complication of diabetes characterized by extremely high blood glucose levels and severe dehydration) with DKA overlap and uncontrolled diabetes with a Hemoglobin A1C goal of less than seven percent with a current reading of 11 percent The physician recommended to continue the insulin drip until the DKA resolved and transition to subcutaneous injections of Lantus (long-acting insulin) 24 units daily and Lispro eight units with a target blood glucose level of 140 to 180 mg/dL. The note stated the resident had a diagnosis of diabetes type two since 2022. Review of Resident #88's hospital physician note dated 07/02/25 revealed the resident had been admitted and treated with DKA and was off the insulin drip with continued Lantus 24 units each day and Humalog one1 unit per eight grams carbohydrate ratio. The note stated the altered mental status, DKA, and acute kidney injury had resolved. Review of Resident #88's hospital Discharge summary dated [DATE] revealed the resident was medically cleared for discharge. The resident was to be discharged with medication recommendations of 24 units of Lantus with instructions to inject 24 units every morning, Lispro insulin per sliding scale with instructions to administer if blood sugar from 150-200 mg/dL give 2 units; 201-250 mg/dL give 4 units; 251-300 mg/dL give 6 units; and 301-350 mg/dL give 8 units, and his home medication of Farxiga 10 mg once daily. During an interview on 10/29/25 at 6:10 P.M., CNA #135 stated she was working with Resident #88 the day he transferred to the hospital (06/27/25) and she notified the nurse that the resident was acting off and was not himself. She reported the resident had several episodes of being incontinent of urine which was not normal for him and he was requiring more assistance than what was normal for him. She stated he was typically independent with most activities of daily living but he was not getting out of bed. She stated he also typically was particular with his meals and that day just took what was served and only ate about 50 percent of his breakfast and lunch. CNA #135 stated Resident #88 was having increased confusion and was staring off and not as talkative or responsive as usual. She informed the nurse in the morning after breakfast. CAN #135 stated she thought the nurse had assessed the resident and checked his blood sugar and said she had talked with CNP #200 herself as she was concerned for Resident #88's health. CNA #135 stated she had heard from the nursing staff that the blood sugar was reading high meaning an actual reading of over 500. After she left her shift, the resident's family had come to the facility and demanded the resident be transferred to the hospital for an evaluation. She was told by staff working with resident the previous day (CNA #127), that Resident #88 had started showing symptoms of a change in condition on 06/26/25 and she was unsure if the nurse or CNP had evaluated him the previous day. During an interview on 10/30/25 at 10:05 A.M., Registered Nurse (RN) #139 stated she was the nurse working with Resident #88 on the day he transferred to the hospital. She stated she did not remember specific details as the change in condition occurred several months prior. RN #139 stated she was informed by CNA #135 of the resident not acting like himself. She talked with CNP #200 about the change in behaviors and took his vital signs which were within normal limits. CNP #200 instructed her to get a blood sugar reading it read high (over 500). She reported the information to CNP #200 who met with the resident and ordered a one-time Lispro insulin dose of two units with a recheck shortly thereafter. A second one-time dose and recheck was then ordered and reported both rechecks read high. When the second recheck came back high, CNP #200 had left the facility and RN #139 stated she contacted the on-call CNP #250 who ordered a sliding scale of eight units and if over 350 mg/dL to call her back. Before the re-check was due, the resident's family had come and demanded Resident #88 be transferred to the hospital. Resident #88 was transferred to the hospital around 6:15 to 6:30 P.M. and she completed a blood sugar check prior to him leaving and it was 404 mg/dL. She stated Licensed Practical Nurse (LPN) #137 was also assisting with the resident's transfer. During an interview on 10/30/25 at 10:25 A.M. with CNA #127 stated she had worked with Resident #88 the day prior to his hospital transfer (06/26/25). Resident #88 had a bowel movement accident and needed cleaned up, which was not normal for him. He was more tired than normal and less talkative. Typically, the resident ordered a bunch of extra items from the kitchen and would send staff to the kitchen several times each meal but did not on 06/26/25. She stated she and another CNA #140 noticed the change in condition and informed the nurse who came in and assessed the resident but was unsure the outcome of the assessment or whether the CNP was notified and she did not remember who the nurse was that completed the assessment/evaluation. During an interview on 10/30/25 at 11:31 A.M., CNP #200 stated Resident #88 had been non-compliant with his diet and had been ordering a large amount of food via Door Dash. After the lab result came back on 05/27/25 with an increase in the Hemoglobin A1C to 7.9 percent, she had a discussion with the pharmacist and the resident, and it was thought the increase from the Hemoglobin A1C was likely from his diet. CNP #200 discussed with the resident about making dietary changes and wanting to lose weight and each resident's needs should be assessed to determine how frequently a residents blood sugar should be checked and at what blood sugar level should the medical provider be notified. For Resident #88, staff should use nursing judgement and inform the medical provider if the blood sugar was over 180 mg/dL and stated it would be concerning to have untreated blood sugars of 300's and 400's. She acknowledged the written order stated to notify the provider for blood sugars over 400 mg/dL. She confirmed she was not informed of any blood sugars in the 300's or 400's and confirmed no one from the facility contacted her regarding the blood sugar reading of 471 mg/dL on 06/23/25. CNP #200 stated she would have assessed the resident and placed a note with new recommendations and/or orders to get the blood sugar within a normal range. CNP #200 stated she was not notified until after lunch on 06/27/25 of a concern related to a change in a condition for Resident #88. Upon assessment, Resident #88 had sluggish responses. She confirmed she was involved with care relating to the two units of insulin given twice without the resident's response and revealed further updates were given through the on-call CNP #250. During an interview on 10/30/25 at 11:45 A.M., LPN #137 stated she was working and assisted the assigned nurse [RN #139] with assessing Resident #88 and administering insulin as ordered. LPN #137 confirmed the resident was provided with a total of four units of insulin and a sliding scale amount of an additional eight units. When the resident's family arrived at the facility they were upset with staff stating they were not doing anything and not caring for the resident and demanded he be transferred out to the hospital. During an interview on 10/30/25 at 1:07 P.M., RN #138 stated she was a nurse working with the resident on 06/26/25. She stated she did not remember the CNA's informing her of any concerns or changes in condition but did state she remembered assessing Resident #88 on 06/26/25 (a Wednesday) and found no concerns. She also stated she took a blood sugar reading and reported it was high. She said she did not remember what the number was but it was likely in the 300's or 400's and confirmed it was not documented in the medical record what the result was. RN #138 also confirmed the CNP #200 was not informed of any concerns or of the blood sugar reading and stated it may have been outside the range to report. Resident #88 had a bad diet and would get extra cranberry and orange juices and he requested six packs of sugar for his drinks, so a higher reading would not be surprising to her. RN #138 was unable to explain what led to the assessment and blood sugar reading on 06/26/25, outside of the regular weekly Monday readings. During an interview on 10/30/25 at 1:15 P.M., the Director of Nursing (DON) stated the staff know the residents very well and would likely identify changes in residents behaviors and needs and revealed the facility had discussed with the CNA's to inform the nursing staff and/or management if they had concerns about a resident or noticed a change in condition. The DON acknowledged, according to Resident #88's medical record, the CNP #200 was first notified of a change in blood sugar readings on 06/27/25 and confirmed the facility had no notes from the reading of 471 mg/dL on 06/23/25 or any mentions of a change in condition, nursing assessments or blood sugar checks on 06/26/25. The DON confirmed if a resident was having a change in condition, including having a high blood sugar reading outside of the physician orders, the medical team should have been notified. The DON also confirmed once notified, the CNP should put appropriate things in place and reported two units twice (total of 4 units) of insulin, when a blood sugar was over 500 mg/dL, would likely have no effect. She stated Resident #88 should have been sent out to the hospital after getting a reading over 500 mg/dL but especially should have been sent out after giving insulin with no change in the blood sugar reading instead of continuing with small insulin amounts over several hours. The DON acknowledged the resident should have been assessed for changes after the high reading on 06/23/25 and should have had more interventions and insulin orders put in place after his Hemoglobin A1C went from 6.5 to 7.9 percent around the same time of getting a blood sugar of 300 mg/dL. The DON revealed resident should have had increased monitoring or more frequent checks being ordered to monitor if changes in Resident #88's diet were having an impact on his blood sugar readings. Review of the facility policy titled, Notifications of Change in Condition, undated, revealed the safety of the residents was of primary importance and the purpose of the policy was to provide guidance related to notifications made to residents, family members, and the medical practitioner during changes in condition. The medical provider shall be promptly notified of significant changes and the medical record must reflect the notification, response and interventions implemented to address the change in condition. Review of the facility policy titled, Blood Glucose Point of Care Testing, undated, revealed safety was the primary concern for the residents. The importance of ongoing glucose monitoring was necessary to detect extremes of high or low blood glucose levels to evaluate the effectiveness of the treatment plan. A nurse may preform a non-routine glucose blood testing at the bedside without a physician order if resident changes were indicative of low or high blood glucose levels. Extremely high blood glucose levels could result in headaches, increased urination, fatigue, fruity breath and dry mouth and if left untreated, could result in coma or death. This deficiency represents non-compliance investigated under Complaint Number 1331272.

Based on observations, record review, policy review, and staff interview the facility failed to implement a comprehensive and individualized pressure ulcer prevention program to ensure adequate interventions were in place to promote healing and prevent new ulcers from developing. Actual Harm occurred on 08/13/24 when Resident #57, who exhibited severe cognitive impairment, had a current pressure ulcer present and required substantial/maximal assistance for bed mobility was assessed to have a new in-house developed pressure ulcer. The resident was assessed to have a deep tissue injury (Deep Tissue Pressure Injury (DTPI): Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to the right ischium/hip that developed due to the lack of adequate interventions including turning and repositioning. This affected one (Resident #57) of three residents reviewed for pressure ulcers. The facility identified four residents with in-house acquired pressure ulcers, including Resident #57. The facility census was 96. Findings include: Review of the medical record for Resident #57 revealed an admitted [DATE] and diagnoses including dementia and protein-calorie malnutrition. On 08/08/24 the resident weighed 97.1 pounds. Review of a Minimum Data Set assessment completed 06/09/24 revealed a brief interview for mental status score of 3, indicating severe cognitive impairment. The resident required substantial/maximal assistance with bed mobility, transfers, and personal hygiene. Review of a pressure ulcer risk assessment completed 12/17/23 revealed a high risk for pressure ulcers. Pressure ulcer risk assessments completed 03/17/24 and 08/13/24 only identified a moderate risk for the development of pressure ulcers (even though the resident had pressure ulcers on 08/13/24). Review of the plan of care for Resident #57 initiated 07/27/24 and revised 07/31/24 revealed the resident was at risk for altered skin integrity related to decreased mobility, kyphosis, contractures of bilateral lower extremities, incontinence, and history of pressure ulcers. The plan of care stated the resident had a deep tissue injury of the left medial foot. The goal was to have improved or maintain current skin status. Interventions included weekly skin checks and encourage resident to turn and reposition or assist as needed as resident allows. The resident had a hospital stay from 07/18/24 to 07/27/24 for a left hip fracture. A skin and wound note by the wound nurse practitioner on 07/31/24 stated the resident had a deep tissue injury pressure ulcer on the left medial foot which was present upon admission (readmission) measuring 2.5 centimeters (cm) by 2.0 cm. with 100 percent epithelial. No other pressure ulcers were identified. Recommendations for preventative measures included ongoing pressure reduction and turning/repositioning precautions per protocol. Review of nursing progress notes revealed a note from a physician on 08/13/24 indicating being notified that Resident #57 had ecchymosis of the right hip 3-5 cm in diameter. The note stated the resident had a recent left hip fracture and the area was likely due to pressure from offloading the resident off the left hip. The note stated to encourage frequent offloading. It further stated the resident should be up in a chair with meals. Physician's orders were obtained on 08/13/24 to encourage frequent offloading of right hip and should be up in chair with breakfast, lunch, and dinner. However, there was a nursing progress note on 08/14/24 that indicated the resident was unable to sit up in chair with meals due to pain. A skin and wound note by the wound nurse practitioner on 08/14/24 stated the resident had a new, deep tissue injury pressure ulcer of the right ischium measuring 6 cm by 7.5 cm. A new treatment order was given 08/14/24 to cleanse area with wound cleanser, apply Triad to base of wound, leave open to air when in bed and cover with border foam if up in chair. Recommendations for preventative measures included ongoing pressure reduction and turning/repositioning precautions per protocol. A skin and wound note by the wound nurse practitioner on 08/21/24 stated Resident #57 had a deep tissue injury pressure ulcer to the left medial foot measuring 2.5 cm by 2 cm which was improving. She also had a deep tissue injury pressure ulcer on the right ischium measuring 6 cm by 3 cm that was improving without complications. Recommendations for preventative measures included ongoing pressure reduction and turning/repositioning precautions per protocol. Observations on 08/21/24 at 10:43 A.M., 12:44 P.M., 1:20 P.M., 1:55 P.M., and 3:26 P.M. revealed Resident #57 to be in bed on her left side. At 1:55 P.M., Nurse Aide #100 was observed to feed the resident in bed on her left side. Nurse Aide #100 confirmed, at that time, that the resident was on her left side. She stated the resident did not have any pressure ulcers. Observations on 08/22/24 at 7:36 A.M., 9:37 A.M., 10:10 A.M., and 10:43 A.M. revealed Resident #57 to be in bed on her left side. Observation of the treatment for Resident #57 on 08/22/24 at 10:43 A.M. revealed an approximate quarter sized open area on the left medial foot. The open area was red with a white center. The area was cleansed with wound cleanser and the betadine was applied to the area. The right ischium was observed to have a deep reddish/purple area with a small scabbed area in the center. The area was cleansed with wound cleanser and Triad was applied. The skin on the left hip area was clear. The resident was placed back on her left side after the treatment was completed. Interview with Nurse Aide #208 on 08/22/24 at 11:03 A.M. revealed she and Nurse Aide #244 were providing care for Resident #57 on 08/22/24. She stated the resident was to be turned and repositioned every two hours by staff. She stated that she had come on duty at 6:00 A.M. She stated the resident was in bed on her right side from 6:00 A.M. until 9:00 A.M. when she was put on her back for breakfast. Then after eating (20-30 minutes) she was turned to her left side. However, when the surveyor stated she had observed the resident in bed on her left side at 7:36 A.M. (not right side as indicated by Nurse Aide #208) she stated she was not sure and Nurse Aide #244 should be asked about it. Interview with Nurse Aide #244 on 08/22/24 at 11:04 A.M. revealed Resident #57 should be turned and repositioned by staff every two hours. She first stated staff were able to do this. She stated she came on duty at 6:00 A.M. She then stated that the resident had been on her left side since she came on duty on 08/22/24. She stated the resident has pain when laying on her right side. She stated she had not reported this to the nurse. Interview with Licensed Practical Nurse #143 on 08/22/24 at 11:05 A.M. revealed he was the nurse for Resident #57 on 08/22/24. He stated the resident should be turned and repositioned every two hours. He stated staff were able to do that. He then stated he was not aware that the resident could not lay on her right side due to pain and was not aware the resident had been on her left side since 6:00 A.M. (five hours). Interview with the Director of Nursing on 08/22/24 at 11:30 A.M. revealed she was not aware Resident #57 could not lay on her right side. She confirmed the turning/repositioning program had not been revised to develop another plan to prevent pressure ulcers since the resident was having pain laying on her right side/getting up. Review of the facility undated policy titled Pressure Ulcer Prevention: High Risk revealed a care plan would be developed for pressure ulcer prevention. It stated to assist in position change as needed, position with pillows/support devices to assist in maintaining position and comfort, turn and reposition per plan of care. The policy further stated to monitor for consistent implementation of interventions, evaluate effectiveness of interventions, revise intervention and/or goals as indicated, and communicate changes in interventions to the caregiving staff. This deficiency represents non-compliance investigated under Complaint Number OH00156977.

Based on medical record review, staff interview, family interview, and review of the facility policy, the facility failed to ensure staff monitored resident nutritional status to prevent unplanned weight loss during a tube feed discontinuation trial. This resulted in Actual Harm for one (Resident #88) who experienced an unplanned weight loss of 4.6 percent (%) in three weeks and had ongoing severe weight loss of 8.5% over less than three months. The facility also failed to monitor weights and nutritional supplements for three (Residents #14, #20, and #56) of seven residents reviewed for nutrition. The facility census was 96 residents. Findings include 1.Review of the medical record for Resident #88 revealed an admitted [DATE] with diagnoses including hemiplegia and hemiparesis, dysphasia, aphasia, atrial fibrillation, muscle weakness and cognitive communication. Review of the nutrition assessment for Resident #88 dated 12/14/23 revealed the resident had received a percutaneous endoscopic gastrostomy tube (PEG) tube at the hospital and was on tube feeding. Review of the nutrition assessment for Resident #88 dated 03/11/24 revealed the resident relied on enteral nutrition to complement her oral intake and meet her needs. Resident #88 received 26 to 50% of her nutrition from her tube feed formula. Resident consumed an average of 77% at meals with ranges from 0% to 100%. Resident #88 had an order with for Isosource 1.5 at 80 milliliters per hour per PEG tube for ten hours daily. Further review of the assessment revealed the dietitian recommended Isosource to be discontinued for Resident #88 and to monitor the resident's weight weekly. Review of the weight records for Resident #88 revealed the following dates/weights: - 02/07/24 weight of 180.3 pounds (lbs.) - 03/07/24 weight of 181.0 lbs. - 04/02/24 weight of 172.6 lbs. - 05/07/24 weight of 168.2 lbs. - 05/14/24 weight of 168.0 lbs. - 05/20/24 weight of 165.6 lbs. - 06/01/24 weight of 166.0 lbs. Review of weights revealed from 03/07/24 to 04/02/24 Resident #88 had a 4.64% weight loss in about three weeks. Review of weights revealed from 03/07/24 to 05/20/24 Resident #88 had a severe weight loss of 8.51% in under three months. Review of progress note per nurse practitioner for Resident #88 dated 03/13/24 and 03/14/24 revealed the resident's tube feeding was on hold and the dietician would follow and monitor the resident. Review of nutrition progress note for Resident #88 per Dietitian #144 dated 04/03/24 revealed the resident had a weight loss of 4.6% during a trial discontinuation of nocturnal tube feeding. Resident #88 resumed nocturnal tube feeding as previously ordered on 04/03/24 after weight loss was identified. Resident's oral intake for 03/11/24 to 04/02/24 was an average of 53% of mechanical soft meals by mouth. Review of the Minimum Data Set (MDS) assessment for Resident #88 dated 05/03/24 revealed the resident was cognitively impaired and required supervision or touching assistance for eating. Resident received an enteral feeding. Review of care plan dated for Resident #88 dated 05/06/24 revealed the resident had a nutrition problem related to dysphasia from cerebrovascular accident (CVA) and was on a mechanically altered diet and enteral nutrition. Interventions included the following: notify the medical provider and resident representative of unplanned weight loss, nutritional consult, obtain labs, obtain weights as ordered. Review of the care plan for Resident #88 dated 05/06/24 revealed the resident received tube feeding related to dysphasia from CVA. Interventions included the following: monitor intake, notify medical provider and resident representative of unplanned weight changes, nutrition consult quarterly and as indicated, obtain weights as ordered. Interview on 06/04/24 at 9:13 A.M. with Resident #88's representative confirmed the facility stopped Resident #88's tube feed on 03/11/24 and because the resident lost weight the facility needed to restart the tube feeds. Interview on 06/06/24 at 3:02 P.M. with Dietician #143 confirmed residents should be weaned from tube feed intakes by cutting the dose over several days and monitoring intake and weights before stopping tube feeds completely. Dietitian #143 confirmed she would typically request weekly weights for residents receiving tube feeding and residents should be monitored closely during tube feed weaning trials. Dietician #143 confirmed Resident #88's record did not include monitoring of resident's weight and nutritional status following the discontinuation of resident's nocturnal tube feeding from 03/11/24 to 04/02/24 per the previous Dietitian #144. Dietician #143 confirmed there were no additional nutritional progress notes or documentation of additional nutritional interventions as Resident #88 continued to lose weight. Dietitian #143 confirmed Resident #88 had an 8.5% weight loss from 03/07/24 to 05/20/24. Interview on 06/10/24 at 1:10 P.M. with Corporate Dietician (CD) #147 confirmed facility had no documentation of Resident #88's weight being monitored from 03/11/24 to 04/02/24 during the tube feed discontinuation trial. CD #147 confirmed weights were not taken weekly as recommended and acknowledged resident was stopped from tube feeding nutrition without weaning and when resident was still obtaining 26 to 50% of her nutrition from her tube feed formula. Review of facility policy titled Diet and Nutrition Care Manual dated 2019 revealed weight changes were considered significant per the following parameters: 1-2% weight loss in one week, 5% weight loss in one month, 7.5% weight loss in three months and 10% weight loss in six months. 2. Review of the medical record for Resident #14 revealed an admitted [DATE] with diagnoses including aneurysm, hemiplegia and hemiparesis, convulsions, diabetes, polyneuropathy, muscle wasting and atrophy. Review of progress note for Resident #14 dated 04/10/24 revealed the resident had a weight change due to possibly due to declining intakes. The dietitian recommended Resident #14's diet to be changed from carb controlled to regular to liberalize choices and to monitor weights weekly for four weeks. Review of weight records for Resident #14 revealed the following dates/weights: - 04/22/24 weight of 188.9 lbs. - 05/17/24 weight of 181.5 lbs. - 05/20/24 weight of 185.4 lbs. Review of nutritional assessment for Resident #14 dated 05/19/24 revealed staff should continue to weigh the resident weekly. Review of the MDS assessment for Resident #14 dated 05/22/24 revealed the resident was cognitively intact required set up assistance with eating. Review of the plan of care for Resident #14 dated 05/23/24 revealed the resident had a potential nutrition problem with interventions to monitor and address significant weight changes and weigh per facility order. Interview on 06/06/24 at 3:02 P.M. with Dietician #143 confirmed the facility had no evidence of weekly weights being obtained and monitored as recommended by the dietitian on 04/10/24. Dietitian #143 confirmed resident went three and a half weeks without updated weights. 41266 3. Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including type two diabetes mellitus without complications, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, contracture of muscle in left hand, contracture of left ankle, dementia, reduced mobility, and need for assistance with personal care. Review of the MDS assessment for Resident #20 dated 04/05/24 revealed the resident was cognitively impaired and depended on staff assistance with eating. Review of the physician's orders for Resident #20 revealed orders dated 02/12/24 for the resident to be weighed weekly on Mondays and offer fortified pudding with lunch and dinner and an order dated 04/01/24 for a pureed textured diet. Review of the weight record for Resident #20 revealed the following dates/weights: -11/08/23 weight of 177 lbs. -01/04/24 weight of 169 lbs. -02/07/24 weight of 156 lbs. -03/07/24 weight of 158 lbs. -03/31/24 weight of 151 lbs. -04/05/24 weight of 153 lbs. -05/07/24 weight of 157 lbs. Review of the progress note for Resident #20 dated from 01/08/24 revealed the resident had lost weight from 11/08/23 to 01/04/24 and a reweight was requested. Review of the progress note for Resident #20 dated 02/08/24 timed at 1:00 P.M. revealed the resident weighed 156 lbs. on 02/07/24 and there had been no reweight following the weight on 01/04/24. This reflected an unplanned weight loss of 7.7% or 13 lbs. in 30 days. The dietitian recommend the addition of fortified pudding with lunch and dinner. Review of progress note for Resident #20 dated 03/11/24 timed at 4:09 P.M. revealed the resident weighed 158 lbs. on 03/07/24 which indicated the resident's weight was stabilizing. No additional new interventions were recommended. Review of the progress note for Resident #20 dated 04/01/24 timed at 3:30 P.M. revealed the resident weighed 151 lbs. on 03/31/24 which reflected an unplanned significant weight loss of 10.7% or 18 lbs. over 90 days. The recommendation was to monitor with weekly weights for four weeks. Review of the progress note for Resident #20 dated 05/19/24 timed at 4:56 P.M. revealed the resident weighed157 lbs. on 05/07/24 which reflected a significant weight loss of 11.4% over 180 days. The resident's meal intakes varied from 26-100%. No additional interventions were recommended. Review of the medical record for Resident #20 revealed it did not include documentation regarding the resident's acceptance of the fortified pudding that was added as a nutritional intervention for significant weight loss which was noted separately from the rest of the resident's meal tray. Interview on 06/05/24 at 2:27 P.M. with Regional Clinical Manager (RCM) #137 confirmed Resident #20 had a physician's order for fortified pudding at lunch and dinner to help stabilize the resident's weight, but the facility had not documented the resident's acceptance of the pudding. RCM #137 further confirmed the facility had not obtained reweights or weekly weights as ordered/recommended for Resident #20. Review of the facility policy titled Resident Height and Weight undated weights would be obtained monthly or as ordered by the physician or practitioner. Staff should compare weight to previous weights obtained. If a variance of five pounds or more was noted staff should reweigh the resident to verify weight. Nutritionally unstable residents would be reviewed by interdisciplinary team (IDT) to determine frequency of obtaining weight. Review of the facility policy titled Fortified Food Program undated, revealed the goal of the fortified food program was to be able to provide a higher calorie and or higher protein food item to residents if the intake of regular foods or beverages were estimated to be unable to meet the resident's nutritional needs. 49039 4. Review of the medical record for Resident #56 revealed an admitted [DATE] with diagnoses including absence of right and left leg above the knee, severe protein calorie malnutrition, depression and muscle weakness. Review of the care plan for Resident #56 care plan dated 11/06/23 revealed the resident had the potential for altered nutrition status related to diagnoses with interventions including nutritional consult, obtaining weights as ordered and monitoring meal intakes. Review of the MDS assessment for Resident #56 dated 02/07/24 revealed the resident was cognitively intact and required staff assistance with feeding. Review of the nutritional assessment for Resident #56 dated 02/07/24 the resident had an average meal intake of 75%. Resident weights had not been obtained for 60 days. Review of the progress note for Resident #56 progress dated 02/08/24 revealed the resident had a weight change from 136.8 pounds on 12/04/23 to 94.6 pounds on 02/08/24 related to bilateral leg amputations. The resident's weight was to be obtained weekly following the amputations. Record of the physician orders for Resident #56 revealed an order dated 02/08/24 to obtain weekly weights. Record of the weight record for Resident #56 from 02/11/24 to 03/18/24 revealed there were no weights obtained for the resident. Interview on 06/06/24 at 8:13 A.M. with Central Supply Coordinator (CSC) #115 confirmed she was responsible for obtaining weekly weights. CSC #115 confirmed Resident #56 had a significant weight loss and was supposed to be weighed weekly, but she had not weighed the resident weekly. Interview on 06/06/24 at 4:00 P.M. with Dietician #143 confirmed Resident #56 was on the weekly weight list due bilateral leg amputations which resulted in a significant weight loss. Dietician #143 confirmed the facility did not obtain required weights. Interview on 06/06/24 at 8:13 A.M. with the Administrator confirmed Resident #56's weekly weights were not obtained per physician order between 02/08/24 to 03/18/24. Interview on 06/10/24 at 1:24 P.M. with Resident #56 confirmed she had weight loss due to surgery and not due to lack of appetite. Review of facility policy titled Resident Height and Weight undated revealed weights would be obtained monthly or as ordered by the physician.

Based on record review, interview, and policy review, the facility failed to provide adequate resident supervision and assistance resulting in a fall with major injury. Actual Harm occurred on 01/19/24 when Resident #1, who was identified at risk for falls, assessed to have cognitive impairment, and required supervision while smoking, exited the facility through two sets of locked doors, to the facility's outdoor smoking area with a cigarette and the intention of helping Receptionist #100 shovel snow due to inclement weather. Once Receptionist #100 discovered the resident was outside, the resident was instructed to return to her room. The resident entered the facility while wearing wet footwear (from snow) and subsequently slipped on the tile floor. The resident sustained a right distal radius and ulnar fracture. The resident was transported to the emergency room for evaluation/splinting and later followed with orthopedic surgery for cast application. This affected one resident (Resident #1) of three residents reviewed for falls. The facility census was 72. Findings include: Review of the Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, chronic obstructive pulmonary disease, heart disease, chronic kidney disease, chronic pain, and acquired absence of right leg, below the knee (Resident #1 used a right leg prosthesis). Review of the care plan, initiated on 10/31/22, revealed Resident #1 as at risk for falls related gait/balance problems, right lower leg prosthesis, and a history of falls. Interventions included to assess for falls on admission, quarterly, and as needed, to ensure the resident was wearing appropriate non-skid footwear, to ensure the resident's room was free of accidents/hazards, fall mat next to bed, ensure bed locks engaged, and to place the call bell within reach and to remind the resident to call for assistance. Review of the fall risk assessment, dated 12/01/23, revealed Resident #1 was identified as a potential risk for falls. Further review revealed the assessment was inaccurate as it indicated there were no predisposing conditions (the form specified loss of limbs as an example of a predisposing condition). The resident had a right leg below the knee amputation and required the use of a prosthetic leg. Review of the 5-Day Minimum Data Set (MDS) 3.0 assessment, dated 12/27/23, revealed the resident had a diagnosis of dementia and was not able to report the correct month or day of the year. The resident had a prosthetic, and had lower extremity impairment on one side. The resident received scheduled opioid pain medication. The assessment indicated there had been no falls since the last assessment. Review of a nursing progress note, dated 01/20/24 at 1:54 P.M., revealed Resident #1 said she had a fall yesterday on 01/19/24 in the smoking area but did not hurt herself. The resident said she didn't mention it because she wasn't hurt and did not hit her hand. The resident's right wrist is swollen. The Physician was notified. Review of a nursing progress note, dated 01/20/24 at 3:36 P.M., revealed an x-ray was ordered of the right wrist. A head-to-toe assessment was completed. The right wrist was swollen with minimal movement. The resident denied wrist pain. The resident was educated on the smoking policy and when she is allowed outside, supervised during smoking time. Review of Receptionist #100's written statement dated 01/20/24, revealed on 01/19/24, while he was in the smoke area shoveling snow and putting down salt, Resident #1 came outside and tried to help him. Receptionist #100 told the resident no and that she needed to go back inside. Upon turning around, he observed a cigarette in her hand trying to smoke. Receptionist #100 told Resident #1 that it wasn't smoke time and she needed to go back in. At this time, Resident #1 turned and started walking toward the door and she slipped and fell . Receptionist #100 asked the resident if she was okay, and she stated that she was fine and got up and walked away. On 01/20/24, the resident's risk for falls care plan was updated to include the following interventions: educate the resident on the smoking policy regarding supervision and smoking times was initiated. Further review of the care plan, initiated on 01/30/24, revealed the resident is a smoker and will be free from injury while smoking with interventions including to complete a smoking evaluation, to educate the resident on the smoking policy and designated smoking area, and to provide safe smoking devices, and to provide supervision during designated smoke times. Review of the x-ray report of the right wrist, date of service 01/21/24, revealed an acute fracture of the distal radius and ulna. Review of a telehealth notification, dated 01/21/24 at 10:58 A.M., revealed the resident had an acute fracture of the right distal radius and ulna. The fall was on Friday (01/19/24) and the resident continues to have pain. Non-emergent transport to the emergency department (ED) for splinting. Review of a nursing progress note, dated 01/21/24 at 1:04 P.M., revealed the nurse practitioner (NP) was notified of the x-ray results indicating a right wrist fracture. A new order was given to send the resident to the emergency room stat. Review of a post hospital encounter Nurse Practitioner (NP) progress note, dated 01/22/24, revealed the resident was seen post fall which occurred on 01/19/24. X-rays were obtained on 01/20/24 and indicated a right wrist fracture. The resident was sent to the ED on 01/21/24 and returned that evening with a right arm splint. According to the resident, she was walking in from the outside and slipped on tile. She caught herself with her hand and had ongoing wrist pain since. X-rays were obtained and showed a radius and ulnar fracture. In the ED, the arm was splinted and a follow-up with orthopedic surgery was recommended. The follow-up was scheduled for 01/24/24. Continue pain control and continue to monitor. Acute chronic pain with Tramadol prescribed and Percocet added and to be administered as needed. The Fall Investigation was unavailable at the time of the on-site survey. During interview on 02/23/24 at 2:17 P.M. the DON revealed Unit Manger/Registered Nurse (RN) #204 had completed the fall investigation and it was in RN #204's office. The DON shared she went into RN #204's office but was unable to locate the fall investigation and RN #204 was off work and unable to be contacted. \ Review of the physician orders revealed the resident had an order to follow-up with orthopedics on 01/24/24 (orthopedics applied a cast to the resident's right wrist/forearm) and a follow-up appointment is scheduled for 02/26/24. The facility continues with the circulation checks each shift as ordered with the initial injury and splint. Observation and interview on 02/23/24 at 11:22 A.M. revealed Resident #1 sitting on the side of her bed. A cast was observed to the right forearm/wrist area. Resident #1 stated a couple of weeks ago, after it snowed, she wanted to go out to the smoking area to help the receptionist shovel snow and apply salt. The resident stated that the receptionist agreed and knew she was going to help and she followed him through two doors, and out into the smoking area. The resident stated after she helped with the salt, she went back into the facility. The resident further stated that after she entered through the exterior door and back inside the facility, she slipped on the wet tile floor and then fell . The resident didn't think she was hurt or injured at the time of the fall and didn't report the fall to the nurse. The resident stated the next day her arm started hurting but she didn't ask for any pain medication because she already gets scheduled pain medicine for other pain. Interview and observation on 02/23/24 at 1:32 P.M. with the Assistant Director of Nursing (ADON) revealed to her knowledge, Resident #1 followed the receptionist out of the doors to the smoking area when he was shoveling snow. The ADON stated the receptionist re-directed the resident and told her it wasn't time to smoke. The resident went back in through the door and slipped on the tile. The resident denied injury at that time to the receptionist. Observation revealed a locked door located on the hallway that opened into a room with a tile floor. A second locked door exited into the designated, outside smoking area. Both door locks had to be unlocked with a key. The ADON confirmed the keys are kept at the nursing station. During interview on 02/23/24 at 1:45 P.M., Receptionist #100 stated he was shoveling snow and putting salt down in the smoking area when Resident #1 followed him out and wanted to help. Receptionist #100 stated that he told her no, and that he was ok. Receptionist #100 stated he saw that the resident had a cigarette and told her it wasn't smoke time and she needed to go back to her room. Receptionist #100 did not know how the resident obtained the cigarette. Receptionist #100 stated, I opened the door for her to go back into the facility and after she entered through the door, she slipped and fell on her knees. I asked her if she was ok, and she said she was ok. I don't know how she got out of the locked doors to the smoking area, she must have followed me out. She is really fast and can get around. Receptionist #100 confirmed that he did not report the fall to anyone because the resident said she was not hurt, however, he has since been educated to report any fall or accident to nursing staff. During a follow-up interview on 02/23/24 at 2:06 P.M., Resident #1 confirmed she did not ask any nursing staff if she could go outside to the smoking area the day she fell . The resident stated she does not recall if the two doors were locked that lead out to the smoking area and could not recall if she immediately followed the receptionist through the doors or if he was already outside in the smoking area. During interview on 02/23/24 at 2:17 P.M., the DON stated it was reported that Resident #1 had a fall in the smoke area after it had snowed. The DON stated she believed the resident came outside and tried to help the receptionist and was also trying to smoke when he told her she couldn't smoke and to go back inside. The DON stated the resident reported pain and swelling the next day. The DON stated, I'm honestly not sure if the door wasn't locked initially or if she just followed him out. The DON confirmed she was not sure how the resident obtained the cigarette because smoking supplies are secured by the nursing staff. The DON confirmed Resident #1 required smoking supervision and was not properly supervised as she should not have been able to exit through the two locked doors and should not have had a cigarette in her possession outside of supervised smoking times. The DON further stated she determined the root cause of the fall was because the resident wasn't properly supervised and should not have been able to get outside to the smoking area. The RN verified the resident should not have been outside, with her smoking item and she should have been assisted back into the facility due to the inclement weather. The DON also verified the receptionist should have reported the fall to the nursing staff. Review of the facility's policy titled, Fall Prevention and Management, revision date of 06/01/22, revealed it is the policy of this facility to provide resident centered care that meets the psychological, physical, and emotional needs and concerns of the residents. Fall prevention and management is the process of identifying risk factors that can minimize the potential for falls and also a process to manage a resident's care if a fall occurs. Process after a fall: Assessment, the resident should not be moved until assessed by a licensed nurse. Review of the facility's policy titled, Resident/Patient Smoking, revision date of 03/24/2016, revealed it is the policy of this facility to promote resident centered care by promoting a safe smoking area for resident/patients that request to smoke and are capable of safe smoking behaviors either independently or with supervision unless the facility is a designated non-smoking facility. A supervised smoker is a resident that is unable to demonstrate safe smoking habits including smoking materials management, lighting, controlling cigarette ash and extinguishing smoking materials and requires staff supervision when smoking. This deficiency represents non-compliance investigated under Complaint Number OH00150837.

Based on medical record review, review of hospital records, review of the guidance on Medscape.com, review of the death certificate, review of the facility's policy, and staff interviews, the facility failed to provide a resident with timely care and treatment when a resident had a change in condition. This resulted in Immediate Jeopardy when one resident (#94) was placed at potential risk for serious life-threatening harm injuries and/or death when he developed hematuria (blood in the urine) and had three separate occasions of mild abdominal pain, burning, and right flank pain on [DATE]. There was no follow up after Certified Nurse Practitioner (CNP) #450 evaluated Resident #94 on [DATE]. On [DATE], Resident #94 was sent to the hospital for a change in condition, treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#94) of four residents reviewed for a change in condition. The facility census was 92. On [DATE] at 3:59 P.M., the Administrator, Director of Nursing (DON), Medical Director #900 and Cooperate Registered Nurse #830 were notified Immediate Jeopardy began on [DATE] when the facility asked CNP #450 to evaluate Resident #94 for complaints of hematuria and three separate occasions of mild abdominal pain, burning and right flank pain on [DATE]. CNP #450's evaluation on [DATE] recommended laboratory testing and a urinalysis, which was not completed by the facility. There was no evidence of any further nursing, CNP, or physician assessments from [DATE] through [DATE] for Resident #94. On [DATE], Resident #94 had a change in condition on the night of [DATE] and was sent to the hospital in the early morning of [DATE]. There was no documentation in the medical record that Resident #94 experienced hematuria, abdominal pain, burning, and/or right flank pain from [DATE] to [DATE] except for the CNP note dated [DATE]. Resident #94 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital notes indicated the nursing home reported Resident #94 had gross hematuria. Resident #94 died in the hospital on [DATE] and his death certificate stated the cause of death was Extended-Spectrum Beta-Lactamases (ESBL) (multi-drug resistant pathogen) Proteus Bacteremia, urinary tract infection, and [CONDITION(S)]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE], Resident #94 was sent to the hospital and subsequently died in the hospital on [DATE]. · On [DATE], all residents received a comprehensive head-to-toe assessment by the DON/designee on [DATE]. The DON/Designee documented the comprehensive head-to-toe assessment and updated any plans of care as indicated in the resident's Electronic Medical Records (EMR), as well as updated the physician as indicated. · On [DATE], the DON/Designee completed an audit of all physician/Nurse Practitioner (NP) progress notes for the past 30 days auditing for physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . · On [DATE], the DON/Designee completed an audit of all laboratory orders and services conducted for the past 30 days to ensure all services have been carried out appropriately. · On [DATE], all licensed nursing staff were re-educated on the change of condition policy in conjunction with the abuse and neglect policy by the DON/Designee. · On [DATE], all licensed nursing staff will be re-educated on clinical assessment and documentation guidelines by the DON/Designee. · On [DATE], individual written education was provided to Licensed Practical Nurse (LPN) #52 providing care to Resident #94 on [DATE] regarding clinical assessment and documentation guidelines by the DON/Designee. · On [DATE], all NPs and physician providers who see residents in the facility will receive additional education and guidelines related to physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This will be completed by Regional Director of Clinical Operations #830 and/or Designee by [DATE]. · On [DATE], the Executive Director held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting to review the results of all initial audits. · Beginning on [DATE], daily audits of all hospital transfers, residents with change of condition, and/or death will be audited for proper assessment, documentation and follow up daily Monday through Friday for six weeks by the DON/Designee to ensure education was effective. · Beginning on [DATE], daily audits of all new orders will be completed to ensure transcription, follow through and documentation daily, Monday through Friday for six weeks by the DON/Designee to ensure education was effective. · Beginning on [DATE], on-going audits of staff knowledge of the change of condition policy, clinical assessment, and documentation guidelines will be conducted with three nurses, three times per week for six weeks by the DON/Designee to ensure education was effective. · On [DATE], the Executive Director will hold specialized QAPI meetings moving forward weekly for six weeks for the duration of the on-going audits to review results and review effectiveness of education. This will continue every Thursday for the six weeks. · Review of the facilities in-service sign in sheet for clinical assessment, change in condition, and documentation education revealed all licensed nursing staff were educated on [DATE]. All resident head-to-toe assessments and audits of the physician/NP progress notes for physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #94's medical record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #94 was receiving [MEDICATION(S)] (a blood thinner) for a previous history of pulmonary embolism, daily since admission. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #94's cognition was intact. Resident #94 required assistance with toileting and was always incontinent. Review of Resident #94's medical record revealed there was no history of bleeding and or urinary tract infections since admission to the facility. The medical record revealed no evidence of concerns from admission through [DATE] until CNP #450 was asked to see Resident #94 for hematuria (blood in the urine) on [DATE]. Review of CNP #450's notes dated [DATE] revealed the facility staff asked the CNP to assess Resident #94 for concerns of hematuria. CNP #450 stated to check the urinalysis (UA) and laboratory values (There was nothing specific mentioned for what laboratory values the CNP wanted to check). CNP #450's notes revealed Resident #94 had stage four [CONDITION(S)]. Resident #94's present illness, had episode of hematuria on [DATE] and Resident #94 stated he had three separate occasions yesterday with mild abdominal pain, burning and right flank pain for two days. CNP #450's notes revealed Resident #94 drinks large amounts of soda through the day and had no fevers reported. Review of the medical record from [DATE] through [DATE], revealed no evidence any physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress notes had no evidence of any further facility nursing assessments, CNP notes or physician visits regarding Resident #94's symptoms of bleeding and or possible urinary infection. Review of the progress notes dated [DATE] at 11:29 P.M. revealed Resident #94 was complaining of nausea and stomach pain. The nurse administered [MEDICATION(S)] (anti-nausea medication). Approximately 15 minutes later when the State tested Nursing Aides (STNA) went to assist Resident #94 to bed, the STNAs came and notified the nurse that Resident #94 was not responding to them. The nurse went into the room and observed Resident #94 shaking, cyanotic and in distress. Vital signs were taken, and his blood pressure measured ,d+[DATE] millimeters of mercury (mmHG), temperature was 99.4 Fahrenheit (F), and oxygen saturation level was 57 percent (%.) The nurse applied oxygen at 15 liters on a non-re-breather and his level increased to 64%. Resident #94 was able to talk and respond to questions. Resident #94 was sent to the emergency room . Again, there was no mention of hematuria. Review of Resident #94's hospital records dated [DATE] revealed upon arrival at the emergency room , Resident #94 was stabilized and sent to the intensive care unit. The notes revealed Resident #94 had gross hematuria at the nursing home and was on a blood thinner for a previous pulmonary embolism. The records revealed a critical care consult dated [DATE] which revealed Resident #94 was suffering from septic shock (blood infection) and acute [CONDITION(S)], likely cause from the [CONDITION(S)]. Review of the hospital discharge summary dated [DATE] at 1:22 A.M. revealed Resident #94's blood cultures were positive for Proteus ESBL (multi-drug resistant pathogen). Despite all aggressive measures, Resident #94 continued to decline and was pronounced dead on [DATE] at 1:22 A.M. Review of Resident #94's death certificate revealed the cause of death was ESBL Proteus Bacteremia, urinary tract infection, and [CONDITION(S)]. Telephone interview with Medical Director #900 on [DATE] at 3:59 P.M. confirmed CNP #450 gave a verbal order to the facility on [DATE] for a Complete Blood Count (CBC), Basic Metabolic Panel (BMP) and urinalysis to be completed on [DATE]. Medical Director #900 confirmed the facility never completed the ordered laboratory testing. Medical Director #900 confirmed it was the nursing staff's responsibility to put the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Telephone interview with the DON on [DATE] at 4:01 P.M. confirmed there was no documentation regarding Resident #94's hematuria and there should have been nursing and CNP/physician follow up. The DON confirmed the nursing staff should have been assessing Resident #94 during [DATE] and [DATE] and this did not occur. Interview with Cooperate Registered Nurse #830 on [DATE] at 11:40 A.M. confirmed the nursing staff should have documented Resident #94's pain and hematuria in Resident #94's medical record. Review of the Medscape guidance titled Urinary Tract Infection ([CONDITION(S)]) in Males, dated [DATE], revealed a sign and symptom of a [CONDITION(S)] could be nocturia, gross hematuria, any changes in the color and/or consistency of the urine. Review of the Medscape guidance titled Proteus Infections, dated [DATE], revealed UTIs can result in [CONDITION(S)] if not recognized and treated rapidly. Failure to treat or a delay in treatment can result in Systemic [CONDITION(S)] Responses Syndrome (SIRS), which carries mortality rate of 20 to 50 percent (%). Review of the facility's Interact Version 4.0 Tool regarding Change in Condition: When to report to the physician (MD/CNP, or physician assistant (PA) dated 2014 revealed immediate notification for any symptom, sign, or apparent discomfort that is: acute or sudden in onset, and a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed. A resident with signs and symptoms possibly related to a [CONDITION(S)] or urosepsis (e.g., fever, burning, sensation, pain in suprapubic or flank area) required immediate reporting to the MD/CNP/PA. A sign or symptom of gross hematuria with pain, fever, or other signs of bleeding at other sites requires immediate notification to the MD/CNP/PA. Review of the facility's policy titled Clinical Documentation Standards, dated [DATE], revealed the facility is to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Safety is a primary concern for the residents, staff and visitors. Maintaining the integrity, quality and safety of medical records can help to provide an effective communication between practitioners that may serve to enhance resident outcomes. A complete record contains an accurate and functional representation of actual experience of the resident and must contain enough information to show that the status of the individual resident is known, and a plan of care has been identified to meet the care needs identified in the medical records. Nurses will follow the basic standard of practice for documentation including but not limited to providing a timely and accurate account of resident information in the medical records. This deficiency substantiates Complaint Number OH 079.

Based on medical record review, staff interview, and observation, the facility failed to ensure nutritional interventions were implemented timely, nutritional recommendations were addressed timely, and failed to ensure diet orders were followed as ordered. Actual harm occurred when Resident #52, who was assessed as a 12 percent weight loss in 30 days, did not have nutritional recommendations addressed timely and nutritional interventions were not implemented timely. Additionally, actual harm occurred when Resident #63, who was assessed as a 21% weight loss in 180 days, did not have nutritional interventions implemented timely and did not receive the appropriate diet. This affected two residents (#52 and #63) of seven reviewed for weight loss. The facility census 92. Findings include: 1. Review of the medical record for Resident #52 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 had moderate cognitive impairment. Resident #52 had a height of 64 inches and weight of 78 pounds. Resident #52 was documented as having experienced a significant weight loss while not on a prescribed weight loss regimen. Resident #52 was documented as not receiving a therapeutic diet. Review of the plan of care dated 09/13/21 revealed Resident #52 had a nutritional problem or potential problem related to impaired dentition, recent hospitalization , and weakness. Further review of the plan of care revealed Resident #52 had a significant weight loss. Interventions included establish a baseline weight, identify food and beverage preferences, monitor meal intake, Ensure (a nutritional supplement) two times a day, and an appetite stimulant. On 09/28/21, the care plan was updated to include Ensure was increased to three times a day, and the appetite stimulant was discontinued due to intolerance. Review of Resident #52's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #52's weight records revealed on 07/16/21 the resident weighed 93.7 pounds, on 07/20/21 she weighed 93.9 pounds, on 08/03/21 she weighed 77.6 pounds, on 08/17/21 she weighed 78.2 pounds, and on 09/07/21 she weighed 72.2 pounds. Resident #52 was weighed on 09/28/21 and was weighed 68.8 pounds. Resident #52's weight of 68.8 pounds on 09/28/21 indicates a clinically significant roughly 12% weight loss since 08/17/21 and clinically significant roughly 26.5% weight loss since 07/16/21. Review of the dietary nutritional assessment dated [DATE], revealed Resident #52 was on a regular diet but was a small eater and her meal intake ranged from 25 to 50% of meals. The resident required supervision at meals. Resident #52 was 64 inches tall and weighed 94 pounds with a Body Mass Index (BMI) of 16.1 indicating she was underweight. Resident #52 was identified as 87% of her ideal body weight and reported her usual weight to be around 90 pounds. The dietitian calculated her estimated nutritional needs to be 1495 calories per day, 51 grams of protein per day, and 1500 milliliters (ml) of fluid per day. Resident #52 requested Ensure twice a day as she wanted to gain weight. The dietitian recommended Ensure twice a day and food according to her preferences. The goal was for Resident #52 to gain one to two pounds a week while consuming more than 50% of her meals. Review of the dietary progress note dated 08/08/21 revealed Resident #52 experienced a weight loss since admission and her weight was 77 pounds. The dietitian recommended Medpass, a nutritional supplement, 120 ml three times a day for a slow positive weight gain for improved health state. The note did not indicate the Certified Nurse Practitioner (CNP) or physician was notified of weight loss. Review of the CNP note dated 08/16/21 revealed no documentation regarding Resident #52's intake or weight loss. Review of the CNP's progress note dated 09/07/21 revealed [MEDICATION(S)] was recommended due to decreased oral intake and appetite changes. Review of the dietary progress note dated 09/13/21, revealed the resident experienced a weight loss of 7.7% in the past 30 days. Resident #52 had always been a small eater and was not interested in foods. Resident #52's interventions were reviewed and included a TLC diet, Ensure supplement twice a day, and [MEDICATION(S)] for appetite. Review of the CNP notes dated 09/14/21 revealed Resident #52's [MEDICATION(S)] was discontinued due to delusions. Interview on 09/28/21 at 1:40 P.M. with Dietitian #231, revealed she was aware of the resident's weight loss and was present in the building three days a week. Dietitian #231 stated the resident was not on weekly weights because I don't ask for something that's not going to get done. Dietitian #231 confirmed Ensure was in place prior to Resident #52's weight loss. Dietitian #231 was unaware Medpass had not been ordered as recommended and reported she usually heard about her recommendations in morning meetings. Dietitian #231 stated Resident #52's [MEDICATION(S)] was discontinued due to hallucinations and confirmed there had been no new nutrition interventions since the [MEDICATION(S)] was discontinued. When discussing further interventions, Dietitian #231 reported she could have considered other appetite stimulant's. Interview on 09/28/21 at 3:51 P.M. with Dietitian #231, revealed Dietitian #231 requested a new weight for Resident #52 and the new weight was 68.8 pounds, which was a loss from her previous weight. Interview on 09/29/21 at 1:28 P.M. with Dietitian #231, revealed resident nutritional needs were calculated during initial assessments, annual assessments, and significant change assessments. She confirmed she did not calculate updated nutritional needs after significant weight changes. Interview on 09/28/21 at 2:31 P.M. with Culinary Manager #211, revealed the dietitian usually kept her up to date on at risk residents. Culinary Manager #211 reported she had not discussed dietary preferences with Resident #52. Interview on 09/28/21 at 4:03 P.M. with the Director of Nursing (DON), revealed the Dietitian communicated recommendations by putting them in mailboxes for nursing staff. The Unit Managers would either complete her recommendations themselves or pass them on to floor nurses to be completed. The DON reported they were able to complete weekly weights as needed. The DON was unsure as to what was being done for Resident #52's weight loss. Interview on 09/29/21 at 5:29 P.M. with CNP #233, revealed she was unsure if she received all of the dietitian's recommendations, due to them being left in her mailbox. She stated she communicates with the dietitian if she doesn't agree with her recommendations but she did not know about the recommendation for Medpass. CNP #233 revealed she was unaware of the amount of weight the resident had lost and denied being notified of the 08/03/21 and 09/28/21 weight loss. The CNP revealed she was aware communication about weight change was a problem in the past, which is why she included weight changes in her notes when she was made aware. She revealed she was informed of Resident #52's weight loss around the time she started the [MEDICATION(S)] on 09/07/21. CNP #233 stated she had to discontinue the [MEDICATION(S)] due to hallucinations. 2. Review of the medical record for Resident #63 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment for Resident #63 revealed the resident had moderate cognitive impairment. Resident #63 was 63 inches tall and weighed 95 pounds. Resident #63 was documented as having experienced a significant weight loss outside of a prescribed weight loss regimen. The quarterly MDS assessment indicated Resident #63 was not on an altered texture or therapeutic diet. Review of the plan of care dated 07/12/21, revealed Resident #63 had an inadequate intake of food and beverages related to appetite as evidenced by significant weight loss, diet restrictions, history of [CONDITION(S)], and [CONDITION(S)] with diuretic use. Interventions included identifying the resident's food and beverage preferences, monitoring meal intake, notifying the medical provider and resident representative of unplanned weight changes, providing meals according to the diet order, providing no sugar added Medpass 120 milliliters twice a day, and vitamin supplements. Review of Resident #63's weights revealed on 03/03/21 she weighed 119 pounds, on 04/03/21 she weighed 123 pounds, on 05/03/21 she weighed 115.6 pounds, on 05/06/21 she weighed 117.2 pounds, on 06/03/21 she weighed 108.6 pounds, on 06/07/21 she weighed 98.4 pounds, on 07/02/21 she weighed 104.8 pounds, on 08/17/21 she weighed 94.8 pounds, and on 09/07/21 she weighed 93.6 pounds. Resident #63's weight of 93.6 pounds on 09/07/21 indicated a significant roughly 21% weight loss in 180 days. Review of Resident #63's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Dietary Nutritional Review assessment dated [DATE] revealed Resident #63 was on a dysphagia diet with no sugar added Medpass 120 ml twice a day. Resident #63's weight was 104.8 pounds with a BMI of 18.6. Resident #63 was 123 pounds three months ago and her weight of 104.8 indicated a significant 15% weight loss in the past three months. The dietitian indicated the weight change was related to mental status. Resident #63's nutritional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It was recommended Resident #63 continue the Medpass supplement for increased calories and promoting weight gain closer to her usual body weight range of greater than 120 pounds. Review of the CNP note dated 07/08/21 revealed the CNP was aware of the abnormal weight loss. The note further revealed Resident #63 reported poor oral intake, 25% of meals, due to dislike of the food and stated she would eat better if she liked the food. The note further revealed supplements were recommended twice a day. Review of the CNP's note dated 07/16/21 revealed Resident #63 had poor oral intake related to not liking the food. Review of the CNP notes dated 07/28/21 and 08/17/21 revealed Resident #63 had abnormal weight loss. Resident #63 continued to report the weight loss and poor meal intake was because she did not like the food. Review of the dietary progress note dated 08/17/21, revealed Resident #63's August weight of 94.8 pounds indicated a significant weight loss of 20% in six months and more than 15% in 30 days. The July weight was believed to be a mistake, however, the dietitian indicated there was weight loss prior to that. The nutritional interventions in place included a regular diet, Medpass 120 ml twice a day, vitamin supplements, and various [CONDITION(S)] medications. The note revealed Resident #63 remained high risk. Review of the CNP's note dated 08/19/21 and 08/23/21 revealed Resident #63 had abnormal weight loss related to varied intake. The family continued to bring food from outside the facility in an attempt to improve meal intake. The CNP revealed she discussed tube feeding with the resident but Resident #63 declined. Resident #63 was eating 26 to 50% of the facilities food but was eating all the food her daughter brought in. Review of the dietary progress note dated 08/23/21, revealed Resident #63 was started on Medpass 120 ml twice a day. The note further revealed Resident #63's weight was 94.8 pounds and had fluctuated. The dietitian revealed the resident was at high nutritional risk. Resident #63 had little oral intake and her nutritional needs were not always met. Review of the Dietary Nutritional Review assessment dated [DATE] revealed Resident #63 was on a TLC diet with regular textures. Resident #63's weight was 95 pounds with an ideal body weight of 103 to 127 pounds. Resident #63's BMI was 16.8, indicating she was underweight. The assessment revealed the resident had a 10% weight loss in the last six months and her average meal intake was 50% while her supplement intake was 100%. The nutritional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The dietitian indicated the resident was declining and her needs were not being met. Review of the dietary progress note dated 09/13/21, revealed Resident #63 weighed 93.6 pounds which was a one-pound loss from the previous month and a 10% weight loss over six months. The dietitian revealed the resident was eating poorly. Resident #63's nutritional interventions were reviewed, and her oral intake remained poor. Resident #63 was not meeting her nutritional needs to promote gradual positive weight gain. The dietitian recommended consideration of an appetite stimulant to improve Resident #63's oral intake. Interview on 09/28/21 at 1:40 P.M. with Dietitian #231, revealed she was aware of the resident's weight loss and was present in the building three days a week. Dietitian #231 stated the resident was not on weekly weights because I don't ask for something that's not going to get done. She stated the resident's weight increase on 07/02/21 may not have been accurate and revealed she does not request reweighs because the facility did not have the staff for it. Dietitian #231 was unable to speak to the resident's dietary preference as she stated that was something the dietary manager handled. She revealed Resident #63 was not on a therapeutic diet because the TLC diet was basically a regular diet. Dietitian #231 revealed her recommendations go in mailboxes for the CNP, Director of Nursing, and other necessary staff members. She stated she was not sure if the nutritional recommendation from 09/13/21 for an appetite stimulant was completed. Dietitian #231 stated snacks could be provided to residents upon request but she had not considered snacks for Resident #63. Dietitian #231 confirmed the resident drank her supplements as ordered but had not considered increasing supplements. Dietitian #231 believed the weight change was likely related to her mental status. Dietitian #231 confirmed she attended clinical meetings in the morning. Interview on 09/29/21 at 1:28 P.M. with Dietitian #231, revealed residents estimated needs were calculated for initial assessments, annual assessments, and significant change assessments. She confirmed she did not recalculate resident nutritional needs after significant weight changes. Interview on 09/28/21 at 2:31 P.M. with Culinary Manager #211, revealed she did not attend clinical meetings, but the dietitian kept her up to date on resident's status. She stated she had not spoke to Resident #63 about her preferences since starting her position in April 2021, and she was not made aware Resident #63 did not like the food. Culinary Manager #211 was not sure what the TLC diet was and did not think Resident #63 was on it as she believed Resident #63 was receiving ground meat. Interview on 09/28/21 at 3:15 P.M. with Regional District Manager of Healthcare Services Group #232, confirmed Resident #63 had been receiving the dysphagia advanced diet. She stated they received an order in June to discontinue the dysphagia advanced diet, however it was never discontinued. Observation of Resident #63 on 09/28/21 at 3:21 P.M. revealed Resident #63 had a had a large cup of coffee as well as chili and a burger from a fast food restaurant. Resident #63 was observed taking two large bites of the burger with less than 25% of the burger remaining. Resident #63 reported the burger was good and better than the ground meat she was used to. Interview on 09/28/21 at 4:03 P.M. with the DON, revealed the Dietitian communicated recommendations by putting them in mailboxes for nursing staff. The Unit Managers would either complete her recommendations themselves or pass them on to floor nurses to be completed. The DON reported they were able to complete weekly weights as needed and the dietitian determined when a resident needed to be reweighed. The DON was aware Resident #63 did not like the facility's food and stated the nursing staff offered her alternatives. The DON could not identify what measures the kitchen was taking to encourage intake. She stated Resident #63 was discussed in the morning meetings in which the dietitian was present. She believed the resident's poor intake was related to food preferences and confirmed she ate food that her family brought in. Interview on 09/29/21 at 5:29 P.M. with CNP #233, revealed she was unsure if she received all the dietitian's recommendations, due to them being left in her mailbox. She was unaware of the dietitian's most recent recommendation for an appetite stimulant for Resident #63. She stated she did communicate with the dietitian if she did not agree with her recommendations. CNP #233 confirmed Resident #63 did not like the food in the facility and she knew the previous dietitian was aware, but was unsure if the current dietitian was aware. She revealed the resident's family brought in food which the resident ate, however, the family told her they shouldn't have to supply her food. She stated they recently had a meeting with the family, which the dietitian was not present for, to discuss her care and she refused tube feeding. She knew nursing was aware of the resident's dislike of the food but did not know if the kitchen was addressing it. She stated she expected nursing staff to communicate with the kitchen staff. CNP #233 admitted there seemed to be a lack of communication involving Resident #63.

Based on a closed medical record review, hospital record review, staff interviews, hospital staff interview and review of the facility's change in condition policy and procedure, the failed to adequately monitor, promptly identify and implement timely treatment following symptoms exhibited by Resident #99 consistent with a urinary tract infection. Actual harm occurred to Resident #99 when the resident, who was assessed to require extensive assistance from the staff for toileting and incontinence care, demonstrated a decreased oxygen level, confusion and weakness. The resident was transported to the hospital and admitted with septic shock and an acute urinary tract infection. The resident was subsequently intubated and did not return to the facility. This affected one (#99) of two residents reviewed for a change of condition. Findings include: Review of Resident #99's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged to an acute care hospital on [DATE] with no return anticipated to the facility. [DIAGNOSES REDACTED]. Review of the plan of care, dated 09/17/19, revealed the resident was incontinent of both bowel and bladder. Interventions included to check every two hours and as required for incontinence and provide incontinence care, monitor/document for signs/symptoms of urinary tract infection [MEDICAL CONDITION], offer toileting upon rising, before and after meals, bedtime and as needed and complete a bladder tracker. Review of the five-day Minimum Data Set (MDS) assessment, dated 09/24/19, revealed the resident had clear speech, understood others, made herself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 15. Review of the mood and behavior section of the MDS revealed the resident had indicators of depression and did not reject care. The assessment revealed the resident required extensive assistance of two staff for transfers, bed mobility, toileting and was frequently incontinent of both bowel and bladder. Review of the resident's physician orders [REDACTED]. Review of the corresponding nursing progress notes from 10/03/19 and 10/04/19 revealed no documentation as to why the urine specimen or laboratory testing was ordered at that time. Review of the laboratory testing results, dated 10/04/19, revealed the resident's white blood cell (WBC) count was elevated at 15.4 (normal level of 4.5 to 10.8 cells per cubic milliliter (cells/cmm) which typically is indicative of an infection). Record review revealed no evidence the physician was notified of the elevated WBC count at that time or that the resident was assessed or monitored for any type of infection at that time. Review of the UA results, dated 10/04/19, revealed the resident had a gram-negative rod (GNR) organism at less than 10,000 colony-forming unit per milliliter (CFU/ml). The resident's urine was positive for glucose at three plus (normal level is negative), a few [MEDICATION NAME] cells (normal level is negative) and hyaline casts (normal level is negative and appear in the urine when the urine is concentrated). Record review revealed no evidence the physician was notified of the results of the UA for further instructions. review of the resident's medical record revealed [REDACTED]. Review of the resident's progress notes from 10/04/19 through 10/14/19 revealed no documented assessments, monitoring or vital signs related to the elevated WBC. Record review revealed a nursing progress note, dated 10/14/19 at 7:00 [NAME]M. and authored by Registered Nurse (RN) #104, which revealed she placed Resident #99's name on the certified nurse practitioner (CNP) list to be seen for a vaginal infection and a mental status change. There was no additional information contained in the nursing progress note related to the resident's overall condition and/or signs/symptoms of infection or why the RN felt she had a vaginal infection. Review of the CNP progress note, dated 10/14/19 at 6:19 P.M., revealed she was asked to see Resident #99 for a follow up on laboratory tests and a yeast infection. The note documented the resident stated she did not feel well. The CNP documented the resident's WBC dated 10/14/19 was elevated at 24.5 an elevated blood urea nitrogen (BUN) of 34 (normal seven to 25 milligrams/deciliter) and an elevated creatinine level of 1.4 (normal 0.6 to 1.3 milligrams/deciliter. The progress note documented the CNP was to recheck the resident's laboratory test. There was no evidence the resident was assessed for an infection at this time or any type of explanation as to why the resident's WBC count was elevated. The CNP ordered the antifungal medication, [MEDICATION NAME] at that time. Record review revealed a physician order [REDACTED]. Review of the nursing progress note, dated 10/16/19 at 12:17 P.M. and authored by Licensed Practical Nurse (LPN) #105, revealed the resident had reported dysuria (pain with urination) with no evidence the resident's physician or the CNP was notified of this new symptom at that time. The next note was dated 10/17/19 at 8:03 [NAME]M. and authored by LPN #105 revealed the resident's oxygen saturation rate was low at 73% and the LPN applied oxygen which raised the resident's oxygen saturation level to 86% (normal range 90-100%). The resident was noted to have confusion and weakness. The CNP was notified at this time and an order was obtained to send Resident #99 to the local emergency room (ER) for an evaluation and treatment. Record review revealed between 10/04/19 and 10/17/19 there was no evidence the resident's urinary output or urinary status was monitored or assessed related to the amount of urine output the resident was having and/or the characteristics of her urine. The facility failed to adequately monitor and promptly identify and implement timely treatment following symptoms exhibited by the resident consistent with a urinary tract infection resulting in the resident requiring hospitalization . Review of the hospital records obtained from the resident's hospital admission, dated 10/17/19, revealed Resident #99 was evaluated in the ER and diagnosed with [REDACTED]. Further review of the hospital documentation revealed the laboratory tests provided by the facility dated 10/14/19 revealed the resident had a urinalysis which showed the resident had an infection and CBC with a WBC of 24 with a mild acute kidney injury. The resident was found unresponsive and an antibiotic (a medication used to treat infection) was not initiated by the facility. The hospital record revealed the resident presented to the ER with a decreased mental status, inability to answer questions or follow commands which led to the need for endotracheal intubation (the placement of a flexible plastic tube to maintain an open airway). The resident was assessed to be hypothermic with a body temperature of 95.9 degrees rectally. She had dry lips, swollen tongue and dry sticky oral mucosa with dry mucosa. She was also assessed to have a significant rash and excoriation of her vulvar region, perineum, as well as her buttocks. The physician documented the resident had very poor genitalia hygiene. She had an indwelling urinary catheter placed with urine that was described as chocolate milk. Her bladder was flushed with return of multiple large blood clots and purulence through the catheter. A continuous bladder irrigation was ordered. The resident was also assessed to have [MEDICAL CONDITION] (low blood pressure) that required 20 half liters of intravenous (IV) fluids and [MEDICATION NAME] (a medication used to treat life threatening low blood pressure). Review of the laboratory testing from the ER revealed a CBC containing a WBC count that was significantly elevated at 42.88, a BUN elevated at 79 and a creatinine elevated at 5.40 (indicative [MEDICAL CONDITION] and [MEDICAL CONDITION]). On 11/04/19 at 10:04 [NAME]M., an interview with the CNP revealed she cared for the resident during the resident's stay at the facility. She said she reviewed the resident's medical record and she seen her on 10/10/19 for the elevated WBC count of 15.4. She said the resident was asymptomatic, so the protocol was to repeat the laboratory tests and the U[NAME] She said that was completed on 10/14/19 and determined the resident had a WBC of 24.5. She said she was unable to determine the source of the infection at that time, so she was waiting on the UA results. She said she came in on 10/17/19 and she was the first resident she seen. She said she immediately seen a change in condition with the resident, including [MEDICAL CONDITION]. She said her first priority was getting the resident to the ER for an evaluation. She said she was never notified of the laboratory results, including the UA results. She said she was not notified the resident had reported dysuria or a change in mental status. She said at that point she would have initiated an antibiotic to treat the elevated WBC because she had symptoms and a source. On 11/01/19 at 3:11 P.M., an interview with the Hospital Case Manager #500 revealed she was assigned to the resident upon the resident's arrival to the ER. She said the resident was in very poor condition and required intubation within an hour of arriving to the ER. She said the resident was so dehydrated her uvula was stuck to the back of her throat. She said in her over [AGE] years of nursing she has never seen urine look like chocolate milk coming from a catheter. She said her WBC was 42 and the ER physician realized she was not treated for [REDACTED]. She said the resident had a severe yeast infection to her perineal area and buttocks. On 11/04/19 at 11:30 [NAME]M., an interview with the Administrator revealed on 10/04/19 laboratory testing revealed Resident #99 had an elevated white blood cell count, indicative of an infection with no evidence the physician was notified, or the source of a potential infection was determined. Record review revealed a lack of evidence the resident's condition (including mental status, urinary status) were monitored between 10/04/19 and 10/14/19 when the nurse asked the CNP to see the resident (due to a vaginal infection and change in mental status). On 10/14/19 the resident was seen by the CNP, who noted the resident's WBC count was elevated at 24.5 (significantly higher than the WBC count on 10/04/19) and an order was given for the antifungal medication, [MEDICATION NAME]. There was no evidence the CNP ruled out the need for antibiotic treatment, assessed the resident's urinary status or determined the source of a potential infection for the resident. Between 10/14/19 and 10/17/19 a nursing progress note (dated 10/16/19) revealed the resident reported painful urination. There was no evidence the resident's urinary status was assessed at that time related to the amount of urine output the resident was having and/or the characteristics of her urine. On 10/17/19 the resident's condition deteriorated, and she was transferred to the hospital where she was diagnosed with [REDACTED]. Review of the facility's policy and procedure titled, Change in Condition, dated 11/30/18, revealed it is the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The purpose of the policy is to provide guidance for notification made to residents, resident representatives and family for resident changes in condition. Changes may include but are not limited to accidents, incidents, transfers, changes in overall health status, significant medical changes, therapy services changes, transfer, hospitalization or death. The nurse will use current regulations and evidence-based practice standards to guide the notification process. This deficiency substantiates Master Complaint Number OH 144 and OH 828.

Based on closed medical record review, review of a facility investigation, review of personnel records, interview with staff, Executive Director (ED) #300, Physician #301, Certified Nurse Practitioner (CNP) #81, review of the facility policies related to Do Not Resuscitate (DNR) Comfort Care (CC) and DNR CC Arrest and Change in Condition and review of the Ohio Administrative Code (OAC) [DATE] titled, Pronouncement of Death, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) and contact Emergency Medical Services (EMS) timely for one resident (#1) who was a Full Code and was found unresponsive without vital signs. Life threatening harm and death occurred when Resident #1 did not receive CPR or EMS services and expired at the facility. This resulted in Immediate Jeopardy for one (#1) of two residents reviewed for emergent change in condition and death. The facility census was 95. On [DATE] at 12:40 P.M., Regional Director of Operations (RDO) #1 and the Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] at approximately 4:15 A.M. when Resident #1 was found by State tested Nursing Assistant (STNA) #18 unresponsive in bed. STNA #18 notified Registered Nurse (RN) #101 the resident was unresponsive, and RN #101 immediately went to her room. RN #101 checked Resident #1's vital signs (none present) and attempted to arouse her (no movement). At that time, STNA #54 (who had accompanied STNA #18 to Resident #1's room), left the room to find Licensed Practical Nurse (LPN) #65 (since he was the nurse assigned to Resident #1). STNA #18 remained in Resident #1's room and stated she did not see any staff perform CPR on the resident. LPN #65 went to Resident #1's room and assisted with checking Resident #1's vital signs (none present). There was no evidence staff had initiated CPR including calling for EMS at that time. At 9:43 A.M., the DON contacted Physician #301 via telephone and informed the physician Resident #1 had expired. Review of Resident #1's medical record revealed no documentation was completed regarding Resident #1 being found unresponsive, the circumstances surrounding her acute change in condition and/or any evidence of care being provided to her by either RN #101 or LPN #65, the two nurses identified in the facility investigation to have been involved. The Immediate Jeopardy was removed on [DATE] when the facility completed the following corrective actions: · On [DATE], RN #101, LPN #65 and STNA #18 were suspended related to the incident involving Resident #1 pending the results of the investigation. LPN #65 was terminated from employment with the facility on [DATE] and RN #101 was terminated from employment with the facility on [DATE] for failure to complete work duties as assigned. STNA #18 returned to work on [DATE] following the completion of the facility's investigation on [DATE]. · Beginning on [DATE], RN #96, LPN #77 and the DON initiated education to all licensed nursing staff regarding change of condition, resident code status, when to perform CPR and contacting EMS. As of [DATE], the facility identified all licensed nursing staff had received the education either in person or via the telephone. · On [DATE], LPN #23, Admissions Director (AD) #90, LPN #77, and Licensed Social Worker (LSW) #122 reviewed all current residents Advance Directives to ensure they were accurate and available for staff to see. · On [DATE], ED #300 performed an audit of the facility's crash cart containing emergency medical equipment to ensure the cart contained the necessary items for staff use in the event a resident requires CPR. · On [DATE], AD #90 reviewed the medical records for all four residents (Resident #101, #102, #103 and #104) who had expired in the last six months and had the Advance Directive of Full Code. No concerns were identified based on the review. · On [DATE], LPN #130, LPN #201, LPN #203, and LPN #205 completed assessments of all current facility residents for changes in condition. · On [DATE], RN #96 initiated staff education for all staff regarding recognizing and reporting changes in condition. The facility provided a staff list that indicated all facility staff were contacted either in person, via telephone or via a voice mail message left with the content of the training on [DATE]. · On [DATE] at 6:30 P.M., RN #96 conducted a mock drill related to finding an unresponsive resident. The following staff participated in the drill: LPN #201, LPN #130, LPN #23, LPN #203, LPN #205, STNA #19, the DON, Activities Director #210, and ED #300. A plan to conduct mock drills once a month for three months was implemented. · Beginning on [DATE] and continuing through [DATE], the DON, LPN #23 and LPN #30 provided questionnaires to random nursing staff regarding CPR and resident Code Status (what to do). A plan to conduct the questionnaires to random staff three times per week for four weeks was implemented. Beginning [DATE], the DON also developed a plan to audit Code Status for all new admissions to the facility three times weekly for four weeks. · On [DATE], a non-mandatory follow-up staff meeting was held in which RN #96 reviewed and re-educated staff that were present regarding CPR and presented a video regarding Stop and Watch related to resident changes in condition. · On [DATE] from 4:49 P.M. to 5:04 P.M., interviews with STNA #110, LPN #143, LPN #211, STNA #401, LPN #402, LPN #23 and STNA #403 revealed they were knowledgeable about the facility change of condition policy and the measures to take when a resident was noted to have a change in condition. The staff interviewed were also knowledgeable about the process of when to start CPR, when to contact EMS and who to contact after a change in condition occurred. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #1's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed Resident #1 had a physician order [REDACTED]. Review of Resident #1's plan of care, initiated [DATE] related to Advance Directives, revealed the resident was a Full Code status. Interventions on the care plan documented the resident was a Full Code, educate resident/responsible party on Advance Directives, Living Will and obtain physician order [REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident had no cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 15. The resident was noted to have been admitted for short term rehabilitation with a discharge plan of care developed with the resident's goal being to return to the community. Review of the nursing progress notes, dated [DATE] at 11:17 A.M. and authored by LPN #30, revealed a Physical Therapy (PT) clarification: discharge patient from skilled PT effective [DATE]. The next nursing progress note, dated [DATE] at 7:45 A.M. and authored by the DON, revealed Family arrived at facility at 7:45 A.M. Body released to funeral home at 9:40 A.M. The next nursing progress note, dated [DATE] at 8:00 A.M. and authored by the DON, revealed it was reported to this nurse per charge nurse (LPN #65) that at 4:30 A.M. Resident #1 was found with tighten muscles, cyanotic in color, and absent of vitals. CPR initiated. Family and CNP #81 called. The next nursing progress note, authored by RN #96 (the facility staff development nurse) on [DATE] at 12:01 P.M., revealed on [DATE] at 1:00 P.M. Resident #1 had an emesis. The note documented the resident was assessed and denied any pain. The note indicated the nurse was going to offer her an anti-nausea medication, [MEDICATION NAME], which was ordered to be administered as needed. However, there was no documentation to support this was offered. Review of Resident #1's medical record revealed the record contained no documentation related to the resident being found absent of vital signs at the time she was found. There was no evidence the care provided to her, if any, was documented by the licensed staff working in the facility at the time of the incident or who had direct involvement in the incident. There was no information documented regarding any incidents leading up to, during, or immediately after her death. There was no documentation to support EMS was contacted at any point. Additionally, there was no evidence the resident's physician (#301) or CNP #81 were notified at the time of the incident. Review of the facility's investigation regarding the death of Resident #1 initiated on [DATE] revealed the facility obtained statements from staff members who were working at the time Resident #1 was found unresponsive. A facility statement obtained from LPN #65 on [DATE] at 10:18 A.M. revealed he was notified by STNA #18 at 4:30 A.M. that Resident #1 was unresponsive. Upon entering resident's room, the two staff members were doing chest compressions. LPN #65's statement included it was evident that rigor mortis had set in. Resident presented to be cyanotic. Staff were unable to obtain vitals at this time. At 4:40 (no A.M. or P.M. documented), CNP #81 and family were called. A telephone interview with LPN #65 on [DATE] at 9:04 A.M. revealed he was working the night of Resident #1's death and was the nurse assigned to care for the resident. He stated he was alerted of a concern with the resident and walked into the resident's room, on [DATE] at approximately 4:30 A.M. He stated he saw RN #101 and an STNA (unable to recall name of STNA) standing by Resident #1's bed. He stated after he determined Resident #1 was not breathing and was dead, he went to the nurse's desk and called CNP #81 and the family to notify them. He stated he had to leave messages for both and did not actually speak to CNP #81. LPN #65 stated he did not attempt to contact the resident's physician and indicated EMS was not called. LPN #65 stated upon entering the resident's room he did not see anyone performing CPR and revealed he did not perform CPR. LPN #65 also stated he did not complete any documentation regarding this incident in Resident #1's medical record including the resident being found unresponsive or the actions he took during the incident. LPN #65 stated following this incident he was terminated from his job because of failure to perform work duties. He stated he was not given any other information from the facility about his termination. A facility undated/untimed statement from RN #101 revealed she was alerted by STNA #54 (no date or time provided) that Resident #1 had a change in condition and immediately went to the resident's room. The statement indicated, RN #101 tried to arouse Resident #1 by shaking her and moving her bed. RN #101 checked the resident's pulse oxygen level - nothing. Assessed the resident to have no vital signs and immediately began compressions and alerted LPN #65 to call 911. The statement indicated the resident was cyanotic, very stiff. However, the facility statement failed to include how long chest compressions were completed, when or why they were stopped and whether any additional care associated with CPR (i.e. suctioning, supplying artificial oxygenation or use of an AED if appropriate) was provided. In addition, there was no documentation contained in Resident #1's medical record by RN #101 to support she completed an assessment of the resident or provided any care to the resident following notification of the resident exhibiting a change in condition by STNA #54. Interview attempts via telephone to reach RN #101 on [DATE] at 4:35 P.M. and [DATE] at 8:59 A.M. and 9:55 A.M. were unsuccessful. An undated facility statement from STNA #18 revealed care had been provided to Resident #1 on [DATE] around 11:00 P.M. The resident had had an emesis and required a bed linen and clothing change. STNA #18 revealed she had reported this to LPN #65. STNA #18 stated she had checked on Resident #1 at around 2:00 A.M. and did not identify any concerns. She stated (on [DATE]) around 4:00 A.M. she was in the resident's room but was afraid to touch her but did and then turned on the lights in the room. She stated she then went and got STNA #54 who confirmed with her the resident was dead and immediately got the nurse. An interview with STNA #18 on [DATE] at 6:04 P.M. revealed she had checked on Resident #1 throughout the night beginning on [DATE] and into [DATE]. She stated the resident had an emesis earlier in the shift and staff helped her get cleaned up. She stated she again started her every two-hour rounds about 3:30 A.M. and got to Resident #1's room about 4:00 A.M. She stated when she saw the resident she thought she wasn't breathing. She stated she went out to the hallway quickly and got STNA #54 to confirm the resident wasn't breathing. STNA #18 stated she did not touch the resident's body at that time. On their way back to the resident's room, they told RN #101 about their thoughts that Resident #1 was not breathing. RN #101 went into the room as well, tried to arouse Resident #1 and she could not be aroused. At that time, STNA #54 left the room to get LPN #65 and STNA #18 stated she went to the other side of the room to help Resident #8 (the resident's roommate). She stated she did not see any staff perform CPR on the resident and was not asked to assist with CPR. She also stated, at no point did she see or hear anyone call EMS and stated that although she was working with the resident's roommate, she was in the room the whole time RN #101 was and would have heard if those things were occurring. She said she did hear STNA #25 ask if they should call 911 and no one responded to that. A facility statement from STNA #25 dated [DATE] revealed she participated in providing care for Resident #1 on [DATE] shortly after 10:00 P.M. and was then again in the resident's room around 12:00 A.M. and 2:00 A.M. She stated around 4:15 A.M., an unknown person told her Resident #1 had passed away. She stated she went to see if staff needed her assistance and when she got to the room she saw LPN #65 in the room. An interview with STNA #25 on [DATE] at 4:22 P.M. revealed she was outside on lunch break on [DATE] when she was told about Resident #1 passing away. She stated she went to Resident #1's room and saw LPN #65 and RN #101 looking over her body. She indicated she did not observe them providing any care to the resident at that time, denied CPR being provided and denied seeing any EMS staff in the facility. A facility statement from STNA #24 dated [DATE] revealed she was alerted by STNA #54 and STNA #18 around 4:30 A.M. that Resident #1 wasn't breathing. She stated she went to the resident's room and in fact she was not breathing. She stated she left the room to answer another resident's call light and then returned to Resident #1's room and saw both RN #101 and LPN #65 in the resident's room. The statement indicated the STNA did not observe what they did at that point because she wasn't present the whole time. An interview with STNA #24 on [DATE] at 4:25 P.M. revealed she was working two hallways on [DATE]. She stated STNA #18 was working the other half of the hallway where Resident #1 was located. She stated STNA staff had gone into the resident's room a few times that night (she threw up on herself, her roommate's bed wasn't working right, roommate needed water) and each time she was in there, she checked on Resident #1. She denied any observed concerns during the observations made. STNA #24 revealed on [DATE] between 4:00 A.M. and 4:15 A.M., STNA #18 spoke to STNA #54 and said Resident #1 was unresponsive and they went into her room and found this was true. On the way to her room, they told RN #101 about this. STNA #24 stated she saw RN #101 enter the resident's room, kicked the bed, picked Resident #1's arm up, and took her vital signs. She stated the resident had no vital signs at that time. STNA #24 revealed she did not see anyone start CPR and indicated she left the resident's room as STNA #54, STNA #18, and RN #101 were there. She stated about five to seven minutes later, she saw LPN #65 walk into the room and then observed as he took Resident #1's vital signs. She confirmed she did not see LPN #65 start CPR. At no point did she see EMS in the facility. During the interview, STNA #24 stated she thought one of the nurses should have started CPR immediately, but she didn't say anything because an STNA doesn't tell a nurse what to do. A facility statement from STNA #54 dated [DATE] revealed she had not provided care to Resident #1 but around 4:00 A.M. to 4:30 A.M., STNA #18 asked her to come look at Resident #1 because she thought she was dead. She stated STNA #18 asked her if the resident usually looked pale when she was asleep. STNA #54's statement revealed she went into the resident's room and shook her bed and her and there was no response. She stated we (herself and STNA #18) then went to go get RN #101. The statement indicated RN #101 said we had to start CPR. LPN #65, (who was Resident #1's nurse) was in another room and she went to get LPN #65 and tell him. The statement indicated, everyone was shocked because they all had been going in her room because Resident #8 (the resident's roommate) kept putting on her light. The statement indicated STNA #18 was upset, she said she was just in there. An interview with STNA #54 on [DATE] at 4:12 P.M. revealed she was working the morning of [DATE] and was outside on break when STNA #18 approached her and asked her if Resident #1 typically looked pale. She stated she replied yes and then both STNAs went to check on the resident. She stated this was around 4:15 A.M. or 4:30 A.M. She stated upon entering the resident's room, she could not arouse the resident. At that time, they got RN #101 from the nurse's desk. RN #101 went to the resident's room and applied gloves. At that time, STNA #54 stated she left the room to go find the resident's nurse, who was LPN #65. She stated as she was walking down the hallway, she overheard RN #101 say we need to start CPR. She stated she immediately found LPN #65 and they returned to the resident's room. STNA #54 revealed she did not see RN #101 or LPN #65 provide CPR or do chest compressions on the resident and did not see EMS in the facility at all that night. A facility statement from LPN #23 dated [DATE] (the date of the onsite investigation) revealed LPN #23 notified CNP #81 on [DATE] at 8:43 A.M. that Resident #1 expired at 4:30 A.M. There was no documentation of this notification in the resident's medical record or any documentation detailing the specifics of the communication between LPN #23 and CNP #81. The facility's undated typed summary of the investigation revealed a review of Resident #1's medical records revealed she had many co-morbidities and had a history of [REDACTED]. The typed summary was not signed by the staff member who completed it. On [DATE] at 1:53 P.M., 2:14 P.M. and 3:01 P.M., interview with the DON revealed Resident #1 had been found by an STNA (name not provided) passed away during the night of [DATE]. The DON revealed she was not present in the facility at the time of the resident's death but found out about it when she arrived to work on [DATE] later that morning. The DON verified the resident had Advance Directives and was a Full Code status and to her knowledge, based on what was reported to her by the staff working, CPR was initiated for the resident. However, none of the staff called for EMS. During the interview, the DON reported the facility initiated an investigation of the incident on [DATE] and completed the investigation on [DATE]. The DON revealed she had completed the summary of the investigation as noted above, however verified she had not signed it. The DON stated she had received information from LPN #65 regarding the details of the night of [DATE]. She stated one of the STNAs went to check on Resident #1 around 4:15 A.M. for the every two-hour check and change visit, and the staff could not wake her. She was told an STNA went to get the nearest nurse, who was RN #101 and reported Resident #1's condition. She stated RN #101 took the resident's vital signs, there were none present, and RN #101 started CPR. She stated RN #101 performed CPR for 15 minutes. She stated LPN #65 called CNP #81 and left a message for the CNP. She stated as a result of the investigation, she identified LPN #65 and RN #101 did not follow the correct facility procedures by failing to call EMS which resulted in their subsequent termination. Interview with CNP #81 on [DATE] at 7:54 A.M. revealed she received a voicemail message from a guy nurse on [DATE] about 4:30 A.M. telling her of Resident #1's death. The message included the resident had no vital signs, was showing signs of stiffness, and CPR was started to no avail. She revealed she was not onsite in the facility to assess the resident and was not sure what, if any, additional care was provided to the resident or what additional notifications were made. Telephone interview with Physician #301, who was Resident #1's physician and the facility medical director, on [DATE] at 8:07 A.M. revealed he was told the morning of the resident's death what had happened. He stated he could not remember the exact time he was called or who from the facility had called him. He stated to his understanding, Resident #1 was showing signs of stiffness and clear death. He stated he did not know if any staff at the facility started CPR, indicating he couldn't remember if that was discussed but he knew the facility did re-training with all the nursing staff regarding code status, providing CPR when necessary, and contacting EMS. He stated he was in agreement, and supportive that the facility would do this training to ensure everyone knew what to do in this type of situation. On [DATE] at 10:01 A.M. and 10:52 A.M., interview with the DON with RDO #1 present verified there was no documentation contained in Resident #1's medical record completed by the nursing staff, RN #101 and LPN #65 who provided care for Resident #1 on [DATE]. The DON revealed neither nurse had contacted her via phone at the time of the actual incident of Resident #1's death and indicated both LPN #65 and RN #101 were still working in the building when she arrived to work that morning, sometime between 7:00 A.M. and 8:00 A.M. The DON stated she was initially notified by AD #90 that Resident #1 had passed away as he was responsible for updating the facility census each day. The DON stated she then went to LPN #65 who told her Resident #1 was a Full Code, he went in the room and saw RN #101 doing CPR and Resident #1 was not revived. The DON said LPN #65 reported he had called CNP #81 at the time of the incident but verified in the interview at this time that only a message was left and no other physician notification was made. The DON indicated she contacted Physician #301 that morning and he pronounced Resident #1's death over the phone given the information that she had provided him. The DON verified the statement obtained from RN #101, which was not dated, revealed the RN indicated she did compressions and told LPN #65 to call 911. Upon further interview, the DON was unable to provide any additional information to support that CPR was initiated for Resident #1. The DON verified based on the facility investigation, EMS was not called. The DON indicated she met with RN #101 on [DATE] to obtain her statement at which time she discussed the lack of medical record documentation regarding the incident in Resident #1's medical record. The DON revealed RN #101 told her she would not make late entries into the electronic medical record regarding the night of Resident #1's death and indicated she felt her statement was sufficient enough. The DON indicated she met with LPN #65 on an unknown date following the incident and discussed with him the lack of medical record documentation regarding the incident in Resident #1's medical record. The DON revealed LPN #65 also told her he would not make late entries into the electronic medical record regarding the night of Resident #1's death. On [DATE] at 10:55 A.M., telephone interview with ED #300 revealed she was the facility administrator at the time of Resident #1's death on [DATE]. ED #300 verified Resident #1 had Advance Directives indicating she was a Full Code. She indicated she was made aware of the death when she arrived to work on [DATE] in the A.M. (exact time not provided). She indicated she recalled being partially involved in the investigation that had occurred following the resident's death. She stated she had also notified RDO #1 of the incident on [DATE] and RDO #1 provided instruction to begin staff training and education immediately following the incident related to the proper steps to take when a resident was found without vital signs. ED #300 was unable to provide any information as to whether or not staff had actually provided CPR to Resident #1 after she was found unresponsive. She stated she thought RN #101 said she did CPR but then stopped and verified no staff had called 911. During the interview, ED #300 revealed she thought the facility admitted all procedures were not followed through regarding the care provided to Resident #1 and that was why staff education was done after the incident. ED #300 revealed she was unaware that neither RN #101 or LPN #65 had documented any information in Resident #1's medical records related to her change in condition on [DATE]. Review of RN #101's personnel record revealed the employee was terminated on [DATE] for failure to perform job duties. Review of LPN #65's personnel record revealed the employee was terminated on [DATE] for failure to perform job duties. There was no evidence either employee worked in the facility following the incident on [DATE] through their termination date. Review of the facility's Change in Condition policy, dated [DATE], defined Immediate Notification as any sign, symptom or apparent discomfort that was acute or sudden in onset and was a marked change (i.e. more severe) in relations to the usual symptoms and signs or was unrelieved by measures already prescribed. The procedure section of the policy revealed unless there were documented extenuating circumstances, the nurse would report immediately change in conditions based on the following criteria for reporting to the physician/provider: systolic blood pressure (BP) of less than 90 mmHg, resting pulse less than 50, respirations less than 10 per minute, and oxygen saturation below 90%. Another immediate reporting criteria listed was sudden changes in level of consciousness or responsiveness. Review of the facility's Do Not Resuscitate (DNR) Comfort Care (CC) and DNR CC Arrest policy dated [DATE] defined CPR as an emergency response treatment that includes calling 911, initiating compression of the chest, initiating suction as appropriate, supplying artificial oxygenation, and use of AED if available and appropriate, for the purpose of circulating oxygen to the vital organs until a higher level of care can be accessed. Code Status was defined as the notation in the electronic medical record that served as a source of information to the facility staff for the proper response by the staff for treatment in the event the resident's heart ceases and/or respirations cease, whether by natural or unnatural means. The code status was based on the decision of the resident/representative, the regulatory requirements being met or not met and the physician/provider. The intent of the facility was to honor the wishes and rights of the resident/representative to make the determination of what, if any, resuscitative measures would be implemented in the event the resident's respirations and/or pulse cease either by natural or unnatural causes. The policy indicated staff would provide basic CPR for those desiring this treatment. A CPR code status alerted the staff in the event that respirations cease and/or the resident does not have a pulse (pulselessness), the staff would initiate CPR including calling 911, begin chest compressions, provide oral suctioning as appropriate, implement the use of a bag-valve mask for supplying oxygen, and employ the use of an AED if available to provide a cardiac shock as indicated by the AED. Upon arrival, the emergency transport staff may provide additional interventions and the facility would hand off care to the emergency care team. Review of the Ohio Administrative Code (OAC) [DATE] titled, Pronouncement of Death, revealed a physician holding a current certificate to practice medicine or surgery or osteopathic medicine may pronounce a person dead without personally examining the body of the deceased on ly if a competent observer has recited the facts of the deceased 's present medical condition to the physician and the physician is satisfied that death has occurred. According to the OAC [DATE], an LPN is not permitted to pronounce an individual's death. Review of the facility's investigative information and the information gathered on [DATE] and [DATE] revealed Physician #301 pronounced Resident #1's death via telephone on [DATE] at 9:48 A.M., over five hours after the resident was found unresponsive and eight minutes after the resident's body was released to the funeral home, based on information provided to him from the DON who was not present in the facility at the time the death. A request for the facility to obtain written verification from Physician #301 regarding his involvement in the pronouncement of Resident #1's death was made on [DATE] at 3:54 P.M. On [DATE] the facility provided a faxed statement from Physician #301 dated [DATE] at 10:40 A.M. that indicated on [DATE] at 9:48 A.M. he was contacted telephonically by the director of nursing regarding the expiration of Resident #1. There have been no additional deaths of residents who had Advance Directives indicating they were Full Code in the facility between [DATE] and [DATE]. This deficiency substantiates Complaint Number OH 374.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observations, medical record review and staff interview, the facility failed to ensure a resident was safely transferred with two person assistance utilizing a sit to stand lift. This resulted in actual harm when the resident fell from the lift and fractured her left fibula and required surgery. This affect one (#75) of three residents reviewed for transfers. The facility census was 95. Findings include: Review of Resident #75's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #75's comprehensive minimum data set assessment dated [DATE], revealed she was alert and oriented. She required extensive assistance for personal hygiene, toilet use and dressing. She required two person plus assistance for transfers and bed mobility. Review of physician orders [REDACTED]. Review of progress notes from 11/01/17 through 06/01/17, revealed Resident #75 had only one fall which was 01/13/17. Review of a progress note dated 01/13/17 at 4:21 P.M., revealed State tested Nurse Aide (STNA) #10 was transferring Resident #75 with a sit to stand lift. Resident #75 slid and was lowered to the floor. In the middle of the process of being lowered to the floor, Resident #75's left ankle got caught underneath the equipment in question. Resident #75 complained intensely with touch to the left ankle and an order for [REDACTED]. At 8:04 P.M., the x-ray was positive for a fracture to the left fibula and Resident #75 was sent out to the emergency room for evaluation. Review of a progress note dated 01/14/17 at 12:20 A.M., documented Resident #75 returned to the facility with a cast on left lower leg. Observation of Resident #75 being transferred with a lift was attempted, Resident #75 stated she did not want the surveyor to watch her during a transfer. Interview with Resident #75 on 06/01/17 at 11:12 A.M., revealed she had a fallen from the sit to stand lift on 01/13/17 and fractured her ankle. She stated STNA #10 came to her room and revealed she was staying over because an STNA was late and proceeded to place the straps on her to lift her out of bed. She stated STNA #10 didn't have the straps placed right and Resident #75 told her she didn't and STNA still proceeded to stand her up. Resident #75 stated she stood me up and the loop came unhooked. As the STNA continued to lift her, she kept sliding until she fell . Resident #75 stated she guessed the lift fell on top of her and broke her leg in two places. Resident #75 stated a nurse came into to help get her back into bed. She stated she was in a lot of pain and an X-ray was completed. She had to go to hospital and a cast was placed on her left ankle. She further stated STNA #10 told her she may as well quit now, because she was going to be fired for this fall. Resident #75 stated she did not want the surveyor to watch her during a transfer. Interview with the Director of Nursing (DON) on 06/01/17 at 12:08 P.M. revealed when using a Hoyer or sit to stand lift, it was required to have two staff assistance for the lift. Interview with Licensed Practical Nurse (LPN) #16 on 06/01/17 at 1:11 P.M., revealed he was called to Resident #75's room on 01/13/17 at about 4:00 P.M. by the STNA #10 and discovered Resident #75 was on the floor and was screaming in pain from her ankle. He revealed the straps were on her and she was facing the machine and with her back up against STNA #10 and her foot was backwards under the machine. LPN #16 stated he assessed Resident #75 and got an order for [REDACTED]. LPN #16 stated STNA #10 did not ask him for help. Interview with Director of Nursing (DON) and Corporate Nurse #5 on 06/01/17 at 1:34 P.M., revealed the fall investigation indicated there was a fall for Resident #75 on 01/13/17 from STNA #10 transferring Resident #75 alone while using a sit to stand lift. Resident #75's knees buckled under her and the STNA lowered her to the floor. They revealed it was the facility policy to always have two staff members when using a sit to stand lift. The STNA's statement was read, which stated she did the transfer by herself and lowered the Resident #75 to the floor, but her left ankle was twisted a little. The statement further revealed I didn't do this to hurt the resident. STNA #10 admitted in the statement she knew Resident #75 was supposed to be a two-person assistance with a sit to stand lift. The DON and Corporate Nurse #5, revealed STNA #10 was suspended pending investigation, but she gave her resignation 01/14/17. Review of policy titled Mechanical Lift dated 06/05/14 revealed general safety precautions included always use two employees for this procedure. As a result of this incident the facility took the following actions to correct deficient practice by 03/27/17: On 01/13/17, in-servicing of all nursing staff began on transferring residents using a mechanical lift policies and procedures and was completed on 01/27/17. On 01/13/17, a competency check-off form for all nursing staff was implemented for the use of mechanical lifts and was completed on 01/27/17. On 01/16/17, audits of resident safe transfers began for staff utilizing the correct lift and the proper procedure for that lift. On 01/26/17, therapy education on safe transfers using a mechanical lift for all nursing staff and was completed on 01/27/17. On 03/27/17, audits were completed and review to evaluate safe transfers of residents. This deficiency substantiates complaint number OH 489 and OH 304.

Based on medical record review, observation, policy review, and interview, the facility failed to comprehensively assess urinary incontinence (Resident #132 and #141) and failed to implement interventions to restore urinary continence (Resident #141). This affected two of three residents reviewed for urinary incontinence. Harm resulted when the facility failed to implement interventions to restore bladder function for Resident #141. Resident #141 was admitted to the facility on [DATE] continent of urine, declined to occasionally incontinent of urine on 06/03/15 without intervention and then further declined to frequently incontinent of urine on 07/01/15 without interventions to restore the resident's bladder function. The facility census was 97. Findings include: 1. Medical record review revealed Resident #141 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #141 was cognitively intact, required supervision of staff for toilet use and was always continent of bladder. Review of the 90-day MDS assessment dated [DATE] revealed Resident #141 required extensive assist of staff for toilet use and had declined to occasionally incontinent of bladder with no toileting program. Review of the Bowel and Bladder Program Screener assessment dated [DATE] revealed the resident's incontinence was less than daily. Review of the quarterly MDS assessment dated [DATE] revealed Resident #141 had declined to frequently incontinent of urine with no toileting program. Review of the Bladder Continence Task List dated 07/01/15 through 07/30/15 revealed the resident had been incontinent 19 times. Review of the record revealed no documented evidence of a comprehensive bladder assessment, care plan or interventions to restore bladder function between 05/24/15 and 07/30/15 for Resident #141. Review of the Bladder Continence Program policy undated revealed to determine if a program was appropriate an assessment including a history of incontinence, type of continence, functional status and ability to participate in a program was to be assessed and then the resident would be evaluated for an appropriate toileting program. On 07/29/15 at 10:45 A.M., interview with Resident #141 revealed he did need help with toileting due to a [MEDICAL CONDITION] in the past and he was to have knee surgery soon. Observation at the time of the interview revealed no signs of incontinence. On 07/29/15 at 5:09 P.M., interview with Registered Nurse #7 verified no comprehensive assessment, care plan or interventions were implemented when the resident declined in urinary continence between 03/10/15 and 06/03/15. On 07/29/15 at 3:50 P.M., interview with the Director of Nursing (DON) stated residents were reviewed quarterly for any declines and if a decline was noted, the resident was assessed and interventions implemented. On 07/30/15 at 1:45 P.M., interview with State tested Nurse Aide (STNA) #6 verified the resident was frequently incontinent of urine and was actually incontinent the last time she had completed her rounds this shift. STNA #6 stated the resident was continent when first admitted to the facility but now the resident's continence status depended on what was going on and if he had pain in his legs because that made it harder for him to get out of his wheelchair. STNA #6 stated the resident was on a check and change program every two hours. On 07/31/15 at 2:46 P.M., interview with the DON verified Resident #141 was continent of urine upon admission, declined to occasionally incontinent of urine on 06/03/15 without intervention and then further declined to frequently incontinent of urine on 07/01/15 without interventions to restore the resident's bladder function. On 07/30/15 at 2:49 P.M., the DON verified episodes of incontinence were documented on the task list and the resident had been incontinent 19 times between 07/01/15 and 07/30/15. 2. Review of Resident #132's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was unable to complete the cognitive evaluation. The resident required extensive assistance of two staff members with toilet use and was frequently incontinent of urine. Review of the MDS 3.0 dated 04/24/15 revealed the resident's cognitive level was unable to be assessed. The resident required extensive assistance of two staff members with toilet use and was always incontinent of urine. Review of the Admission assessment dated [DATE] revealed the resident was frequently incontinent of urine. The clarity of the resident's urine could not be assessed due to the resident did not void at the time of assessment. Review of the Bowel and Bladder Program Screener dated 04/17/15 revealed the resident never voided (urinated) appropriately without incontinence and was immobile or required two staff assistance with toileting needs. Further review of the assessment revealed the resident was sometimes aware of the need to toilet, was forgetful but followed commands and had no predisposing factors to contribute to her incontinence. On 07/30/15 at 1:46 P.M. interview with the DON verified the admission assessment dated [DATE] did not address the resident's urinary incontinence in relation to the type, the resident's mobility and required assistance in relation to her toileting needs or the resident's ability to participate in a bladder program. On 07/30/15 at 2:35 P.M. interview with the DON verified the the bowel and bladder program screener dated 04/17/15 did not address the resident's type of urinary incontinence or her ability to participate in a bladder program. The DON also verified no other assessments were completed in relation to the resident's urinary incontinence for 01/31/15 and 04/17/15.