Every finding on record at Continuing Healthcare at Beckett House

Based on record review, observations, interviews, and policy review, the facility failed to ensure beds were appropriate length for residents. This affected one resident (#22) of three residents reviewed for bed length. The facility census was 73. Findings include:Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including thrombosis and embolism of superficial veins in the left lower extremity. Review of a minimum data set (MDS) dated [DATE] revealed Resident #22's cognition remained intact and he did not have any behaviors. Interview on 08/20/26 at 11:18 A.M. with Resident #22 revealed his bed has been too short for him since he was admitted to the facility. Resident #22 stated he is six foot five inches tall. He stated the facility removed the footboard and added an extender to the bed but it doesn't work because it slopes down at the end and does not provide support. Observation and interview on 08/20/26 at 11:38 A.M. with Resident #22 revealed he was resting in bed and the mattress hung off the end of the bed just about over one foot (12 inches). Resident #22 stated the mattress slides down because they took off the footboard to add the extender and there was no support because of the slope at the end of the bed. Resident #22 stated he isn't comfortable while laying in bed watching television. Resident #22 stated he reported the issue with the bed to the main people but they said it was the biggest bed they had and the staff will just have to slide the mattress back up. Resident #22 reported staff do slide the mattress back up but it slides back down right away. Certified Nursing Assistant (CNA) #210 entered the room and confirmed the mattress had slid down and did not have anything to keep the mattress from sliding down at the bottom. Interview on 08/20/26 at 11:43 A.M. with the Administrator and Director of Nursing (DON) revealed when Resident #22 was admitted to the facility, they added an extender to the bed with a footboard but it did not work because his feet touched the footboard. Then, they got a different extender without a footboard which is what he is using now and did not know of any concerns with the mattress or bed. The Administrator stated Resident #22 had been at the facility for three months and if the bed bothered him, she was sure he would have told them. Review of a policy titled Accommodation of Needs Guidance dated 03/2026 revealed the facility will provide to the best of it's ability the necessary medical equipment, nursing care, and therapy services. This deficiency represents non-compliance investigated under Complaint Number 3157318.

Based on observation, review of most recent pest report, and interview, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect 64 residents who received meals prepared in the kitchen, there was one resident who did not receive from the kitchen. The facility census was 65. Findings include:Observation of the kitchen on 07/16/26 at 11:25 A.M. revealed the floor of the dry goods storage room covered with dirt and dust-like debris, three pieces of torn paper, two pieces of torn plastic, several sticky black spots and black wheel marks. Observation of the kitchen floor, located between the food steamer and the bread cart, revealed dirt and dust-like debris, several small pieces of torn trash, and one piece of torn plastic with a fly inside the plastic.Interview on 07/16/26 at 11:30 A.M. with Regional Dietary Director #400 confirmed the storage room floor was not clean; then immediately proceeded to sweep and mop the floor. Regional Dietary Director #400 further confirmed the black wheel marks on the floor were from the delivery cart and the last delivery was on Tuesday, 07/14/26. Regional Dietary Director #400 stated the floor should have been mopped since that delivery.Interview on 07/16/26 at 11:35 A.M. with Dietary Manager (DM) #4 confirmed the kitchen floor and storage room floor were not clean and should have been swept and mopped by the staff during the previous evening. DM #6 further confirmed the piece of plastic with a fly inside should not be lying on the floor. She stated the exterminator had recently treated the kitchen.Interview on 07/16/26 at 3:40 P.M. with Corporate Director of Nursing #300 confirmed he toured the kitchen and agreed that it was not clean and sanitary. This deficiency represents non-compliance investigated under Complaint Number 309362.

Based on work order review, interviews, and observations, the facility failed to ensure resident rooms were kept at comfortable temperatures. This affected 12 residents (#26, #30, #72, #86, #90, #92, #94, #102, #104, #156, #158, #172 ) of 15 reviewed for temperature. The facility census was 65. Findings Include:Review of work orders dated 03/23/26 to 06/18/26 revealed fourteen work orders placed related to heating, ventilation, and air conditioning (HVAC) system in the facility. Interview on 07/15/26 at 2:26 P.M. Resident #30 stated her room was hot.Interview on 07/15/26 at 2:40 P.M. wife of Resident #172 stated the room was hot and was fanning herself with a paper. Interview on 07/15/26 at 3:13 P.M. the Administrator stated the air conditioner repair person was done for the day and had to order a part for the fan in the air conditioner (AC). The Administrator stated the AC had been out in the front business area of the facility for about two weeks. Th Administrator stated she did have it repaired two weeks ago and it went out again on 07/13/26. The Administrator stated she had the AC repair person back on 07/13/26 to reassess the AC. The Administrator stated there had been an AC repair person at the facility 07/13/26, 07/14/26, and 07/15/26. The Administrator stated the AC in back of the building where the resident rooms are located just went out on 07/14/26 in the afternoon. The Administrator stated the AC repair company stated the cooling tower in the AC is damaged and not repairable. The Administrator stated she was getting a quote for replacing the AC unit. The Administrator stated she was working with a rental company to get AC rentals for the building. The Administrator stated there are a few window units which were installed in resident rooms on 07/14/26 after the AC went out in resident rooms. The Administrator stated the AC was working in the main dining room and common areas, and we are encouraging residents to come out of their rooms to the common areas and to increase hydration. The Administrator stated the facility had no Maintenance Director for about a month.Observation of temperature checks on 07/15/26 at 3:52 P.M.-4:09 P.M. Maintenance Director #12 revealed Resident #26's room was 83.3 degrees, Resident #30's room was 86.5 degrees, Resident #72's room was 83.1 degrees, Resident #86 and Resident #158's room was 86.2 degrees, Resident #90 and Resident #104's room was 84 degrees, Resident #92's room was 81 degrees, Resident #94's room was 81.5 degrees, Resident #102's room was 82.6 degrees, Resident #156's room was 84 degrees, and Resident #172's room was 83.7 degrees.Interview on 07/15/26 at 4:20 P.M. Administrator verified the temperature should be between 71 degrees and 81 degrees in the facility where residents are located.Interview on 07/15/26 at 4:46 P.M. Regional Nurse #300 stated the Regional Director of Operations #310 was buying fans for all the residents in the facility and would have them in place tonight 07/15/26.Interview on 07/15/26 at 4:58 P.M. Regional Nurse #300 stated no residents had been sent to the hospital for heat-related issues.Interview on 07/16/26 at 2:05 P.M. Administrator stated the AC repair person was in the facility on 07/16/26 and revealed there was a patch which he instructed the Maintenance Director to perform which would have the AC running until the new AC unit could be installed. The Administrator stated the replacement AC unit was on order and would take 12 weeks for it to arrive. The Administrator stated the AC unit would be fully installed at that time.Observation of temperature checks on 07/16/26 at 1:12 P.M.-1:31 P.M. Regional Nurse #300 revealed all resident rooms had fans in them and all resident rooms were under 81 degrees except for Resident #86 and Resident #158's room which was at 82.4 degrees.The following deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on observation, interview, and policy review, the facility failed to maintain a clean environment. This had the potential to affect 73 of 73 residents in the facility. Findings include:Observations on 06/15/26 from 8:27 A.M. to 8:38 A.M. during the initial tour of the facility revealed in the sunroom at the end of each hallway there were dust accumulations and dead bugs on the floors along the edges of the walls. Observations and interview on 06/15/26 at 4:09 P.M. with Housekeeping Supervisor (HS) #200 revealed in sunrooms at the end of each hallway there was an accumulation of dust and dead bugs as well as behind all fire doors on each hall. HS #200 confirmed findings. Review of a policy titled Housekeeping Policy dated 11/2025 revealed the facility will be cleaned on a regular basis. The hallway floors are to be clean and dry, corners and edges of the floor are to be clean and free of wax buildup. This deficiency represents non-compliance investigated under Complaint Number 3024730.

Based on record review, facility assessment review, job description review, staff schedule review and interview the facility failed to ensure a registered nurse was scheduled for eight consecutive hours, seven days per week. This had the potential to affect all 73 residents residing in the facility. The facility census was 73.Findings include:Review of the facility assessment dated [DATE] revealed Registered Nurses (RNs) are part of nursing services and are needed to provide support and care for facility residents.Review of the nursing services schedule revealed there was not an RN scheduled for 05/23/26. In an interview on 06/15/26 at 11:00 A.M. the Administrator verified there was not an RN scheduled/who worked on 05/23/26.Review of the Registered Nurse Employee Job description, revised 09/01/25, revealed the primary purpose of the RN job position was to provide direct nursing care to residents and to supervise day-to-day nursing activities. Further review revealed RN job duties include directing the day-to-day functions of the nurses and nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility. This deficiency represents non-compliance investigated under Complaint Number 3024730.

Based on observation, interview, and policy review, the facility failed to ensure residents received the correct texture diet. This affected one (#6) of three residents observed for correct diet texture. The facility census was 73. Findings include:Record review revealed Resident #6 admitted to the facility on [DATE] with diagnoses including other sequelae of other cerebrovascular disease, vascular dementia, and anxiety disorder.Review of an order dated 10/10/25 revealed Resident #6 required a regular diet with mechanical soft texture, thin liquids, a divided scoop plate, and a spout cup.Review of a care plan dated 12/04/25 revealed Resident #6 had a nutritional problem or potential nutrition problem related to cerebrovascular disease, dementia, metabolic encephalopathy, a mechanically altered diet, and hospice services. The goal was for Resident #6 to tolerate the least restrictive diet texture without difficulties. Interventions included but were not limited to determine likes and dislikes and provide diet as ordered.Review of a minimum data set (MDS) completed 06/04/26 revealed Resident #6's cognition was severely impaired, he was dependent on staff for eating assistance, and was on a mechanically altered diet.Observation on 06/15/26 at 11:29 A.M. revealed Resident #6 was in the dining room with his lunch. His meal ticket revealed he needed a mechanical soft diet including soft breads. Resident #6 received a biscuit with his meal. Licensed Practical Nurse (LPN) #216 stated she would ask the kitchen if he received the correct bread. At 11:40 A.M. kitchen staff brought out buttered bread and removed the biscuit from Resident #6's plate.Interview on 06/15/26 at 11:47 A.M. with Regional Nurse (RN) #300 confirmed Resident #6 was given a biscuit as part of his mechanical soft diet and it was removed. Interview on 06/16/26 at 12:01 P.M. with Speech Therapist (ST) #301 revealed each building is different regarding what is or is not considered mechanical soft. Some buildings would say no to a biscuit and some would say yes. ST #301 stated she was aware if biscuits sat long enough or by the time they were delivered to resident's they could get hard.Voicemail received from ST #301 on 06/16/26 at 1:12 P.M. revealed she had reviewed her professional dysphagia (difficulty swallowing) diet guidelines and a biscuit was considered to be a regular diet, not mechanical soft. Review of a policy titled Pureed and Mechanical Soft Foods Production dated 09/08/21 revealed a mechanical soft diet consists of foods that are in an easy to chew form for residents with chewing difficulty, teeth loss, poor fitting dentures, mouth pain, or residents that require extensive time to complete a meal. Regular menu items should be mechanically altered, chopped or ground, so it can be consumed by a resident with chewing difficulty. Food characteristics include: can be eating with a spoon, fork or chopsticks; can be mashed/broken down with pressure from spoon, fork or chopsticks; a knife is not required to cut food; chewing is required before swallowing; soft, tender and moist throughout; and bite sized pieces (half an inch or less). This deficiency represents non-compliance investigated under Complaint Number 3034800.

Based on record review, Food and Drug Administration Medication Information review, and interview the facility failed to ensure residents were free of unnecessary medications. This affected on resident (#28) of two reviewed for a facility reported incident. The facility census was 73.Findings include:Review of Resident #28's medical record revealed an admission date of 07/30/25 and diagnoses including unspecified dementia with behavioral disturbance, other symptoms and signs involving appearance and behavior (aggressive behaviors), COPD, anxiety disorder, restlessness and agitation, chronic pain syndrome, hypertension, and major depressive disorder.Review of Resident #28's significant change Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status score of five indicating the resident had severe cognitive impairment. Further review of the MDS revealed Resident #28 utilized a walker and a wheelchair for mobility, was independent with bed mobility, required supervision with transfers, partial/moderate assistance with toileting hygiene and had two or more falls without injury since the previous MDS was completed. Further review of the MDS revealed Resident #28 was receiving hospice services.Review of Resident #28's progress notes revealed a note written on 06/02/26 at 6:56 P.M. by Licensed Practical Nurse #225 This nurse is made aware that patient was involved in a patient to patient altercation down 200 hall. This patient was asked by another patient what is his name. This patient becomes agitated & the physical altercation is heard by a family member & staff is quickly alerted. Patients are separated & distracted. Both patients have new skin tears as a result. Family & on call physicians are notified.Review of Resident #28's physician's orders revealed an order dated 06/03/26 for depakote oral tablet delayed release 250 MG (Divalproex Sodium) give one tablet by mouth two times a day for target behaviors: agitation, anxiety related to unspecified dementia, unspecified severity, with behavioral disturbances.In an interview on 06/16/26 at 1:30 P.M. Regional Nurse #300 verified the depakote was ordered for agitation, anxiety related to unspecified dementia, unspecified severity, with behavioral disturbances and those were not approved diagnosis for administration. Review of the United States Food and Drug Administration labeled uses for depakote revealed the medication was approved for use in patients who had seizures, manic episodes of bipolar disorder and for migraine prevention.This deficiency is an incidental finding discovered during the complaint investigation.

Based on record review and interview the facility failed to develop and implement care plans for behaviors and dementia care for Resident #28. This affected one resident (#28) of two reviewed for a facility reported incident. The facility census was 73.Findings include:Review of Resident #28's medical record revealed an admission date of 07/30/25 and diagnoses including unspecified dementia with behavioral disturbance, other symptoms and signs involving appearance and behavior (aggressive behaviors), COPD, anxiety disorder, restlessness and agitation, chronic pain syndrome, hypertension, and major depressive disorder.Review of Resident #28's significant change Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status score of five indicating the resident had severe cognitive impairment. Further review of the MDS revealed Resident #28 utilized a walker and a wheelchair for mobility, was independent with bed mobility, required supervision with transfers, partial/moderate assistance with toileting hygiene and had two or more falls without injury since the previous MDS was completed. Further review of the MDS revealed Resident #28 was receiving hospice services.Review of Resident #28's progress notes revealed a note written on 06/02/26 at 6:56 P.M. by Licensed Practical Nurse #225 This nurse is made aware that patient was involved in a patient to patient altercation down 200 hall. This patient was asked by another patient what is his name. This patient becomes agitated & the physical altercation is heard by a family member & staff is quickly alerted. Patients are separated & distracted. Both patients have new skin tears as a result. Family & on call physicians are notified.Review of Resident #28's care plan revealed no behavior or dementia care plans were in place prior to 06/03/26. In an interview on 06/16/26 at 1:30 P.M. Regional Nurse #300 verified there was not a care plan for behaviors or dementia care prior to 06/03/26.Review of the policy titled Care Plan Policy, revised 02/2022, revealed an individual care plan will be developed to identify the physical, mental, psychosocial needs of each resident in a manner that will promote each resident feeling of well-being, self-worth and self-esteem. Care plans will address diagnoses, physician orders, dietary needs, medications, treatments, general care, devices and interventions, behaviors, advanced directives, choices, cultural preferences, and other needs and preferences specific to the resident. The care plan will be used by the care team to coordinate and manage the resident's goals, preferences, choices, past trauma care, and services that will be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.This deficiency is an incidental finding discovered during the complaint investigation.

Based on observations, interviews and policy review, the facility failed to ensure all residents seated at the same table were served their meals at the same time, leaving one resident without food while the other residents ate their meal. This affected one (#29) of three residents reviewed for dining. The facility census was 73. Findings include:Record review revealed Resident #29 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, depression, and anxiety disorder.Review of a minimum data set (MDS) dated [DATE] revealed Resident #29's cognition was intact.Observation of the lunch meal in the dining room on 06/16/26 starting at 11:32 A.M. revealed Resident #29 was seated at a table with five other residents. Each of the other five residents were served their lunch meals and Resident #29 was not. After serving Resident #29's table, three other tables, located in the dining room, were given their meals for a total of 15 residents being served before Resident #29. Resident #29 was interviewed and stated she usually had her food and wondered where it was since the others had been served their meal.Interview on 06/16/26 at 11:55 A.M. with Licensed Practical Nurse (LPN) #216 confirmed all meal trays had been passed in the dining room and Resident #29 still did not have a tray. LPN #216 requested the resident's meal tray from the kitchen so she could be served her lunch.Review of a policy titled Dignity, Respect, and Privacy dated 01/2026 revealed care should be provided to residents while maintaining their dignity and privacy. Residents should always be treated with respect and cared for in a manner that protects their privacy. This deficiency represents non-compliance investigated under Complaint Number 3034800.

Based on record review, observations, interviews, and policy review, the facility failed to ensure all resident rooms were maintained at a comfortable temperature. This affected seven (#2, #3, #4, #6, #7, #10, and #12) of 13 residents reviewed for heating concerns, and had the potential to affect 13 of 13 residents reviewed for heating concerns. The facility census was 74. Findings include:Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including dementia and difficulty in walking. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and congestive heart failure. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including polyneuropathy and normal pressure hydrocephalus. Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including myocardial infarction and acute respiratory failure. Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction and anemia. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including vascular dementia and anemia. Record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including dementia and muscle wasting and atrophy. Review of temperature audits dated 11/24/25 at 7:30 A.M. revealed the outdoor ambient temperature was 53 degrees and clear weather. Temperatures of rooms were as follows (degrees Fahrenheit): 68 in room [ROOM NUMBER], 67 in room [ROOM NUMBER], 72 in room [ROOM NUMBER], 70 in room [ROOM NUMBER], 71 in room [ROOM NUMBER], 70 in room [ROOM NUMBER], 71 in room [ROOM NUMBER], and 71 in room [ROOM NUMBER]. Review of temperature audits dated 11/25/25 revealed the outdoor ambient temperature was 53 degrees and rainy weather. Temperatures of rooms were as follows (degrees Fahrenheit): 65 in room [ROOM NUMBER], 65 in room [ROOM NUMBER], 68 in room [ROOM NUMBER], 65 in room [ROOM NUMBER], 64 in room [ROOM NUMBER], 65 in room [ROOM NUMBER], 67 in room [ROOM NUMBER], and 65 in room [ROOM NUMBER]. Review of temperature audits dated 11/28/25 at 9:00 A.M. revealed the outdoor ambient temperature was 29 degrees. Temperatures of rooms were as follows (degrees Fahrenheit): not taken in room [ROOM NUMBER], 65 in room [ROOM NUMBER], 65 in room [ROOM NUMBER], 65 in room [ROOM NUMBER], 65 in room [ROOM NUMBER], 65 in room [ROOM NUMBER], 71 in room [ROOM NUMBER], and 69 in room [ROOM NUMBER]. Review of temperature audits dated 12/01/25 at 9:00 A.M. revealed the outdoor ambient temperature was 28 degrees. Temperatures of rooms were as follows (degrees Fahrenheit): 71 in room [ROOM NUMBER], 68 in room [ROOM NUMBER], 69 in room [ROOM NUMBER], 69 in room [ROOM NUMBER], 69 in room [ROOM NUMBER], 67 in room [ROOM NUMBER], 71 in room [ROOM NUMBER], 68 in room [ROOM NUMBER], and 68 in room [ROOM NUMBER]. Interview on 12/02/25 at 12:50 P.M. with Resident #7 revealed her room was cold and the heater was not working. Interview and tour on 12/02/25 starting at 2:30 P.M. and ending at 2:42 P.M. with Maintenance Director (MD) #106 revealed he started working in the facility in the spring and was aware several heating units were not functioning or were about to stop functioning. MD #106 stated he told his corporate supervisors about his concerns but they had not started working on ordering heating equipment until Monday (12/01/25). They got two separate estimates and intended to place an order for five units, then two or three additional units each month until all were replaced. MD #106 stated he has been taking the temperatures for a couple weeks to monitor the temperature of rooms without heat. During the tour, temperatures were as follows: 68 degrees in room [ROOM NUMBER], 68 degrees in room [ROOM NUMBER], 68 degrees in room [ROOM NUMBER], 69 degrees in room [ROOM NUMBER], 65 degrees in room [ROOM NUMBER], 65 degrees in room [ROOM NUMBER] (empty room), 68 degrees in room [ROOM NUMBER], and 65 degrees in room [ROOM NUMBER]. The outdoor ambient temperature was 32 degrees. MD #106 confirmed temperatures within the facility should be maintained between 71 and 81 degrees unless requested by a resident. Interview on 12/02/25 at 3:07 P.M. with Resident #4 revealed he did not have heat in his room. Resident #4 stated he wasn't cold, but he was having to use four blankets which made it hard to move around but he was comfortable laying in bed. Interview on 12/02/25 at 3:11 P.M. with Resident #6 revealed she arrived to the facility a month ago and the heat was broken before she got there. Resident #6 stated she was not cold but she dresses like this (she was wearing a turtleneck sweater, a jacket, sweatpants, long socks and tennis shoes). Resident #6 stated she also sleeps in the same outfit, which is not typical for her because she prefers to sleep in a nightgown. Interview on 12/02/25 at 3:20 P.M. with Resident #10 revealed his room was cold. Interview on 12/02/25 at 3:40 P.M. with Resident #12 revealed her room was cold but she was using extra blankets to stay warm. Review of a policy titled Temperature Extremes dated 06/2019 revealed the facility should provide a comfortable and safe temperature level maintained between 71 and 81 degrees Fahrenheit. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2645381.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on observation, record review, interview, and review of the facility self-reported incident (SRI), the facility failed to provide care and services to assist a dependent resident with activities of daily living (ADL) and the resident was identified to have maggots in her hair. This affected one (#11) of three residents reviewed for personal hygiene. The facility census was 76.Findings include: Review of the medical record for Resident #11 revealed an initial admission date of 01/19/23 and a readmission date of 11/04/25. Resident #11 was transferred to the hospital on [DATE]. Diagnoses included: multiple sclerosis, neuromuscular dysfunction of bladder, unspecified, seborrheic dermatitis, and cellulitis of head. Review of the most recent Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had a Brief Interview for Mental Status (BIMS) of 15. The resident was assessed to require dependence on staff for bed mobility, oral hygiene, toileting hygiene, eating, bathing, and transfers. Section M revealed Resident #11 was at risk for pressure ulcers and did not have any wounds.Review of Resident #11's ADL care plan revealed Resident #11 required assistance with ADL's, prefers showers, and resident refuses to allow staff to soak hair and address skin conditions. Review of Resident #11's physician's orders dated 06/11/25 revealed an order for ketoconazole shampoo 2%. Apply to scalp (shampoo) topically every day shift every Wednesday, Sunday for tinea versicolor (bath days) and Lotrisone Cream 1-0.05% (Clotrimazole-Betamethasone), apply to scalp topically two times a day for skin integrity dated 01/22/25. Review of a nursing progress note dated 10/29/25 revealed live myiasis (maggots) in Resident #11's hair and scalp. The resident's hair was washed and cream applied to open area to scalp. Hospice notified. Orders were received to send Resident #11 to the emergency room (ER).Subsequent review of medical record for Resident #11 revealed point of care (POC) task sign off documentation for scheduled bathing revealed not applicable on 09/08/25, 09/22/25, 09/26/25, 10/13/25, 10/20//25, and 10/24/25. Review of shower sheets for Resident #11 revealed missing documentation for shower or bed baths provided for dates 09/01/25, 09/05/25, 09/07/25, 09/14/25, 09/15/25, 09/21/25, 09/28/25 , 10/03/25, 10/10/25, and 10/17/25.Review of the facility's self-reported incident dated 10/30/25 revealed environmental factors such as flies in Resident #11's room may have contributed to the exposure of the wound. Review of pest control invoices dated 09/24/25, 10/30/25 and 11/10/25 revealed fly activity detected.Interview on 11/12/25 at 9:40 A.M. with Resident #11 revealed she prefers to have the hospice provider provide her with showers during visits and stated she was not getting the prescribed medications applied to her scalp as ordered prior to going to the hospital on [DATE]. Since returning from the hospital Resident #11 stated she is receiving daily showers provided by staff and topical medication to her scalp. Observation of Resident #11 at the time of the interview revealed a topical ointment applied to her scalp and Resident #11 appeared clean and well groomed.Interview on 11/12/25 at 3:15 P.M. with Licensed Practical Nurse (LPN) #10, revealed the facility has had fly issues. She usually kills 4-5 flies a day, but states they have gotten better during the weather change and since they have had Orkin (pest control company) come in.Interview on 11/12/25 at 3:20 P.M. with the Maintenance Director confirmed the facility had fly issues. The Maintenance Director stated Orkin comes into the facility monthly and as needed. The deficient practice was corrected on 10/30/25, when the facility implemented the following corrective actions:On 10/30/25, Resident #11's room was deep cleaned by facility housekeeping.On 10/30/25, an initial audit by the wound nurse conducted skin checks on all residents with wounds to ensure no additional residents were impacted.On 10/30/25, an audit completed by the Maintenance Director of all resident windows and other access sites to ensure there were no holes, tears, or openings that would allow entry access for flies.On 10/30/25, Orkin (pest control) was contacted to provide treatment for fly control.On 10/30/25, the Director of Nursing (DON) or designee educated all nursing staff on wound care protocols.On 10/30/25, the Housekeeping Supervisor educated all housekeeping staff on enhanced cleaning procedures. The DON/or designee will audit wound treatments and documentation for all residents with wounds two-three days a week for four weeks and then as determined necessary to ensure compliance. The Administrator or designee will complete visual inspection audits two-three times a week for four weeks and then as determined necessary of resident care areas to ensure the environment remains free of pests. Audits completed by the DON/designee on 10/30/25, 11/04/25, 11/07/25, and 11/11/25.Audits completed by Administrator/designee on 10/30/25, 11/05/25, 11/07/25, and 11/11/25. This deficiency represents non-compliance investigated under Complaint Number 2662527.

Based on the interview and resident council meeting minute review the facility failed to provide preferred resident activities including community outings to residents in the facility. This affected two residents (#17 and #37) of three residents reviewed for activities. The facility census was 77. Findings include: Interview on 06/12/25 at 11:00 A.M. Resident #37 reported she would prefer to do her own shopping and would like to go on outings in the community. She went on to say the facility does not have a working vehicle to take her. Interview on 06/12/25 at 11:11 A.M. Resident #17 reported she never gets to go on outings and would, love to go shopping Stated has brought it up many times with the facility but it was not addressed. Review of the resident council meeting minutes for 05/01/25 revealed the residents wanted to discuss future outings. Review of the Activity Calendar from January 2025 to May 2025 revealed the facility did not have any activities scheduled for outside of the facility. Review of the June 2025 activity calendar revealed on 06/19/25 the facility had an outing scheduled but it did not say what they would be doing. Interview 06/12/25 at 11:08 A.M. revealed Staff #165 did the transporting of residents in a SUV. She stated the SUV had not been used for taking residents on outings. She was the last one to drive the transport bus and it had not been working since May 2024. She reported they wanted to schedule an outing for 06/19/25 but she will not be able to transport that day due to another resident needed surgery, and she would have to take her instead. This was the first time she was aware of a facility outing being planned since the bus broke down in May 2024. Interview on 06/11/25 at 4:24 P.M. interview with Activities Aide (AA) #173 reported the facility had not had a working vehicle to transport any residents to outside activities since she had worked at the facility. Interview on 06/12/25 at 9:13 A.M. AA #172 reported the facility had not had a working vehicle to transport any residents to outside activities since she had worked at the facility. Interview on 06/12/25 at 1:23 P.M. Activity Director #171 reported she had been with the company since October 2024. She continued that the facility had not had any community outings since she had been at the facility. She stated she was aware that residents wanted community outings and believed the facility was working with another facility to borrow their van but as of now a plan had not been put in place. She stated they had something on the June calendar, but it will need rescheduled due to not having a driver available that day. Interview on 06/12/25 at 11:32 A.M. the Administrator confirmed the facility had not had a working vehicle to transport residents to outside activities in the facility. The Administrator reported they were in the process of establishing a system with another facility to borrow their vehicle.

2. Observation on 06/09/25 at 12:13 P.M. of Resident #42 and #224's room revealed a dark yellow orange stain in front of toilet, two broken linoleum with a raised uneven floor by Resident #42's chair and one broken linoleum in bathroom and two going into bathroom. Observation on 06/09/25 at 12:17 P.M. of Resident #68's room revealed the drywall was damaged between her chair and side table. Observation on 06/09/25 at 12:19 P.M. of Resident #65's room revealed five cracked linoleum tile on the floor. Observation on 06/09/25 at 12:40 P.M. revealed Resident #62's walls were damaged with holes behind her chair and to the side of the bed. Observation on 06/09/25 at 3:39 P.M. of Resident #49's room revealed a large hole in the wall behind her bedside table. Observation on 06/09/25 at 5:14 P.M. the wall behind Resident #23's electric wheelchair and the side wall were plastered and not painted. There were six broken linoleum tiles with pieces missing on the floor and the bathroom door had two holes in it. Interview on 06/11/25 at 4:22 P.M. with the Administrator confirmed she was aware of environmental issues. She informed the company was having the maintenance men join together certain days of the week to go to each others facilities to assist with big projects. Based on resident interview, staff interview, and observation, the facility failed to provide a clean home-like environment in resident rooms. This affected twelve residents (#8, #11, #23, #26, #42, #49, #53, #54, #62, #65, #68 and #224) of 77 residents reviewed for environment. The facility census was 77. Findings include: Observation on 06/09/25 at 3:23 P.M. revealed Resident #53's wall with gouges on the wall behind the bed and a plastic phone jack with wires hanging from it. Interview with Resident #53 revealed they were from an old bed that was removed between four to five months ago. Observation on 06/09/25 at 3:23 P.M. revealed Resident #53 and Resident #54's baseboard to the center wall between the rooms was missing. Observation on 06/10/25 at 3:53 P.M. revealed Resident #11 and Resident #26's baseboard to the center wall between the rooms was missing. Resident #11's wall with big gouges behind the bed. Resident #11 stated the staff hit the wall whenever they move her bed. Observation on 06/10/25 at 4:00 P.M. revealed Resident #8's baseboard was noted to coming off the wall. Interview on 06/11/25 at 8:00 A.M. with Maintenance Director #174 confirmed the gouges on the walls and missing baseboards in rooms. Stated he was aware of the environmental issues.

Based on observation, record review, and interview, the facility failed to clean a dependent resident's eyeglasses. This affected one resident (#23) of four residents reviewed for activities of daily living. The census was 77. Findings include: Review of Resident #23's medical record revealed a 09/30/21 admission and a 02/10/24 readmission. Diagnoses include type 2 diabetes, chronic obstructive pulmonary disease, peripheral vascular angioplasty with implants and grafts, Alzheimer's disease, weakness, cognitive communication deficit, abnormality of gait and mobility, muscle wasting and atrophy, dementia, vitamin D deficiency, osteoarthritis of left knee, neuromuscular dysfunction of bladder, hypertension, anemia, benign prostatic hyperplasia, transient ischemic attack and cerebral infarction without residual deficits, cardiomegaly, moderate protein calorie malnutrition, atherosclerotic heart disease, congestive heart failure, gastroesophageal heart disease, anxiety disorder, depressive disorder, hyperlipidemia, retention of urine, overactive bladder and history of pulmonary embolism, and venous thrombosis and embolism. Review of a 10/11/21 Alteration in Visual Function Related to Decreased Vision plan of care included the resident wore glasses and had an intervention to ensure eyeglasses are clean. Review of the 03/18/25 quarterly Minimum Data Set (MDS) Assessment revealed the resident was moderately impaired for daily decision making with no behaviors. The resident was dependent for hygiene. Observation on 06/09/25 at 5:42 P.M. revealed the resident's eyeglasses were dirty. The lenses had white smears on them. There were debris embedded where the lenses and frame met. Observation on 06/10/25 at 3:50 P.M. revealed the resident's glasses had the same smearing and debris as the previous day. At the time of the observation, interview with Certified Nurse Aide (CNA) #154 revealed she had cleaned his glasses in the past. She stated she usually used a wipe they had at the nurse station. She used soap and water at the bathroom sink wetting and applied soap several times. She was attempting to get the dirt off around the frames where it met the lens. She verified the glasses were soiled and verified the resident would not be able to get the eyeglasses clean himself.

Based on observation of medication administration, and staff interview , the facility failed to ensure proper hand washing was completed during medication administration. This affected two residents (#50 and #57) of six residents observed for medication administration. Findings include: On 06/11/25 observation between 7:07 A.M. and 7:15 A.M. revealed Licensed Practical Nurse (LPN) #136 put on gloves and prepared medication for Resident #57, removed her gloves and put on new gloves without washing her hands and went in to the Resident #57's room and administered the medication, then removed her gloves and used hand sanitizer. LPN #136 then again put on new gloves, prepared medication for Resident #50, changed her gloves and went into the resident's room to administer medications. On 06/11/25 at 7:18 A.M. interview with LPN #136 verified she had not washed her hands between glove changes.

Based on medical record review, observation, and staff interview, the facility failed to ensure accurate documentation in the medical record. This affected one resident (#12) of one resident reviewed for edema. The census was 77. Findings included: Review of Resident #12's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included hemiparesis and hemiplegia, cerebral infarction, peripheral insufficiency, congestive heart failure, chronic ischemic heart disease, aphasia, high blood pressure, major depression, and anxiety. Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition was moderately impaired. He required set up or clean up assistance for eating, oral hygiene, dependent for toileting, substantial/maximal assistance for bath/showering, personal hygiene and turning and repositioning. The resident was occasionally incontinent of urine and always continent of bowel. Review of the physician orders revealed an order dated 03/18/25 to apply compression stockings to bilateral lower legs after applying treatment. Leave on for six to eight hours every day shift, 14 days on and seven days off for skin integrity. Review of the treatment record revealed the compression hose were documented as applied when reviewed on 06/12/25 at 10:34 A.M. Observation on 06/12/25 at 8:48 A.M., 10:30 A.M. and 1:34 P.M. revealed the compression stockings were not applied. On 06/12/25 at 1:37 P.M. interview with Registered Nurse (RN) #143 revealed the resident's compression hose are usually put on in the morning before getting the resident up by the certified nurse aides (CNA's). RN #143 revealed he had not gotten to apply the resident's compression stockings but verified he had already signed off as the hose application was completed. On 06/12/25 at 2:08 P.M. interview with the Director of Nursing revealed it was her expectation treatments are not signed off until completed.

Based on record review and interview, the facility pharmacist failed to identify a psychotropic medication needed a 14 day stop date. This affected one resident (#14) of five residents reviewed for unnecessary medication. The census was 77. Findings include: Review of Resident #14's medical record revealed a 05/28/21 admission with diagnoses including Alzheimer's disease, adjustment disorder with mixed anxiety and depression, dementia, hypertension, hypothyroidism, difficulty in walking, osteoarthritis, insomnia, pain in right knee, lumbago with sciatica, muscle wasting and atrophy, and abnormalities of gait and mobility. Review of the 05/07/25 quarterly Minimum Data Set Assessment revealed the resident was severely impaired for daily decision making with disorganized thinking, that comes and goes, changes in severity. Physician orders included Compound: Ativan (Lorazepam) Gel Apply to skin topically two times a day for target behaviors: agitation, anxiety milligram (mg) per milliliter (ml), apply 0.5 ml to inner wrist and apply to wrist topically every 12 hours as needed for target behaviors ordered 12/16/24 and discontinued 05/22/25. There was not a 14 day stop for the as needed controlled medication. The medication should have been discontinued 12/20/24. Review of pharmacy reviews dated 12/24/24, 01/25, 02/25, 03/09/25, and 04/25 did not identify the need for the Compound: ativan (Lorazepam) Gel to have a 14 day stop date due to being an as needed antianxiety medication. Review of the medication administration records revealed the medication was administered 01/07/25, 01/08/25, 01/11/25, 01/13/25, 01/17/25, 01/17/25, 01/21/25, 01/26/25, 01/31/25, 02/01/25, 02/04/25, 03/23/25, 04/06/25, 04/20/25, 05/04/25, 05/09/25, 05/12/25, and 05/16/25 (all dates after the medication should have been discontinued). Review of the facility's Antipsychotic Medication Use policy (revised 04/2023) included as needed orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. Interview on 06/11/25 at 4:34 P.M. with Pharmacist #185 included the nurse practitioner put the routine and the as needed antianxiety medication on the same prescription. He included when one prescription is sent in the insurance company will pay for both. When the routine and as needed dose is written as different prescriptions the insurance company will not always pay for both medications. We think of it as one prescription and a quantity so it did not trigger with the pharmacist to write a recommendation to discontinue the medication because it was all on one prescription. Interview on 06/11/25 at 5:04 P.M. with Regional Clinical Support Staff #186 verified the pharmacist did not write a pharmacy recommendation for the physician to write a 14 day stop date

Based on record review, policy review, and interview, the facility failed to ensure a psychotropic medication had a 14 day stop date. This affected one resident (#14) of five residents reviewed for unnecessary medication. The census was 77. Findings include: Review of Resident #14's medical record revealed a 05/28/21 admission with diagnoses including Alzheimer's disease, adjustment disorder with mixed anxiety and depression, dementia, hypertension, hypothyroidism, difficulty in walking, osteoarthritis, insomnia, pain in right knee, lumbago with sciatica, muscle wasting and atrophy, and abnormalities of gait and mobility. Review of the 05/07/25 quarterly Minimum Data Set (MDS) Assessment revealed the resident was severely impaired for daily decision making with disorganized thinking, that comes and goes, changes in severity. Physician orders included Compound: Ativan (Lorazepam) Gel Apply to skin topically two times a day for target behaviors: agitation, anxiety milligram (mg) per milliliter (ml), apply 0.5 ml to inner wrist and apply to wrist topically every 12 hours as needed for target behaviors ordered 12/16/24 and discontinued 05/22/25. There was not a 14 day stop for the as needed controlled medication. The medication should have been discontinued 12/20/24. The medication should have been discontinued on 12/20/24. Review of the medication administration records revealed the medication was administered 01/07/25, 01/08/25, 01/11/25, 01/13/25, 01/17/25, 01/17/25, 01/21/25, 01/26/25, 01/31/25, 02/01/25, 02/04/25, 03/23/25, 04/06/25, 04/20/25, 05/04/25, 05/09/25, 05/12/25, and 05/16/25 (all dates after the medication should have been discontinued) Review of the facility's Antipsychotic Medication Use policy (revised 04/2023) included as needed orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. Interview on 06/11/25 at 5:04 P.M. with Regional Clinical Support #186 verified the antianxiety medication did not have a 14 day stop as required. Interview on 06/11/25 at 5:43 P.M. with the Director of Nursing verified the facility did not follow the facility policy and regulations.

Based on the review of the facility job description, personnel record review and staff interview, the facility failed to ensure the Activities Director was qualified for the position. This had the potential to affect 77 out of 77 residents. The facility census was 77. Findings include: Review of the facility Job Description for an Activity Director (AD) revealed the AD must be a qualified therapeutic recreation specialist or an activities professional who is licensed by the state and is eligible for certification as a recreation specialist or as an activities professional; must have as a minimum two years' experience in a social or recreation program within the last five years one of which was full time in a patient activities program in a health care setting or must be qualified occupational therapist or occupational therapy assistant; or must have a training course approved by the state. AD #171 signed the job description on 10/02/24. Review of the personnel file for AD#171 revealed a hire date of 10/02/24. The personnel file revealed the AD's only activity experience was from May 2023 through February 2024 at another facility. The personnel file did not have evidence where the AD met any of the qualifications to become an Activities Director. Interview on 06/11/25 at 8:35 A.M. AD #171 reported when hired Administration spoke with her about completing an approved training to be a qualified Activities Director but she declined the training stating it was not something she wants to pursue at this time. Interview on 06/11/25 at 4:24 P.M. interview with Activities Aide (AA) #173 feels like she was not properly trained for her position. She stated she is overwhelmed in the position and has several concerns. She stated she can never find AD #171, was told she isn't allowed to make substitutions if resident do not like the scheduled activity, doesn't always have enough supplies for the residents, and the AD does not always have events planned for special occasions and holidays. Interview on 06/12/25 at 9:13 A.M. AA #172 reported she did not receive any formal training by the AD when hired. She went on to say she feels as though the resident trained her. AA #172 stated communication in the activity department is not good. She stated there have been several recent events where AD #171 did not communicate what the activity was or where supplies were located. AA# 172 reported she even took the AD course on her own so she could receive training on how the activity department is supposed to function. Interview on 06/11/25 at 2:46 P.M. the Administrator confirmed AD #171 did not meet the requirements to be the Activity Director. She stated the facility has self-identified issues in the department and are working with the staff to resolve the issues.

Based on observation, medical record review, and interview, the facility failed to maintain a clean and safe living environment for residents. This affected one (#40) of three residents sampled and two additional residents (#6 and #67) identified during environmental tour. The facility census was 78. Findings include: 1. Medical record review revealed Resident #40 was admitted on [DATE] with diagnoses including myocardial infarction and cerebral infarction. Observation on 12/16/24 at 8:10 A.M. revealed Resident #40 was independently ambulating in his room. Resident #40's bathroom revealed a missing floor tile approximately 10 inch in length by four inches in width at the entrance of Resident #40's shower. Interview with Resident #40 at the time of the observation stated he showers in his room and the tile had been broken since he moved in. 2. Observation on 12/16/24 at 11:20 A.M. of the 500-hall central bath revealed two opened bags of soiled linens, including a towel protruding out of the top of the bag resting against the lower wall outside the shower stall covered with a dark brown substance. The bags of soiled linens were not secured and gnats were observed flying around the linens. There was no staff or residents observed in the central bath and the shower floor was dry. Interview with Licensed Practical Nurse (LPN) #102 verified the soiled linen bags were not secured and should not be on the floor. 3. Observation on 12/16/24 at 11:27 A.M. of Resident #6's wall behind the bed revealed three heavily damaged areas of drywall measuring approximately 14 inches in length by three inches in width. Large pieces of dry wall was observed to be missing from two of the areas including one area that penetrated completely through the drywall exposing the inner wall. There was also an outlet box with grey wires observed without an outlet cover next to the night stand near the window. 4. Observation on 12/16/24 at 11:29 A.M. of Resident #67's floor tiles revealed a 1/4 to 1/2 inch wide linear crack with missing tile pieces that extended the width of the room, from the entrance of the bathroom to the wall adjacent to the resident's closet. The subflooring was observed to have black build-up where the floor tiles were cracked/broken. Interview with Resident #67 at the time of the observation stated he did not know what had happened to the flooring. Interview on 12/16/24 between 11:35 A.M. to 11:42 A.M. with Maintenance Director #103 verified the above observations. This deficiency represents non-compliance investigated under Complaint Number OH00159451.

Based on record review, hospital record review, and interviews, the facility failed to ensure Resident #23 received adequate care for treatment of an urinary tract infection. This affected one resident (#23) of three residents reviewed for urinary tract infections. Facility census was 57. Actual harm occurred on 02/03/24 when Resident #23, who had a diagnosis of Alzheimer's disease and cognitive impairment, exhibited signs of an urinary tract infection including dark, cloudy urine without evidence of timely identification or treatment of the infection. On 02/07/24 at 10:45 P.M. (four days later) the resident was assessed to have an elevated temperature of 102.3 degrees Fahrenheit with altered mental status. The resident was transferred to the emergency room and subsequently admitted with a diagnosis of sepsis with acute metabolic encephalopathy due to acute urinary tract infection/acute pyelonephritis. The resident was hospitalized for three days. Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, Alzheimer's disease, neuromuscular dysfunction of bladder, history of transient ischemic attack, and overactive bladder. An assessment/plan from urologist dated 01/24/24 revealed Resident #23 had benign prostatic hyperplasia that was managed with an indwelling catheter. Resident #23 also had bladder perforation. A new catheter was placed on 01/24/24. A general note dated 02/03/24 at 4:55 A.M. revealed a nursing assistant notified the nurse Resident #23 had dark cloudy urine. The note indicated Resident #23 would continue to be monitored. A general note dated 02/05/24 at 1:18 A.M. revealed a nursing assistant reported to the nursing staff Resident #23's urine continued to be dark and cloudy. Resident #23 was on the certified nurse practitioner list to be seen on rounds. A general note dated 02/05/24 at 5:57 A.M. (documented on 02/06/24 at 5:59 P.M.) revealed the nurse spoke with Resident #23's urologist office regarding Resident #23's urine results due to Resident #23 had traces of blood and thick orange/yellow urine. The urologist office stated they were trying to find Resident #23's results and would return the call when the results were found. A general note dated 02/06/24 at 12:59 P.M. revealed a message was left with Resident #23's urologist office regarding Resident #23's urine results. A general note dated 02/07/24 at 10:45 P.M. revealed the nurse entered Resident #23's room to perform evening nursing assessment. Resident #23 had a large bowel movement and appeared shaky. When Resident #23 was asked if he was okay, Resident #23 just looked at the nurse and did not say anything. The nursing assistant stated Resident #23 was not acting like his normal self. Resident #23's blood pressure was 118/67 mmHg, pulse was 124 beats per minute, oxygen saturation was 93% on room air, respirations were 24 breaths per minute, and temperature was 102.3 degrees Fahrenheit . A decision was made to send Resident #23 to the hospital for evaluation due to altered mental status and abnormal vitals. Review of the hospital discharge summary dated 02/10/24 revealed Resident #23 was brought to the hospital on 02/07/24 with complaints of altered mental status and fever. The nursing home staff reported Resident #23 was more confused than dementia baseline. Resident #23 was admitted to the hospital with sepsis (the body's overwhelming and life-threatening response to an infection which can lead to tissue damage, organ failure, and death) due to acute urinary tract infection/acute pyelonephritis (kidney infection). Resident #23 had acute metabolic encephalopathy (disturbance of brain function caused by a chemical imbalance in the blood) due to sepsis. Resident #23 was ordered Keflex (antibiotic) 250 milligram three times a day for 21 days. A general note dated 02/10/24 at 3:00 P.M. revealed Resident #23 returned to the facility in stable condition. Resident #23 had an indwelling catheter draining cloudy, yellow urine. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had cognitive impairment and an indwelling catheter. Interview on 03/21/24 at 2:52 P.M. Registered Nurse (RN) #129 revealed the urologist was the only one able to change Resident #23's indwelling catheter. RN #129 stated the urologist was contacted when the catheter could not be flushed. RN #129 stated she believed Resident #23 had the indwelling catheter in place for more than 14 days so a urine sample could not be obtained. Review of the documentation revealed the indwelling catheter was placed on 01/24/24. Resident #23 had dark cloudy urine ten days after catheter had been placed. RN #129 stated the facility had called the urologist to obtain the urinalysis results from the urologist during the 01/24/24 visit. Interview on 03/21/24 at 3:21 P.M. RN #400 revealed the RN worked for the urologist who saw Resident #23. The RN verified the urologist was the only one allowed to change the resident's catheter. RN #400 revealed if there were any changes or concerns, the facility could contact the urologist office. RN #400 revealed there was no evidence the facility had attempted to call the urologist regarding Resident #23. The urologist was notified by the hospital that Resident #23 was admitted with a urinary tract infection. RN #400 verified if the urologist office was closed and there were any concerns, Resident #23 could be sent to the hospital for evaluation. The urologist was on call at the hospital for patients who were seen in the emergency department.

Based on observation, record review and interview the facility failed to ensure Resident #48 was provided adequate assistance during a transfer to the toilet to prevent an injury. Actual Harm occurred on 04/07/22 when Resident #48, who was assessed to require two staff for transfers and toileting was lowered to the floor while being assisted by only one staff member resulting in a displaced fracture of the left femur/hip. The resident was hospitalized as a result of the injury and required surgical repair of the fracture. This affected one Resident (#48) of three residents reviewed for accidents and falls. Findings include: A review of the medical record for Resident #48 revealed an admitted [DATE] with diagnoses including right above the knee amputation, [CONDITION(S)], [CONDITION(S)], and hypertension. Resident #48 was admitted to the facility from home because of difficulty with caring for herself. A pre-admission referral document, dated 03/25/22 included a progress note (dated 03/01/22) from the resident's family physician. The progress note included details regarding an inability of the resident to live at home. The resident was not able to walk because of her amputation, could not safely transfer herself and assisted living or nursing home care would be needed for the resident. A review of the admission document titled, [NAME] House Health and Rehabilitation New Resident Report Sheet, dated 04/01/22 revealed Resident #48 required two assist from staff for transfers, was not able to ambulate and needed a wheelchair for mobility. Review of the baseline care plan, dated 04/01/22 revealed a goal indicating Resident #48 was to have minimal fall risk with an intervention to anticipate and meet her needs. Upon admission, an assessment completed by Licensed Practical Nurse (LPN) #72 revealed Resident #48 required staff assistance with bed mobility and transfers because of weakness as well as being at moderate risk for falls. On 04/01/22 the Assistant Director of Nursing (ADON) completed an assessment of the resident's usual performance for toilet transfer which identified the resident was dependent on staff. Subsequent assessments for usual performance with toilet transfers completed on 04/01/22, 04/02/22, and 04/03/22 revealed the resident did not assist with the effort, the resident did none of the effort or two assistance of staff was required. On 04/05/22 LPN #85 again assessed the resident to be dependent on staff for toilet transfers. A review of the State tested Nursing Assistant (STNA) documentation for Resident #48 revealed the resident was dependent with two staff assist for toilet assistance and transfers on 04/01/22. The documentation further revealed Resident #48 required extensive assistance from two staff for toileting and transfers on 04/02/22, 04/03/22, 04/05/22, 04/06/22 and 04/07/22. A review of a nursing progress note, dated 04/07/22 at 6:49 P.M. revealed LPN #10 was notified by an aide that Resident #48 was on floor. The note further revealed Resident #48 was being assisted to the bathroom, stood up from the wheelchair, then was lowered to floor. No injuries were observed at that time. On 04/07/22 at 10:50 P.M. Resident #48's daughter had called LPN #85 to tell her Resident #48 was complaining of more pain in her leg. An X-ray was ordered on 04/07/22 for her left leg. Review of the facility fall investigation, dated 04/07/22 revealed Resident #48's leg had given out while she was being transferred to the toilet. Resident #48 had no prior history of falls. A statement by STNA #16 revealed she was unsure of how much assistance Resident #48 needed to go to the restroom so she asked another staff member. STNA #16 stated she was told by an unidentified staff member that Resident #48 was a stand-pivot transfer. STNA #16 stated Resident #48 was in a standing position when her knee gave out a split second after moving the wheelchair so she lowered her to the floor. A statement from STNA #74 revealed it took three staff to assist Resident #48 back up and into her bed after the fall. Further review of the nursing progress notes revealed a note, dated 04/08/22 at 4:46 A.M. which revealed an X-ray of the left leg showed a a displaced supracondylar fracture of the left femur. Resident #48 was discharged to the hospital to undergo surgical repair of the fracture. A review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/08/22 revealed the resident had no short term memory problems and had modified independence with decision making. The assessment revealed the resident had no behaviors and required extensive assistance with transfers and toileting during the seven day look back period. On 05/09/22 at 11:51 A.M. interview with Resident #48 revealed she had suffered a fall several days after admission that resulted in a fracture of her left leg. Observation of the resident's room at the time of the interview revealed the resident did not have access to a bedside commode in the room. On 05/11/22 at 2:25 P.M. during a follow up interview with Resident #48, the resident revealed she was admitted to the facility because her husband could not take care of her anymore as it was too hard for him to assist her. The resident reported she had hoped to receive therapy services following her admission, but no therapy had been provided. Resident #48 further shared it took two staff to transfer her and she had asked for a bedside commode because that was what she was used to using at home. During the interview, the resident reported she had sustained the fall and fracture because one staff member was trying to transfer her alone despite the resident stating she told the staff member it normally took two staff to assist her to the bathroom. On 05/11/22 at 3:37 P.M. interview with the Director of Nursing (DON) revealed Resident #48 did not have therapy upon her admission because she was private pay. The DON also denied any knowledge of the resident requesting a bedside commode for use in toileting. On 05/12/22 at 3:30 P.M. during a follow up interview with the DON, the DON confirmed Resident #48 was being assisted/transferred by one STNA on 04/07/22 at the time she was lowered to the floor resulting in the left hip/femur fracture.

Based on observation, review of a closed medical record, facility investigative notes, video camera footage, facility Elopement-Residents at Risk policy and procedure, staff and family interview and interview with Physician #100, the facility failed to implement interventions to prevent the elopement of one resident (Resident #20), who was assessed to be cognitively impaired, high risk for elopement, exhibited wandering behaviors and required a wander guard bracelet device to be worn. This resulted in Immediate Jeopardy on 07/08/19 at 9:35 A.M. when Resident #20 exited the exterior sun room door at the end of the 200 unit without staff knowledge. The resident was found by local high school students laying on the ground at the bottom of a steep embankment between the facility and neighboring school. Actual Harm occurred as a result of the incident when the resident was transported to the local hospital and diagnosed to have two cervical (neck) fractures. The resident did not return to the facility following the incident. An additional identified finding that did not rise to the level of Immediate Jeopardy occurred when review of a closed medical record for Resident #30 revealed the facility failed to provide adequate supervision and implement individualized and effective interventions to prevent episodes of the resident wandering to unsafe areas including the exterior of the facility unsupervised. Resident #30 was cognitively impaired, was at high risk for elopement with exit seeking behaviors and wore a wander guard. Resident #30 sustained multiple bruising areas and swelling to her hand following an incident on 12/26/18. This affected two residents (Residents #20 and #30). The facility identified 14 additional residents at risk for elopement and who wore wander guard devices. (Residents #203, #206, #209, #222, #241, #243, #248, #250, #255, #257, #258, #259, #266, and #268). On 07/24/19 at 3:05 P.M. the Administrator, Director of Nursing (DON) and Regional Director of Operations #102 were notified Immediate Jeopardy began on 07/08/19 at 9:35 A.M. when Resident #20 eloped from the facility. Video camera footage showed a resident, identified by Director of Maintenance (DM) #32, to be Resident #20 exiting the 200 unit exterior door unsupervised by staff on 07/08/19 at 9:35:31 without evidence the wander guard system functioned as designed (i.e. there was no evidence the door locked when Resident #20 attempted to open it and only released after 15 seconds of applied pressure). The resident and/or her shadow remained in view on the camera until 9:36:31. On 07/08/19 at 9:36:36 (five seconds later) video camera footage showed a staff member, identified by Maintenance Director #32 to be State tested Nursing Assistant (STNA) #10 at the 200 unit door. Per camera footage, STNA #10 looked out the window of the door for five seconds without opening the door or going outside the building to conduct any type of resident search. The resident was found lying on the ground at the bottom of a steep embankment, next to the facility in a weeded ditch area, by local high school cross country runners who alerted facility staff on 07/08/19 at 9:48 A.M. The resident was subsequently transported by Emergency Medical Service (EMS) staff to a local hospital where she was assessed to have two cervical (neck) fractures. The Immediate Jeopardy was removed on 07/25/19 when the facility implemented the following corrective action: · On 07/08/19 immediately following the incident, Resident #20 was transported to the hospital by EMS. The resident did not return to the facility. · On 07/08/19 beginning at 10:15 A.M. the Administrator and/or Designee implemented in-service education for all staff with emphasis including that when a door alarm sounded and no resident was immediately seen, a full house head count must occur AND a thorough outside property search would be initiated. The education also revealed an elopement binder was at the nurse ' s station which included all high risk residents face sheet/picture. The facility identified 92 total employees. As of 07/09/19 all employees who routinely worked in the facility had received the education. · On 07/08/19 an elopement binder was updated to ensure all residents assessed to be at high risk for elopement had information contained in the book. A map of the facility doors was added to the binder on 07/08/19. · Beginning on 07/08/19 the facility implemented a plan for DM #32 to conduct Elopement drills to evaluate the effectiveness of staff response to door alarms. A plan for the drills to be conducted two times per week beginning on 07/08/19 for three weeks was identified. · On 07/08/19 a plan for the Administrator/DM #32 and/or designee to check the function of all door alarms daily for seven days and then weekly for an indefinite time period was implemented. · On 07/08/19 the DON and/or designee completed re-assessments for all residents, (Residents #203, #206, #209, #222, #241, #243, #248, #250, #255, #257, #258, #259, #266, and #268) identified to be at risk for elopement to evaluate current interventions · On 07/24/19 the Administrator and/or designee obtained statements from staff in regard to the incident that occurred on 07/08/19 when Resident #20 eloped as part of a facility investigation of the incident. Statements were obtained from Human Resource #60, Assistant Director of Nursing, Registered Nurses (RN) #20 and #78, DM #32, Licensed Practical Nurses (LPNs) 18, #44 and #34, STNAs #24, #22, #10, #36, #84, #87, #40, Housekeeper #69, RN #15 and Activity Assistant #92. Prior to 07/24/19 the only statements as part of the facility investigation were from the cross- country coach, a statement written by the Administrator from one of the high school students and a statement from Licensed Practical Nurse (LPN) #44 of her conversation with STNA #10. · On 07/24/19 the Administrator implemented a plan for a nursing staff member to be assigned to the nurse's station to monitor the door alarm board to provide a quicker response if an exterior door alarm sounded. The Administrator indicated at the time of the incident on 07/08/19 she believed the door alarm on the 200 unit sounded properly but staff did not react/respond as they should have. · On 07/24/19 and 07/25/19 the Administrator completed education audits with all staff to ensure all staff were knowledgeable regarding how to respond to door alarms. · On 07/25/19 the facility updated the elopement binder to include narrative information identifying High Risk Areas Outside the facility which included pond, parking lot, highway, steep embankment and ditch. The steep bank was identified to be outside the 200 unit sunroom. · On 07/25/19 Regional Quality Assurance RN #103 indicated the facility had started to look (on 07/24/19) at different alarming/alerting systems and security systems to use on the exterior doors to provide security for residents at risk for elopement. · On 07/25/19 DM #32 installed smart alarm bars (which provided an audible alarm when the bar was crossed by a resident wearing a smart alarm bracelet) in the hallway of the 200 and 500 unit to alert staff of wandering behaviors prior to a resident reaching the exit doors on these units. · On 07/25/19 RN #103 provided education to the DON to ensure all incidents of elopement were captured on the facility incident and accident log. The incident involving Resident #20 on 07/08/19 was coded on the facility log as a fall prior to 07/25/19. · On 07/25/19 RN #103 and Regional Minimum Data Set 3.0 (MDS) RN #105 reviewed all 14 residents (Residents #203, #206, #209, #222, #241, #243, #248, #250, #255, #257, #258, #259, #266, and #268) identified to be at high risk for elopement to ensure all 14 residents had accurate orders and care plans for both a wander guard bracelet and a smart alarm bracelet. · On 07/25/19 a new policy and procedure was developed titled Door Alarm Response Protocol with a purpose to identify the type of door alarms in place in the facility and the protocol for staff response. As of 07/25/19 at 3:51 P.M. 32 of the facility 92 employees had been trained on the new policy. A plan for the Administrator to conduct training in person for staff working on 07/25/19 during the afternoon and night shift and for the staff working on each shift on 07/26/19 was initiated. Any staff not trained at the end of 07/26/19 would either be contacted by telephone or trained on their next scheduled day to work. · On 07/25/19 from 2:05 P.M. until 2:45 P.M., interview with LPNs #18, #61, #85, #89 and STNAs #10, #40, #43, #56, #63, #84, #93, and #95 revealed the staff interviewed were knowledgeable of which residents were at high risk for elopement and the functionality of the exterior doors on the nursing units. All interviewed staff verified they had received in-service training related to resident elopement. · On 07/25/19 at 2:02 P.M. observation revealed an elopement binder was at the central nurse ' s station which contained the required information on each resident at risk for elopement. LPN #89 was observed monitoring the cameras at the nursing station. · On 07/25/19 at 3:33 P.M. the smart alarm bars were observed to be in place on the 200 and 500 halls. Although the Immediate Jeopardy was removed on 07/25/19, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of evaluating the monitoring systems/device options available for the exterior doors which could be accessed by residents within the facility, completing additional staff training and conducting audits to ensure effective staff training was in place. Findings include: 1. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician order, dated 06/19/18 revealed the resident had an order for [REDACTED]. Record review revealed the resident had a plan of care, dated 01/08/19 for wandering/elopement risk related to impaired cognition, impaired safety awareness and a history of elopement attempts. Interventions included to involve the resident in activities of choice, provide diversional activities of interest as needed, offer re-direction as needed, and the use of a wander guard alarm. Review of the quarterly MDS assessment, dated 05/21/19 revealed the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The MDS revealed the resident exhibited daily wandering behavior and was monitored with a wander guard alarm. Review of the Elopement Risk Assessment, dated 06/21/19 revealed the resident was at high risk for elopement. Review of a nursing progress note, dated 07/08/19 at 9:45 A.M. as a late entry note revealed local cross-country student runners entered the facility and notified staff they found a resident (identified to be Resident #20) laying on the ground outside of the facility, in a drainage ditch, on her back. The resident complained of neck pain, her neck was stabilized, and 911 was called. Per the note, the resident was transported to the local emergency room at 9:55 A.M. Review of the local Emergency Medical Services (EMS) run report, dated 07/08/19 revealed a call for assistance was received at 9:46 A.M. EMS arrived to the facility at 9:47 A.M and found a [AGE] year-old female lying on her back, in a ditch, outside the nursing facility. The EMS narrative documentation revealed staff from the facility were not sure how or when the resident escaped or for how long the resident was in the ditch. The resident was found by a passerby who stated she found the resident 30-40 minutes prior to the call. The resident had a history of [REDACTED]. The resident complained of back and neck pain, she was stabilized, and transported to the emergency room at 10:04 A.M. Review of hospital documentation, dated 07/08/19 revealed a cat scan (CT) of the cervical (C) spine was obtained and indicated a fracture at the base of the odontoid process and fractures through the anterior and posterior arch of the C1 vertebra. (The resident was assessed to have cervical neck fractures) and was transferred from the local hospital to a trauma hospital for continued care and treatment. During an interview on 07/23/19 at 9:35 A.M., the Administrator revealed on 07/08/19, Resident #20 exited the 200 hall exit door, fell and sustained a fractured neck. The Administrator further revealed she was notified by local high school students, at approximately 9:45 A.M., during a morning staff meeting, that a resident was lying in a ravine, between the facility and the middle school, yelling for help. The Administrator revealed that she and other staff responded to the scene and found Resident #20 lying on her back complaining of neck pain. 911 was called and the resident was transported to a local emergency room and diagnosed with [REDACTED]. A request of the facility investigation of the incident was made at that time. Review of the facility investigation revealed it contained a timeline of events written by the Administrator and included a statement from the cross country coach, a statement written by the Administrator from one of the high school cross country runners and a statement from LPN #44 based on a conversation she had with STNA #10. Review of the undated witness statement from the cross country coach revealed the coach was notified on 07/08/19, by members of the team, of a person located in the weeds of a ditch, yelling for help. She stated she ran down to the ditch, located by the middle school, and saw an elderly person in the weeds. She immediately sent two members of the track team to the nursing home to inform them of the resident lying in the ditch. The nursing home staff arrived and notified EMS and the resident was taken to the hospital. Review of a statement from LPN #44, dated 07/08/19, revealed she spoke with STNA #10 regarding Resident #20's elopement. STNA #10 told LPN #44 Resident #20 had no unusual behavior and that she did not show signs of exit seeking that morning. Review of timeline, provided by the Administrator, revealed on 07/08/19 at 9:36 A.M. the resident was seen leaving facility (per the monitor), at 9:38 A.M. Staff (no name provided) were seen looking outside/responding to the alarm (per the monitor). At 9:45 A.M. the cross country team entered the facility and alerted staff (names not provided) of a resident outside, at 9:50 A.M. 911 was called. At 10:00 A.M. the resident' s physician (Physician #100) was notified, the resident's power of attorney was notified, and the facility head count was clear. The facility investigation failed to include a conclusion as to how Resident #20 was able to exit the facility unsupervised by staff, failed to contain staff statements from all staff directly involved or with first hand knowledge of the resident/incident on 07/08/19 and failed to include any information from EMS staff who responded to provide care at the scene. The incident was not included on the facility incident and accident log as an elopement, but rather only as a fall for Resident #20. On 07/23/19 at 10:15 A.M. interview with LPN #14 revealed Resident #20 constantly wandered up and down the hallways, usually the 200 and 500 unit hallways, daily. LPN #14 revealed the resident frequently opened the sunroom doors, exiting the facility unsupervised. On 07/24/19 at 8:40 A.M. telephone interview with STNA #10 revealed on 07/08/19 she was the only STNA working on the 200 hall (the hall Resident #20 eloped from). STNA #10 revealed she had just returned from a break and was in a resident room providing personal care with the door closed. During the interview the STNA was unable to recall who the resident was that she was providing care for but indicated she had been in the room for approximately 10-15 minutes and upon exiting the room she heard an audible alarm. She stated she went to the sunroom at the end of the 200 hall and observed the exit door ajar. She indicated she looked outside and did not see anyone, however, she did not look over the hillside. During the interview, STNA #10 stated on 07/08/19 at the time of Resident #20's elopement, she was not sure what the facility policy and procedure for responding to an alarm and opened door was and was unable to verbalize who the residents were who were assessed to be at high risk for elopement. STNA #10 stated she would only know which residents were high-risk for elopement by looking for an elopement bracelet and confirmed there was not a book or readily available information listing the residents who were wandering/elopement risks. STNA #10 could not recall when she last received education related to wandering/elopements. On 07/24/19 at 9:02 A.M. observation of the video surveillance camera footage with DM #32, revealed on 07/08/19 at 9:35:31 A.M., a resident, identified by DM #32 as Resident #20, was observed exiting the door at the end of the 200 hall unsupervised by staff. There was no evidence the wander guard alarm system functioned properly as designed (i.e. there was no evidence the door locked when Resident #20 attempted to open it). The door opened immediately without delay. Resident #20 and/or her shadow remained in view on the camera until 9:36:31. On 07/08/19 at 9:36:36 A.M. (five seconds later) video camera footage showed a staff member, identified by DM #32 to be STNA #10, at the 200 hall exit door. Per camera footage, STNA #10 looked out the window of the door for five seconds without opening the door or going outside the building to conduct any type of resident search. On 07/08/19 at 9:37:32 STNA #10 exited the 200 hall door. The STNA remained outside the facility for 23 seconds, returning at 9:37:55 with no evidence she located any resident outside this door. The resident was found lying on the ground at the bottom of a steep embankment, next to the facility in a weeded ditch area, by local high school cross-country runners who alerted facility staff on 07/08/19 at 9:48 A.M. The resident was subsequently transported by EMS staff to a local hospital where she was assessed to have two cervical (neck) fractures. During the observation of the video footage, DM #32 verified STNA #10 responded to the 200 hall sunroom door five seconds after the resident was out of view of the camera but failed to open the door or look outside for a resident at that time. When STNA #10 returned to the door a second time and did go outside, no resident was observed. On 07/24/19 at 9:45 A.M. a request was made to test the wander guard system on the 200 hall exit door that Resident #20 used to elope. DM #32 indicated the wander guard system did not consistently work on that door, which had been identified during routine maintenance checks (actual date identified as not working was not provided). DM #32 stated the facility had installed a screamer alarm on the door and were in the process of upgrading the wander guard system (no documentation related to this upgrade was provided). Observation of the 200 hall door revealed the door was unlocked and could be opened by using the door handle. When the door was opened an immediate audible alarm sound was heard. The alarm remained activated until the door was closed, at which time the audible alarm stopped sounding at the location of the door. The audible alarm did continue to sound at the nursing station until it was de-activated by staff at the nursing station. On 07/24/19 at 9:55 A.M. interview with DM #32 revealed although the 200 hall exit door was unlocked from the inside, once the door was shut, the door would be locked from the outside, preventing a person from getting back into the facility. DM #32 stated the screamer alarm, which was only an audible alarm, had been placed on the exterior hall doors approximately two years ago, to deter residents from exiting. DM #32 again revealed the wander guard system was ineffective, did not always work properly and did not work when Resident #20 exited the facility unsupervised on 07/08/19. On 07/24/19 at 10:02 A.M., interview with the Administrator confirmed the wander guard alarm system was only installed and fully functional on the facility front/main entrance doors and was not functional on the 200 unit door. The Administrator revealed she was aware the wander guard system was not functional on the 200 unit door and it had not been working consistently for some time (unable to give exact date). She also indicated the facility had installed a screamer alarming device to the exterior doors on the nursing units as an audible deterrent for residents attempting to leave the building. The Administrator verified that although this change to the alarming device and security features had been made, Resident #20 continued to have a physician order [REDACTED]. On 07/24/19 at 10:05 A.M. observation of the exterior grounds off the 200 hall exit door with DM #32 and the Administrator revealed a relatively flat lawn area extending from the door to a hillside observed to have a steep embankment. The embankment appeared to be at an approximate 45-degree downward angle. A weeded, ravine/ditch area was located at the bottom of the hillside/embankment. Measurements were obtained on 07/25/19 at 11:07 A.M. by DM #32 and the surveyor and noted an area approximately 31 feet wide of relatively flat but slightly uneven grassy area extending from the exit door to the top of the embankment. From the door to where the top of embankment where the resident was found at the bottom was approximately 83 feet. The actual embankment, from the top to the bottom where the resident was found was 46 feet steep. On 07/24/19 at 11:11 A.M., telephone interview with Physician #100 revealed he was notified on 07/08/19 Resident #20 had eloped from the 200 hall exit door, fallen outside and sustained a cervical neck fracture. Physician #100 verified Resident #20 ' s order for a wander guard alarm was due to wandering behavior and revealed he was unaware the wander guard system in the facility only functioned at the front door, stating he had assumed all of the exit doors were utilizing the wander guard alarm system. On 07/24/19 at 4:18 P.M., interview with LPN #18 revealed she was returning from giving report at the morning meeting, when she heard an alarm sounding at the nursing station. She stated she checked the alarm monitoring panel, located in the nursing station, which revealed an active alarm on the 200 hall. She stated she proceeded to the 200 hall sunroom, did not observe any residents, then notified STNA #10 of the alarm and asked her to go outside and look for any residents. LPN #18 was unsure who de-activated the alarm for the 200 hall door. During a telephone interview on 07/24/19 at 5:10 P.M. with Resident #20's daughter, the daughter revealed she was notified on 07/08/19 at approximately 10:10 A.M. that her mother had fallen and was being sent to the hospital. She stated she received a second call later, at approximately 11:30 A.M. notifying her that her mother had exited the facility unsupervised and a fall had occurred outside of the facility and her mother was injured. During the interview, Resident #20's daughter verbalized she felt her mother should have been more closely supervised and verified she sustained a neck [MEDICAL CONDITION] and C2 area as a result of the incident. The resident's daughter revealed following the fall and subsequent hospitalization , Resident #20 had sustained a significant decline in condition, was currently unable to walk, was unable to have any type of conversation, refused to eat and had lost 15 pounds. The resident's daughter also shared that the resident had been in excruciating pain since the incident occurred. Review of the facility's undated policy titled, Elopement-Residents at Risk revealed the facility would provide an elopement risk assessment of a resident to ensure optimal safety and clinical outcome. The process included consideration of chart documentation, staff reports/observations, family input as appropriate. Factors to be considered in assessing risk included but were not limited to, resident history, individual resident characteristics, environmental features and the match between the resident and the environment. If a resident attempted to leave the facility grounds, the nearest staff should intervene, provided they may leave their prior task without endangering another resident. If a resident was believed to have left the facility and whereabouts are currently unknown, the Missing Resident Policy and Procedure should be followed. The incident should be documented in the appropriate facility documentation as well as the resident's record. 2. Review of Resident #30's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to another long term care facility on 12/27/18. Review of the Elopement Risk Assessment, dated 09/12/18 revealed Resident #30 was assessed to be at high risk for elopement. Review of a physician's orders [REDACTED]. Review of the MDS assessment, dated 09/19/18 revealed a Brief Interview for Mental Status (BIMS) score of five, indicating the resident had severe cognitive impairment. The MDS further revealed the resident was monitored with a wander guard alarm. Review of the plan of care, dated 09/24/18 revealed the resident was at risk for elopement related to increased exit seeking behaviors with interventions including to notify the nurse and physician of increased agitation and attempts to leave the facility, to provide re-direction and one to one activities during periods of increased wandering and attempts to leave the facility without assistance, maintain code alert bracelet every day/every shift to alert staff of resident whereabouts. Review of a nursing progress note, dated 11/24/18, revealed Resident #30 opened the 200 hall (exterior) door several times, and at one point left the building and was assisted back inside per staff without incident. Review of the nursing progress notes revealed no information related to how long the resident was outside the facility, who assisted the resident back inside the facility, what the resident was wearing at the time of the incident and how the resident was able to exit the facility unsupervised. Review of the nursing progress note revealed no evidence the resident ' s family/responsible party was notified of the incident at the time it occurred. Record review revealed no evidence immediate interventions were implemented to prevent the resident from exiting the facility unsupervised. Review of a social services note, dated 11/26/18 revealed the resident was moved to a room on the 300 hall for safety due to increased exit seeking behaviors. Review of a nursing progress note, dated 12/01/18, revealed the resident was wandering into other residents' rooms and went out of the 300 hall door, was redirected back in with much encouragement. Record review revealed no new interventions were initiated following this incident to prevent the resident from wandering outside/exiting the facility unsupervised following this incident. In addition, there was no evidence the resident ' s family/responsible party were notified of this incident. Review of a nursing progress note, dated 12/17/18 revealed Resident #30 continued to wander up and down the hall, opened the door, then turned around, shut it, and came back in with assistance. The note stated the wander guard was on the ankle and was working. However, record review revealed no new interventions were initiated following this incident to prevent the resident from wandering outside the facility unsupervised and revealed no evidence of family notification following this incident. Review of a nursing progress note, dated 12/26/18 at 11:41 A.M. revealed Resident #30 exited the building, unsupervised, three times, at 9:30 A.M., 9:45 A.M., and 10:00 A.M., into an enclosed, fenced area at the end of the Emsley and(NAME)hallways. The (door) alarm sounded with each episode. The top of resident ' s right hand was observed to be swollen with purple, blue, and brown bruising noted and the resident complained of tenderness to the area. Record review revealed no new interventions were initiated following this incident to prevent the resident from wandering outside the facility unsupervised. There was no evidence the resident ' s first emergency contact was notified at the time of these incidents. Review of Resident #30's nursing progress note, dated 12/26/18 at 9:53 P.M., revealed a purple and blue colored bruise to the top of the right hand with swelling was noted, and bruising to the 2nd, 3rd, and 4th digits with darker blue bruising noted. The note indicated the resident had been brought back into the facility by therapy staff and STNAs. Review of Skin Incident Report, dated 12/26/18, revealed the resident came in from her third elopement and LPN #18 noted a purple, raised bruise on the top of the right hand likely the result of three elopements and hitting the door jamb on the way out. Review of Skin Incident Report, dated 12/27/18, revealed Resident #30 had a bruise to the top of the left foot, a bruise to the right knee, and a bruise to the top of the right hand, contributed to going outside three times on 12/26/18. Review of the Incident and Accident Log, from (MONTH) (YEAR) through (MONTH) 2019 failed to include any incidents of elopement or wandering outside the facility unsupervised (unsafe wandering behaviors) for Resident #30. During an interview on 07/24/19 at 9:55 A.M., DM #32 revealed the wander guard system did not properly function on any of the exterior hall doors, including on the 200 and 300 unit which was where Resident #30 resided during her stay. During interview on 07/24/19 at 11:11 A.M., Physician #100 verified Resident #30 had an order for [REDACTED]. During an interview on 07/25/19 at 9:03 A.M., the DON confirmed Resident #30 was ordered a wander guard due to exit seeking behavior and had exited the facility without staff supervision on 11/24/18, 12/01/18, 12/17/18 and 12/26/18. The DON confirmed an investigation was not completed following each of these exiting/wandering incidents and verified witness statements were not obtained from all witnesses, including STNA and therapy staff who were documented as bringing the resident back in to the facility to determine how the resident was able to exit the facility unsupervised, how long the resident had been outside the facility, the weather conditions at the time the resident exited the facility and the resident ' s condition at the time of each incident In addition there was no root cause determined for the exit-seeking behavior and incidents and no evidence safety interventions were initiated following each incident to prevent reoccurrence. This deficiency substantiates Complaint Number OH 885 and Complaint Number OH 802.

Based on observation, record review and interview the facility failed to ensure Resident #50 was provided adequate assistance during a transfer with a mechanical (Hoyer) lift resulting in a fall. Harm occurred when the lift sling pad placed under the resident for the transfer was not properly positioned causing the resident to slide out of the mechanical lift during a staff assisted transfer resulting in a fractured right humerus (arm) and subsequent increased pain to the resident. This affected one resident (Resident #50) of three residents reviewed for accidents. Findings include: Review of Resident #50's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/10/16 revealed Resident #50 had severe cognitive impairment and was dependent of two staff members with bed mobility, transfers, dressing, toilet use and personal hygiene. The resident was dependent on one staff member with locomotion and eating. Further review revealed the resident was incontinent of bowel and bladder and had impaired range of motion to both lower extremities. Resident #50 had no falls since the prior assessment period. Review of the fall risk assessment dated [DATE] identified Resident #50 was at high risk for falls. Review of the a plan of care related to self-care deficit with activities of daily living, initiated 09/23/13 revealed Resident #50 required the use of a mechanical (Hoyer) lift for transfers. The plan revealed this was per physical therapy recommendations for safety. Record review revealed staff had been using the Hoyer lift to transfer the resident since 11/25/14. The resident's plan of care was updated on 01/10/17 to reflect a fractured humerus. Review of the nursing progress notes, dated 12/25/16 at 1:30 P.M. revealed staff called the nurse to the resident's room where Resident #50 was found lying on the floor, more leaning onto her left side with her right upper extremity tucked to her side and her left upper extremity to her left side. The right lower extremity was stretched out and the left lower extremity was in a contracted position which was normal for the resident. Staff stated the resident got her arm caught in the Hoyer lift sling causing her to fall from the Hoyer while being transferred to the bed. Resident #50 also had skin tears to the left side of her neck and to her left forearm. The resident denied hitting her head and staff did not observe the resident hit her head. Resident #50 complained of right hip and leg pain. The resident was also noted to make moaning sounds. Resident #50 was moving her head around and a pillow was placed under the resident's head for comfort. Emergency transport was contacted as well as the resident's family and physician. Resident #50 was sent to the emergency room for evaluation. Further review of the nursing progress notes, dated 12/25/16 at 7:15 P.M. revealed Resident #50 returned to the facility via ambulance with a closed fracture at the proximal end of the humerus and the resident's right arm was in a sling. Additionally, on 12/28/16 Resident #50 had an appointment with an orthopedic doctor with orders to stop the sling to the right upper extremity, avoid lifting the resident by her right arm and to support the right upper extremity with pillows for pain control. The family was notified of the new orders. Review of the medication administration record from December 2016 to January 2017 revealed Resident #50 displayed signs of pain as well as verbalization of pain. The resident received as needed pain medication 22 times during the month of December 2016 and 22 times from 01/01/17 through 01/17/17. The resident's pain location was documented in her back and right arm due to a fracture. On 01/11/17 at 12:00 P.M. the primary care physician was notified of the resident having increased pain due to the fracture of the right humerus, not taking oral medications well and her intake decreasing. A new order for the narcotic analgesic, Roxanol which could be administered oral or sublingual was received to be given every hour as needed for pain. Review of the facility investigation revealed a staff interview with State tested Nursing Assistant (STNA) #104. STNA #104 revealed she was lifting Resident #50 out of the chair with the mechanical lift when she noticed the resident was slipping. She started to lower Resident #50 back into the chair but the resident slipped out and her right arm stopped her. STNA #104 used her body to lower Resident #50 to the floor and got staff assistance. Review of the documented interview with STNA #104 dated 12/27/16, with the DON , revealed Resident #50 slid out of the bottom of the mechanical lift pad. STNA #104 went to her knee with the resident landing on her bottom and the STNA catching the resident's upper body on her lap. The lift and pad were functioning properly but the resident had not been centered on the pad when lifted. On 01/17/17 at 12:45 P.M. Resident #50 was observed in a specialized tilt and space wheelchair with her daughter present. The resident's daughter was observed pushing her in the wheelchair. On 01/17/17 at 1:00 P.M. interview with the DON verified Resident #50, who was dependent on staff for transferring via a Hoyer lift, fell out of the lift sling during a staff assisted transfer. The DON indicated the sling was not centered under the resident at the time of the transfer which contributed to the fall. Although the MDS 3.0 assessment, dated 10/10/16 assessed the resident to require two staff for transfers, the facility's current plan of care for transferring revealed Resident #50 was dependent on one to two staff for transfers and manufacturer information for the use of the Hoyer lift reflected the lift could be operated by one staff. There was no additional information contained in the resident's plan of care as to when it was necessary to have two staff to transfer the resident or when only one staff was required. On 01/17/17 at 1:53 P.M. interview with STNA #104 revealed she had been employed at the facility almost three months and was working the day Resident #50 fell from the mechanical sling lift. STNA #104 indicated another STNA was providing incontinence care to another resident so STNA #104 began to assist residents to bed. STNA #104 indicated Resident #50 was up in her wheel chair with the sling lift pad already under her when she arrived to her room. STNA #104 stated she was unsure who placed the sling lift pad under the resident because the resident was already up in her chair when STNA #104 started her shift at 7:00 A.M. on 12/25/16. STNA #104 indicated when she had Resident #50 lifted up in the mechanical lift; more of the lift pad was under her left side than her right which caused the resident to tilt to her right in the mechanical sling lift. The resident began to slide out of the sling pad and when STNA #104 reached Resident #50 her lower body was out of the sling and STNA #104 assisted the resident to the floor. Resident #50's right arm remained in the sling lift while the rest of her body was on the floor. STNA #104 stated she removed the resident's arm from the sling lift pad, ensured Resident #50 was safe and then went to get the nurse. Additionally, STNA #104 indicated the sling lift pad was the correct size for the resident but was not centered under the resident. STNA #104 indicated she was responsible to make sure the sling lift pad was under the resident correctly before she used the lift. This is an example of Past Noncompliance This deficiency substantiates Complaint Number OH 960.

Based on observation, record review, staff interview, and policy review the facility failed to prevent, assess, and provide physician notification of pressure ulcers development in a timely manner. This affected one resident (Resident #135) of four residents reviewed for pressure ulcers. Harm occurred when Resident #135, who was identified at high risk for pressure ulcer development and was a two person extensive assist with bed mobility, developed an unstageable pressure ulcer to the left heel without evidence adequate pressure reducing interventions were in place prior to the development. The facility failed to ensure timely monitoring and evidence of the implementation of pressure reducing/relieving measures to prevent the development of additional pressure ulcers to the coccyx/buttocks area. Findings include: Review of Resident #135's medical record revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #135's admission skin inspection dated 02/15/16 revealed Resident #135 had a scab on left forearm, scattered bruising on arms, and [MEDICAL CONDITION] on bilateral lower extremities. Review of Resident #135 Braden Scale risk assessment dated [DATE] to 04/13/16 indicated Resident #135 was at very high risk for pressure ulcers. Review of Resident #135's care plan dated 02/16/16 revealed Resident #135 had a potential for alteration of skin integrity related to pain, decreased tissue/lean body mass, impaired/decreased mobility and dementia. Further review revealed on 02/26/16 Resident #135 was encouraged to reposition every two hours and as needed, monitor for tissue tolerance and notify the charge nurse, offer alternatives if refusal of meals/fluids, notify dietary associates and skin nurse of low [MEDICATION NAME]/[MEDICATION NAME], pressure mattress, elevate head of bed, notify skin nurse of any changes, pressure redistributing seating, weekly skin checks, report alterations to doctor and skin nurse, observe for any alterations during routine care and report to nurse. Review of Resident #135's admission orders [REDACTED]. Review of progress notes dated 02/18/16 and 02/22/16 revealed Resident #135's feet were tender. The note indicated the resident required extensive assistance with bed mobility. Further review revealed no evidence of any new skin interventions or preventive pressure reducing/relieving measures implemented at that time. Review of Resident #135 treatment administration record (TAR) dated 02/2016 revealed the weekly skin assessment was only performed once on admission. The TAR indicated the skin assessments were to be performed on 02/22/16 and 02/29/16 which were blank. Further review revealed treatments indicated for pressure reducing mattress and a pressure reducing cushion when up. Review of the progress note dated 03/09/16 revealed a state tested nursing assistant (STNA) reported Resident #135 had an area measuring 6.2 centimeters (cm) by 6.0 cm to left heel with a small amount of dark drainage from the heel. The area was cleansed with normal saline, skin prep was applied and heels off loaded with heel protectors. Review of the progress note from the wound nurse dated 03/09/16 revealed the wound to the left heel was consistent with an unstageable deep tissue injury (DTI) and measured 4.8 cm by 6.1 cm. The resident was noted to have slight pain and discomfort noted during treatment. The area was intact and maroon in color, margins were regular, periwound skin was fragile and dry. Recommend skin prep twice daily and bilateral heel boots. On 03/17/16 a wound was noted above the resident's left ankle and was consistent with a Stage I (reddened non-blanchable area of intact skin) pressure area. The area measured 9.9 cm by 1.0 cm and depth was unable to be determined. Wound was assessed to be intact, pink, and non-blanchable. Recommended dermagram ointment to the area twice daily. A wound was also noted on the resident's right buttock, assessed to be a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough) pressure ulcer and measured 2.0 cm by 1.5 cm by 0.1 cm. Recommended cleansing with wound cleanser and apply [MEDICATION NAME] every 3 days and as needed. Review of wound care clinic notes dated 03/25/16 revealed Resident #135 had necrotic left heel ulcers that looked like pressure type [MEDICAL CONDITION]. The wound clinic debrided a little skin flap sharply. The note indicated no debridement was done over the calcaneus area, as this would never heal, there would be bone coming out that would probably just continue to lead toward an amputation. Review of wound note dated 03/29/16 revealed the resident's left heel was unstageable and measured 8.0 cm by 6.0 cm. The wound was assessed to be partially dark purple and partially an intact blister, wound margins are irregular, skin is fragile, continue with treatments. Interview with Licensed Practical Nurse (LPN) #59 on 04/11/16 at 2:44 P.M. verified Resident #135, who was dependent on staff for bed mobility and activity of daily living care developed an unstageable pressure ulcer to left heel and a Stage II pressure ulcer to the buttocks. Observation of Resident #135 with LPN #54 on 04/13/16 at 3:16 P.M. revealed the resident's left heel was completely black. Further observation revealed two dressings were noted on the resident's buttocks. One dressing was noted on the right outer buttocks dated 04/06/16 and the other one was noted on the right inner right buttock and was dated 04/09/16. There were also two new pressure ulcer areas observed on the right buttocks and one on the right gluteal fold at that time. LPN #54 revealed she was only aware of the one area on the right buttocks that was dated 04/06/16. LPN #54 verified there were no physician orders for treatment, no assessments, or evidence the physician was notified of the pressure ulcer associated with the dressing dated 04/09/16. LPN #54 verified she would assess the area dated 04/09/16 and the two new areas and notify the physician. Review of Resident #135 skin alteration records dated 04/13/16 revealed a Stage II on the right gluteal fold measuring 0.5 cm by 1.9 cm by 0.1 and Stage II on the coccyx measuring 0.3 cm by 0.5 cm by 0.1 cm. Review of physician orders, obtained 04/13/16 revealed to discontinue soft heel boots and heel cushions. New orders for bilateral Prevalon boots to be worn at all times except when care was provided. Treatment orders were obtained to cleanse right gluteal area and coccyx with wound cleanser, apply [MEDICATION NAME] and change every three days and as needed. And to apply chamosyn cream topically every shift and as needed with incontinent care. Review of progress notes dated 04/13/16 revealed Resident #135 currently had a left heel pressure ulcer that was unstageable due to necrotic covering measuring 4.2 cm by 5.8 cm. Wound margins were irregular, and periwound skin was fragile. A pressure ulcer to the coccyx, assessed to be a Stage II measuring 0.3 cm by 0.5 cm by 0.1 cm with wound margins regular, periwound skin was fragile. A new pressure ulcer to the right gluteal folds was assessed to be a Stage II pressure ulcer and measured 0.5 cm by 1.9 cm by 0.1 cm with wound bed pink, margins regular, and periwound skin fragile. A new pressure ulcer to the sacrum assessed to be a Stage I, measuring 1.1 cm by 0.3 cm. The area on the right buttocks that had not been previously documented on documented as being resolved on this date. Interview with the Director of Nursing (DON) on 04/14/16 at 1:35 P.M. verified Resident #135 was at high risk for pressure and required extensive assistance of two staff for bed mobility. The DON verified the weekly skin assessments on the TAR were not completed on 02/22/16 and 02/29/16. The DON verified the treatment observed on Resident #135's coccyx dated 04/09/16 had no evidence of assessment, physician orders for treatment, or evidence the physician was notified of area at the time it developed. The DON verified Resident #135 had developed the above identified pressure ulcers while residing in the facility. Review of the facility pressure ulcer definition and staging policy undated revealed a Stage 1 was intact skin with non-blanchable redness of localized area usually over bony promise. Stage 2 was partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. Suspected deep tissue injury was a purple or maroon localized are of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure/shearing. Unstageable was a full thickness loss in which the base of the ulcer is covered by slough in the wound bed.

Based on medical record review and staff interview, the facility failed to monitor blood pressures for a resident receiving anti-hypertensive medications in regard to potential adverse reaction. This affected one of five residents reviewed for medication monitoring (Resident #33). The census was 95. Harm occurred when Resident #33 was administered anti-hypertensive medication without adequate blood pressure monitoring and the resident was admitted to the hospital secondary to hypovolemic shock. Findings include: 1. Review of Resident #33's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the August 2013 monthly Physician order [REDACTED]. On 08/08/13 at 12:00 P.M. per the vital signs history, the oral temperature (T) was 97.7 degree's Fahrenheit (F), Pulse (P) 60, Respirations (R) 18 and Blood Pressure (B/P) 102/60 millimeters of Mercury (mmHg). On 08/27/13 at 1:54 P.M. T 97.3, P 71, R 16, B/P 83/47 mmHg. There was no documentation in the medical record of follow up assessment or notification of Resident #33 primary care physician (PCP) regarding the low B/P reading. On 08/30/13 at 12:00 P.M. T 97.3, P 65, R 20, B/P 86/59. There was no documentation in the medical record of follow up assessment or notification of Resident #33's PCP. No other vital signs were located in the vital signs history. Review of the Initial Medication Review from the pharmacy dated 08/08/13 and 08/09/13 did not indicate the need to obtain anti-hypertensive administration parameters from the physician or how frequently to monitor the resident's B/P while receiving anti-hypertensive medications. Review of the Nurses' Progress Note dated 09/02/13 at 11:00 A.M., the writer was called to Resident #33 room for report of the resident not looking good. The resident was sitting up in bed. Skin was cool, dry, fleshtone. No [MEDICAL CONDITION]/swelling. Denied nausea, pain or feeling dizzy. Per the Nurses' Progress note, staff were unable to obtain a B/P per machine or manual cuff. Doppler BP was 58, P was 78 and the resident's T was 95 degrees F. The resident had received the anti-hypertensive's as ordered. On 09/02/13 at 11:25 A.M., the PCP was updated and ordered to send the resident to the emergency room (ER). On 09/02/13 at 11:43 A.M., Resident #33 was transferred to the hospital and was admitted with severe [MEDICAL CONDITION], hypovolemic shock, severe dehydration, acute kidney injury and dementia. Review of the History and Physical (H&P) from the hospital dated 09/02/13 revealed the resident was lethargic upon arrival to the ER, poor appetite and had not been eating or drinking for some time. The resident was very dry. Urine output was less than 100 cubic centimeters (cc) at that time. BP ranging from 54/36 mmHg to 80/52 mmHg. Oral mucosa was dry with decreased skin turgor. Interview with Registered Nurse (RN) #12 on 10/02/13 at 11:40 A.M. revealed the only documented vital signs in the Nurses Notes were for 08/08/13, 08/27/13 and 08/30/13 except for the vital signs upon transfer to the hospital and that no other vital signs were documented on the Medication Administration Record (MAR). Interview with Licensed Practical Nurse (LPN) #7 on 10/03/13 at 11:10 AM revealed staff should call the physician if no parameters were provided regarding when to administer the anti-hypertensive medications and the resident's B/P was low. Interview with Resident #33's Primary Care Physician (PCP), also the facility's medical director, on 10/03/13 at 1:27 P.M. revealed the resident's low B/P and decreased intakes warranted a call to the PCP or the on-call physician in his absence. The PCP stated he was available for calls on Sunday, 09/01/13 and he had spoken with the facility three times on that date. He stated the staff did not discuss Resident #33 weight loss, fluid intakes or low B/P's at that time. The PCP stated the hospitalization may have been avoided had he been updated regarding the resident's condition timely. Interview with the Administrator, Director of Nursing and Registered Nurse (RN) #10 on 10/03/13 at 1:50 P.M. verified the lack of documentation of notification for Resident #33's low B/P readings . The interview also verified no doses of the anti-hypertensive medications were held due to low B/P.

Based on medical record review and staff interview, the facility failed to ensure residents received adequate hydration. This affected one of one resident sampled for hydration (Resident #33). The census was 95. Harm occurred when Resident #33 who had a history of [REDACTED]. Findings include: Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 required set-up help and supervision with eating. Review of the Dietary Plan of Care (POC) dated 08/13/13 revealed to monitor meal and intake and output. Monitor diet preferences and offer substitute as needed. Review of the Dietary Progress notes dated 08/12/13 revealed intakes were poor. Resident #33 had a history of [REDACTED]. The resident required 2100 cubic centimeters (cc) of fluid based on the Average Body Weight of 69 kilograms (156 pounds). Review of the Dietician's Progress Note dated 08/29/13 revealed Resident #33 was with a high nutritional risk score. Intakes were still poor but improved since admission. The progress note indicated staff were aware of the resident's history of dehydration and would encourage more fluids. Review of Resident #33's 24 hour total fluid intakes dated 08/08/13 through 09/02/13 revealed: a. On 08/08/13, there was no documentation of fluid intake. b. On 08/09/13, 360 cc's for 24 hour intake. c. On 08/10/13, intake was 480 cc's. d. On 08/11/13, intake was 720 cc's. e. On 08/12/13, intake was 720 cc's. f. On 08/13/13, intake was 240 cc's. g. On 08/14/13, intake was 480 cc's. h. On 08/15/13, no documentation of fluid intake. I. On 08/16/13, 840 cc's of fluid was consumed in the 24 hour intake period. j. On 08/18/13, intake was 840 cc's. k. On 08/19/13, intake was 288 cc's. l. On 08/20/13, intake was 720 cc's. m. On 08/21/13, no documentation of fluid intake was available. n. On 08/22/13, 920 cc's was consumed. o. On 08/23/13, no documentation of fluid intake was available. p. On 08/24/13, according to the fluid intake documentation, 1000 cc's was consumed. q. On 08/25/13, 340 cc's was documented as consumed. r. On 08/26/13, 720 cc's were consumed. s. On 08/27/13, the intake was 600 cc's. t. On 08/28/13, the intake was documented as 540 cc's. u. On 08/29/13, 480 cc's were consumed. v. On 08/30/13, the intake was 120 cc's. w. On 08/31/13, the intake for the 24 hour period was 1300 cc's. x. On 09/01/13, 240 cc's were consumed. y. On 09/02/13, the resident was sent to the emergency room . Review of Resident #33's vital signs revealed the following: a. On 08/08/13 at 12:00 P.M. per the vital signs history, the oral temperature (T) was 97.7 degree's Fahrenheit (F), Pulse (P) 60, Respirations (R) 18 and Blood Pressure (B/P) 102/60 millimeters of mercury (mmHg). b. On 08/27/13 at 1:54 P.M., T 97.3 , P 71, R 16, B/P 83/47 mmHg. There was no documentation in the medical record of follow up assessment or notification of Resident #33 primary care physician (PCP). On 08/30/13 at 12:00 P.M. T 97.3 , P 65, R 20, B/P 86/59 mmHg. There was no documentation in the medical record of follow up assessment or notification of Resident #33's PCP. No other vital signs were located in the vital signs history of the medical record. On 08/30/13 at 12:00 P.M., the State tested nurse aide reported to the nurse that Resident #33 was having discomfort. The resident was slumped to the left side, lying in bed. The resident was repositioned and the head of the bed was lowered. The resident stated she felt better. Per the Nurses's Progress note on 08/30/13, Resident #33 denied further pain or discomfort. Resident #33 had a B/P of 86/59 mmHg. Review of the Nurses' Progress Note dated 09/02/13 at 11:00 A.M., the writer was called to Resident #33's room for report of the resident not looking good. The resident was sitting up in bed. Her skin was cool, dry, fleshtone. No [MEDICAL CONDITION]/swelling. Denied nausea, pain or feeling dizzy. Per the Nurses' Progress note, staff were unable to obtain a B/P per machine or manual cuff. Doppler BP was 58, P was 78 and the resident's T was 95 degrees F. On 09/02/13 at 11:25 A.M., the PCP was updated and ordered to send to the resident to the emergency room (ER). On 09/02/13 at 11:43 A.M., Resident #33 was transferred to the hospital and was admitted with severe [MEDICAL CONDITION], hypovolemic shock, severe dehydration, acute kidney injury and dementia. The medical record lacked documentation of the resident's hydration status. There was no documentation regarding the resident's skin turgor, mucus membranes or addressment of the resident's low fluid intakes. Review of the transport documentation from 09/02/13 from the facility to the emergency room (ER) revealed the primary impression was hypovolemic shock, with a BP 60/40 mmHg. A second set of vitals signs were attempted during transport but were unable to auscultate BP. Review of the History and Physical (H&P) from hospital dated 09/02/13 revealed the resident was lethargic upon arrival to the ER, poor appetite and had not been eating or drinking for some time. The resident was very dry. Urine output was less than 100 cc at that time. BP ranging from 54/36 to 80/52 mmHg. Oral mucosa was dry with decreased skin turgor. Interview with the Dietary technician on 10/02/13 at 11:30 AM verified fluid and meal intakes were documented on the Activity of Daily Living (ADL) Data Report and what were documented on the ADL Data Report were the only intakes recorded for Resident #33. Interview with Registered Dietician (RD) #1 on 10/03/13 at 11:21 AM verified only two interventions were documented initially pertaining to the resident's history and risk for dehydration. RD #1 verified the resident was not receiving enough fluid to prevent dehydration and that hypovolemic shock could be an indication of not enough fluid or excessive urination/output. Interview with Resident #33's primary care physician (PCP) who was also the facility's medical director, on 10/03/13 at 1:27 P.M. revealed the resident's decreased intakes warranted a call to him or the on-call physician in his absence. The PCP stated he was not aware of the information contained in the fax dated 08/30/13 as he was out of his office and was not due to return until Tuesday 09/03/13. The PCP stated he was available for calls on Sunday 09/01/13 and he spoke with the facility three times on that date. He stated staff did not discuss Resident #33 weight loss, fluid intakes or low blood pressures at that time. The PCP stated the hospitalization may have been avoided had he been updated on the resident's condition timely. Interview with the Administrator, Director of Nursing and Registered Nurse (RN) #10 on 10/03/13 at 1:50 P.M. verified the lack of documentation of notification for Resident #33 with low blood pressure readings and fluid intakes. The interview also verified there were no other fluid intakes recorded other than the ones documented on the ADL Data Record.