Every finding on record at Continuing Healthcare at Cedar Hill

Based on resident interviews, staff interviews, review of mealtimes, and review of dietary schedules, the facility failed to ensure evening meals were served at normal times due to adequate and qualified staff. This had the potential to affect all 21 residents residing on the back East Hall. The facility census was 79.Findings include: Interview on 06/28/26 at 9:30 A.M. with Resident # 42 revealed meals are never served on time and on 06/26/26 dinner was not served until 9:00 P.M. Interview on 06/28/26 at 10 :00 A.M. with Resident # 35 revealed meals have been late for two weeks. Interview on 06/29/26 at 2:30 P.M. with Dietary Aide # 451 revealed she had only employed at the facility since last week and on 06/26/26 Dietary Manager #551 had to stay over to help until 8:00 P.M. Interview on 06/29/26 at 2:43 P.M. with Dietary Manager #551 verified on 06/26/26 the evening dinner trays did not get delivered until 7:00 P.M. and it was outside the normal meal timeframe. She stated there was no reason why specifically just running behind, she was working with two new employees who just started that week. Review of the dietary staffing sheet dated 06/26/26 revealed the Dietary Manager #551 was scheduled 6:00 A.M. to 2:00 P.M. and from 12:00 P.M. to 7:30 P.M. two employees were scheduled; Dietary Aide #451 and Dietary Aide # 651. Review of the facility document titled Meal Times undated, revealed the facility served breakfast between 7:00 A.M. and 8:20 A.M., lunch between 11:00 A.M. and 12:20 P.M., and dinner between 4:30 P.M. and 5:50 P.M.

Based on observation, interview, product information review, and policy review, the facility failed to ensure multi-use insulin vials and insulin flex pens stored in the medication administration carts were properly dated, stored, and/ or discarded when needed. This affected four residents (Resident #9, #35, #68, and #70), who had their insulin stored in the medication administration cart for the East Back Hall. The facility also failed to ensure medications were stored securely, this affected three resident (#35, #12 and # 65), who were observed to have medication/wound treatment at the bedside. This had the potential to affect four residents (Resident #13, #36, #67, and #73) on the East Hall and five residents, (#2, #25, #34, #48, and #57) on the secured behavioral unit who were cognitively impaired and identified as independent with ambulation or mobile in wheelchairs. The facility census was 79. Findings include: 1.) On 07/01/26 at 10:35 A.M., an observation was made of the East Back Hall medication administration cart for the proper storage and labeling of medications. Regestered Nurse (RN) #160 was present and observed the surveyor go through the medication cart looking for any unlabeled or expired medications. Several insulin vials and one insulin flex pen were found in the small pull out drawer on the upper right side of the medication cart that were not dated when first accessed, not stored in the refrigerator before being first accessed, or had not been discarded after 28 days of being used as required. Findings as followed: 1 a.) Resident #70 was noted to have a multi-use vial of Lantus (slow acting insulin injection) 100 units/ milliliter (ml) in the top of the medication administration cart that had an access date of 05/12/26. The Lantus was not discarded after 28 days following first use as required. Findings were verified by RN #160. 1 b.) Resident #9 was noted to have a multi-use vial of Lantus 100 units/ ml in the top drawer of the medication administration cart that had been accessed with no date when that first access occurred. Findings verified by RN #160. An interview with RN #160 at the time of the observation confirmed, without a date indicating when the vial was first accessed, they would not know when the vial needed to be discarded. She believed they had 28 days or so that the vial could be used, after being first accessed, and when needing to discard the remainder of the medication being stored at room temperature. 1 c.) Resident #35 was noted to have a vial of Insulin Lispro (fast acting insulin injection) 200 units/ ml in the top drawer of the medication administration cart. There was a date that indicated the vial was first accessed on 05/12/26. Findings were verified by RN #160. She confirmed the insulin had not been discarded after 28 days of it first being used. 1 d.) Resident #68 was noted to have a Novolog Flex pen stored in the top of the medication administration cart. The flex pen had not been used and there was no date to indicate when it had been removed out of the refrigerator. The plastic bag the flexpen was stored in provided instructions to refrigerate until used. Findings were verified with RN #160 that the flexpen should have been stored in the refrigerator until used. Review of a package insert that came with the Lantus insulin revised May 2025 revealed, after Lantus vials had been opened (in-use) they could be stored in the refrigerator between 36 degrees Fahrenheit (F.) to 46 degrees Fahrenheit (F). or at room temperature below 86 degrees F. for up to 28 days. The Lantus bottle being used should be thrown away after 28 days, or if the expiration date has passed, even if it still had insulin left in it. The facility denied they had any product information that was sent to them from the pharmacy for the Insulin Lispro. Review of drug information from MedScape for Insulin Lispro revealed the 3 ml Solostar pens (flexpens) should be refrigerated at 36- 46 degrees F. until the expiration date or at room temperature for up to 28 days. Opened (used) 3 ml flexpens should be stored at room temperature (less than 86 degrees F.) for up to 28 days. 2.Review of the medical record for Resident #35 revealed an admission date of 06/12/21 with diagnoses including heart failure, Type II Diabetes Mellitus, generalized anxiety disorder, major depressive disorder, and mild cognitive impairment. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact.Observation on 06/29/26 at 9:29 A.M. of medications on bedside table in a cup crushed in applesauce. Review of the physician orders revealed Resident #35 did not have an order to self-administer medications or for medications to be left at bedside. Interview on 06/29/26 at 9:35 A.M. with Licensed Practical Nurse (LPN) # 256 revealed she prepared Resident #35's medications. LPN #256 confirmed she left the medications on the bedside table and further confirmed Resident #35 does not have an order for self-administration or for medications to be left at bedside. Review of the updated facility policy titled Administration and Documentation of Medications dated April 2026, revealed it is the policy of this facility that every resident receives medications by a licensed nurse as prescribed by a licensed physician or other healthcare provider legally permitted to prescribe medications safely, properly and in a timely manner, and that medications shall be accurately and completely documented. 3. Review of Resident #12's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia, major depressive disorder, conduct disorder, history of suicidal ideations, adult-onset diabetes mellitus, obstructive and reflux uropathy, and chronic osteomyelitis (bone infection) of the left foot and ankle. Review of Resident #12's physician's orders revealed he had treatment orders in place to receive suprapubic catheter care every shift. The treatment included cleansing the suprapubic site with normal saline solution and covering the site with a drain sponge daily. No other treatment orders were noted to be in effect. On 06/28/2026 at 1:04 P.M. an observation of Resident #12's room noted him treatment supplies in his room on the window sill next to his bed. The treatment supplies included a 437 milliliter bottle of Dakin's solution (a diluted, hospital-grade bleach mixture used as an antiseptic to clean wounds) at 1/4 strength. On 06/30/26 at 9:05 A.M., a follow up observation of Resident #12's room revealed he continued to have treatment supplies sitting on the windowsill next to his bed. Dakin's solution was still on the window sill and he was also noted to have a tube of Clotrimazole Cream 1-0.05% sitting on the same window sill. An interview with the resident at the time of the observation revealed he was not sure why the treatment supplies were left in his room and denied that he had requested them to be there. He suspected they were left in his room for staff convenience. On 06/30/26 at 9:07 A.M., an interview with RN #160 revealed treatment supplies should not be stored in a resident's room and should be kept in the treatment cart when not in use. The nurse was observed to remove the treatment supplies from the resident's room, after she had been made aware. Review of a Minimum Safety Data Sheet (MSDS) for Dakin's Solution Products Wound Clenz revealed it's active ingredient was Sodium Hypochlorite (bleach). A warning label advised not to take internally and it was for external use only. If swallowed, the MSDS advised to get medical help or contact Poison Control Center right away. Review of the MSDS for Clotrimazole revealed the medicated cream was indicated for the topical treatment of candidiasis (fungal infection of the skin). First aid measures for exposure of the eyes included immediately flushing the eyes with plenty of water for at least 15 minutes. For ingestion, it was suggested to not induce vomiting unless directed to do so by medical personnel. If large quantities of that material were swallowed, it was advised to call a physician immediately. 4. Review of Resident #65 's medical record revealed an admission date of 03/24/2026. Diagnoses included fractures of lumbar/thoracic vertebrae, Type II Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD), asthma, hypertension, and hyperlipidemia. Review of the wound provider note dated 06/23/2026 revealed the resident was evaluated for a diabetic ulcer to the right lateral foot. The note documented the resident was cooperative and consented to care, was alert and oriented, comfortable, and in no acute distress. The wound status was documented as improved/healing. The note indicated the orders for treatment were Dakin's solution cleanser, collagen as the primary dressing, ABD pad and wrap with Kerlix as the secondary dressing, and daily and PRN frequency.Observation on 06/28/26 at 10:32 A.M. revealed wound treatment supplies/medications were sitting out on the nightstand in Resident #65's room. The supplies/medications included Dakin's Solution 0.125% / 1/4 strength, Triad Hydrophilic Wound Dressing Paste, and Nystatin Cream 100,000 units/gm. The supplies/medications were accessible in the resident room at the time of the observation.Review of Resident #65's physician orders revealed Dakin's Solution was ordered to be applied to the right foot topically every night shift for wound treatment. Triad Hydrophilic Wound Dressing Paste was ordered to be applied to the buttocks topically every shift for skin breakdown. Nystatin Cream was ordered to be applied to the buttocks and right axilla topically every shift for excoriation.Review of the product labeling for Dakin's Solution, Triad Hydrophilic Wound Dressing Paste, and Nystatin Cream revealed the products stated to keep out of reach of children.During the observation on 06/28/26 at 10:32 A.M., Certified Nurse Aide (CNA) #553 and CNA #153 acknowledged the wound treatment supplies/medications were sitting out in Resident #65's room and were available for easy access. CNA #153 confirmed this was a concern due to multiple residents residing on the secured behavioral unit who were independently ambulatory and had cognitive impairment. CNA #153 removed the wound treatment supplies/medications from Resident #65's room and took them to the nurse to be secured.Review of the facility's policy on Medication Storage reviewed May 2025 revealed the facility should store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff should be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The facility should not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs should be returned to the dispensing pharmacy or destroyed. Medications must be stored in temperature in accordance with manufacturer's specifications.

Based on record review, interview and facility policy review, the facility failed to ensure one resident (#70) with cognitive impairment was supervised while leaving the facility resulting in a fall in the parking lot. This affected one resident of seven reviewed for accidents. The facility also failed to ensure fall prevention interventions were implemented as care planned for Resident #10 and #29. The facility census was 79.Findings Include: 1.Review of Resident #70's medical record revealed an admission date of 03/30/26 with diagnoses that included acute diastolic (congestive) heart failure, Type II Diabetes Mellitus without complications, schizoaffective disorder, depression, anxiety and repeated falls. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed moderate cognitive impairment. He had no impairment to his upper or lower extremities and required partial to moderate assistance with ambulation. Review of the fall risk assessment dated [DATE] revealed he was at moderate risk for falls. Review of the care plan for Resident #70 dated 04/03/26 revealed he had an Activities of Daily Living (ADL) self-care performance deficit related to high-risk medication, falls, schizophrenia and depression. Interventions included resident transfers with physical assist of one staff member. Review of the care plan dated 03/30/26 revealed Resident #70 was at high risk for falls and potential injury related to history of falls and high-risk medication use. Interventions included education provided to sign out with nurse when going outside dated 06/22/26. Review of the facility fall investigation dated 06/22/26 at 8:45 A.M., Resident #70 was seen by assisted living staff falling in the parking lot. He stated he was going to the gas station and complained of right hip and right shoulder pain and was subsequently sent to the emergency room. He returned to the facility on [DATE] and suffered superficial abrasions. Interview on 06/30/26 at 10:33 A.M. with Director of Rehab #168 revealed at the time of Resident #70's fall according to his therapy Discharge summary dated [DATE], his balance was fair with the use of a rollator, transfers was moderate to supervision with assistive device/rollator, he ambulated 100-200 feet with a rollator and required standing recovery periods and supervision due to shortness of breath. He should have been supervised with ambulation and he was not safe to leave the building on his own. Interview on 06/30/26 at 11:03 A.M. with Certified Nursing Assistant (CNA) #164 revealed Resident #70 should not go outside unsupervised, he would get short of breath walking to the bathroom. CNA # 164 verified the Kardex for Resident #70 stated th resident required physical assist of one person. 2. Review of the medical record for Resident #10 revealed an admission date of 09/09/16 with diagnoses including cerebral infarction, syncope and collapse, anxiety disorder, nontraumatic subdural hemorrhage, traumatic subdural hemorrhage with loss of consciousness, dementia and age-related osteoporosis without current pathological fractures. Review of Resident #10's care plan dated 02/26/21 revealed she was at risk for falls and potential injury related to dementia, decreased safety awareness and syncope and collapse. She will take self to bathroom without using the call light for assistance. Interventions included but not limited to bright colored tape to call light dated 03/25/26. Review of the facility fall investigation dated 03/25/26 at 6:00 A.M. revealed Resident #10 fell out of bed and received a skin tear to left arm. Intervention added bright colored tape to call light. Subsequent review of Resident #10's medical record revealed a progress note dated 03/25/26 at 6:56 A.M., resident fell out of bed and was seen lying on left side partially under bed. She complained of pain to the left hip and was transferred to the emergency room for evaluation. She returned on 03/27/26 with no injuries. Review of the fall risk assessment dated [DATE] revealed Resident #10 was at high risk for falls. Observation and interview on 06/28/26 at 10:47 A.M. of Resident #10's call light wrapped around her grab bar on the bed near the wall and resident unable to reach it. No bright colored tape was observed on the call light. Licensed Practical Nurse (LPN) # 654 verified resident could not reach her call light and no bright colored tape to the call light. 3. Review of Resident #29's medical record revealed an admission date of07/31/22, a re-entry date of 06/28/24 and diagnoses including fracture of upper end of right humerus, dementia, chronic diastolic (congestive) heart failure, chronic kidney disease stage five, paroxysmal atrial fibrillation, Alzheimer's disease, anxiety disorder, and hypertension. Review of Resident #29's fall care plan initiated 08/09/22 revealed the resident was at risk for falls related to gait and balance problems and had an intervention dated 08/29/25 for grip strips to the floor on bilateral sides of the bed. Review of Resident #29's quarterly Minimum Data Set (MDS), dated [DATE] revealed a brief interview for mental status score of nine indicating the resident had moderate cognitive impairment. Further review of the MDS revealed the resident utilized a walker and a wheelchair for mobility and required partial/moderate assist with toileting hygiene and was occasionally incontinent of bladder. An observation of Resident #29's room on 06/30/26 at 10:20 A.M. revealed there were no grip strips on the floor in the resident's room. An observation of Resident #29's room on 06/30/26 at 10:30 A.M. revealed there were no grip strips on the floor in the resident's room. In an interview on 06/30/26 at 10:30 A.M. the Director of Nursing (DON) verified the grip strips were not on the floor as indicated on the care plan. In an interview on 06/30/26 at 10:45 A.M. Licensed Practical Nurse (LPN) #454 stated she had seen Resident #29 kick at or scuff his foot over the strips when they were on the floor but had not seen him try to remove them. In an interview on 06/30/26 at 10:50 A.M. Certified Nursing Assistant (CNA) #159 stated she had not seen Resident #29 try to remove the grip strips from his floor and was not aware that they were not on the floor. In an interview on 06/30/26 at 10:55 A.M. Housekeeper #365 stated Resident#29 was usually out of his room when she cleaned it so she had not seen him try to remove the strips. Housekeeper #365 further stated she had not even noticed that the strips were not in place when she cleaned his room earlier that morning. In an interview on 07/01/26 at 9:25 A.M. the Regional Maintenance Director stated the grip strips had been on the floor and there was no way the resident would have been able to remove them as they are very sticky and require a utility knife or scrapper to get them off of the floor. Review of the facility policy titled Fall Policy dated August 2025, revealed it is the policy of this facility to assure proper review of resident fall risk and implementation of interventions to attempt to prevent or reduce falls/accidents and injuries related to falls.

Based on observation and staff interview, the facility failed to clean dishes in a safe and sanitary manner. This affected all 79 residents residing at the facility. Findings include:Observation on 06/29/26 at 10:02 A.M. with Regional Dietary Manager #468 of the dishwasher cycles revealed wash temperature of 160 Fahrenheit (F) and rinse temperature of 150 F. She ran five more cycles and temperatures still did not meet minimum requirements.Review of the dishwasher logs for December 2025 revealed on 12/26/25 the breakfast wash cycle was 138 F.No dishwasher logs for January 2026.Review of the dishwasher logs for February 2026 revealed wash cycles on 02/01/26, 02/02/26, 02/04/26, 02/05/26, 02/07/26, 02/09/26, 02/10/26, 02/12/26, 02/15/26, 02/16/26, 02/17/26, 02/18/26, 02/19/26, 02/21/26, 02/22/26, 02/24/26, 02/26/226 did not meet minimum temperature requirement of 150 F.No dishwasher logs for March 2026.Review of the dishwasher logs for April 2026 revealed wash cycles on 04/22/26 did not meet minimum requirement of 150 F; and rinse cycles on 04/03/26 and 04/22/26 did not meet minimum requirement of 180 F.Review of the dishwasher logs for May 2026 revealed wash cycles on 05/10/26 did not meet minimum requirement of 150 F; and rinse cycles on 05/19/26, 05/20/26 and 05/24/26 did not meet minimum requirement of 180 F.Review of the dishwasher logs for June 2026 revealed wash cycles on 06/15/26, 06/18/26, 06/26/26 and 06/28/26 did not meet minimum requirement of 150 F; and rinse cycles on 06/06/26, 06/07/26, 06/19/26 and 06/26/26 did not meet minimum requirement of 180 F.Interview on 06/29/26 at 10:15 A.M. with Regional Dietary Manager # 468 verified the abnormal dishwasher temperatures. Review of facility policy titled Cul. - Dish Machine Operation Policy reviewed May 2026, revealed temperatures, as required by the manufacturer, are as follows: wash temperatures varies 150-165 degrees Fahrenheit and final rinse varies 180-195 degrees Fahrenheit.

Based on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately to include all known diagnoses and medication classifications received during the assessment reference date. This affected one (Resident #1) of 24 residents reviewed for MDS assessments. Findings include: Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included major depressive disorder, rheumatoid arthritis, polyneuropathy, and chronic pain syndrome. Review of Resident #1's active physician's orders revealed the resident was receiving Atorvastatin (a cholesterol lowering medication) 40 milligrams (mg) by mouth (po) every night at bedtime (hs) for hyperlipidemia. The order originated on 04/08/26. The resident also had an order to receive Citalopram (an antidepressant) 40 mg po every morning for depression. That order also originated on 04/08/26. The resident was also receiving Suboxone (a medication used to treat opioid use disorder by reducing cravings and withdrawal symptoms; it was a combination of a partial opioid agonist that satisfied cravings and an opioid antagonist meant to prevent misuse) sublingual (under the tongue) film 8-2 mg three times a day for chronic pain. That order had been in place since 04/08/26. Review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was not coded as having the diagnosis of hyperlipidemia, despite the resident receiving Atorvastatin every hs for hyperlipidemia. The resident was also not indicated to have the diagnosis of depression, despite having the diagnosis of major depressive disorder, and receiving Celexa 40 mg every morning for depression. Section (N.) that documented classifications of medications the resident received during the seven day assessment period revealed the resident was indicated to have received an antidepressant. She was not coded on the MDS assessment as having received an opioid medication, despite receiving Suboxone three times a day for chronic pain. On 06/29/26 at 4:10 P.M., an interview with RN #650 revealed she was the facility's nurse that completed the MDS assessment for reimbursement purposes. She confirmed Resident #1's admission MDS assessment dated [DATE] was not coded accurately, as it did not include the diagnoses of depression and hyperlipidemia, when she was receiving medications to treat both conditions. She stated she must have overlooked the fact that the resident was receiving medication to treat both diagnoses and she should have added the diagnoses to the diagnoses list. She further acknowledged the resident should have been coded as receiving an opioid, since the resident had been on Suboxone at the time the MDS assessment was completed. She did not code the resident as receiving an opioid due to the drug information they used did not identify it as such. She acknowledged that Suboxone included Buprenorphine, which was a partial opioid agonist (a substance like a drug that binds to a cell receptor and triggered an active biological response).

Based on record review, observation, and interview, the facility failed to ensure one resident (# 11) had a care plan that included appropriate interventions to prevent her from causing skin impairment when picking at her skin. The facility also failed to ensure a resident had a comprehensive care plan that addressed vision impairment with the use of glasses for one resident, (# 17). This affected two (Resident #11 and #17) of 24 residents reviewed for care plans. The facility census was 79. Findings include:1.) Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included adult-onset diabetes mellitus, obsessive-compulsive disorder (OCD), allergic dermatitis, anxiety disorder, and Schizo-affective disorder. Review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and she was cognitively intact. She was not known to display any behaviors or reject care during her seven day assessment reference period (03/25/26- 03/31/26). She was dependent on staff for personal hygiene and transfers. Review of Resident #11's physician's orders revealed the resident had orders in place to receive Benadryl (an antihistamine) 25 milligrams (mg) by mouth (po) every 24 hours as needed for itching. She was also receiving Hydroxyzine (an antihistamine) 50 mg po every eight hours as needed for itching. The Benadryl was ordered on 06/09/26 and the Hydroxyzine was added on 06/28/26. Review of Resident #11's active care plans revealed she was at risk for impaired skin integrity related to requiring staff assistance with her activities of daily living (ADL's) and picking at her skin related to her diagnosis of OCD and dermatitis. The goals included no picking at her skin. The interventions did not include the need to assist the resident with trimming her fingernails to prevent her from causing an impaired skin integrity due to picking at her skin. On 06/28/26 at 4:23 P.M., observations of Resident #11 noted her to be lying in bed. She was noted to have multiple scabbed areas of skin to the left side of her head and her bilateral arms. Her fingernails were noted to be long and in need of being trimmed. An interview with the resident at the time of the observation revealed she generally liked to have her fingernails a little longer but she knew the staff were needing to keep her nails trimmed due to her having a history of picking at her skin. She reported she would be fine with the staff trimming them for her. On 06/29/2026 1:49 P.M., a follow up observation of Resident #11 noted her to be in bed watching TV. Her fingernails remained long and in need of being trimmed. Her head had been shaved to a short length and she was noted to be rubbing her head. She continued to have scabbed areas on her scalp where she had been picking at her skin. The resident reported she did not sleep well last night due to itching, but denied any itching at present. On 06/30/26 at 9:48 A.M., an interview with Resident #11 revealed her itching had improved but continued to be an issue for her. She stated the night before last she was not able to get any sleep due to itching and last night she only slept for only about three hours. She was noted to continue to have the scabbed area to the left side of her head. Scratch areas were noted to the left side of her face near her chin and along her jaw line. She had multiple scabbed areas and scratches on her bilateral upper extremities. The resident's fingernails remained long on some of her fingers that extended about an inch past the end of her digits. The resident was again asked if she would be in agreement to allowing the staff to trim her fingernails. She again stated she knew she was supposed to keep them trimmed to prevent from scratching herself and would be okay with staff trimming them. She then commented she would like that if they did. On 06/30/26 at 10:01 A.M., an interview with Registered Nurse (RN) #160 revealed Resident #11 was considered a total assist with personal care. She reported the resident was under hospice care and the hospice aide was there two times a week to do her bed baths. She was asked if she was aware of the resident having any skin issues. She reported the resident had been scratching and that was the only skin issue she was aware of. They had the resident on a Medrol (steroid) dose pack and she was receiving Hydroxyzine and Benadryl on an as needed (prn) basis. She was not sure why the resident was itching. She stated last week the resident had them shave her head and then she started digging at her scalp. She confirmed the resident had scabbed areas from picking at her skin. They were applying lotion to her arms but she was not sure if it was Lac-Hydrin lotion or Hydrocortisone cream. A week and a half ago, the resident was told she needed to have her nails trimmed. She claimed the resident allowed them to do some, but not all of them. She described the resident's fingernails as being long, long then, and also dirty underneath. She denied she had documented anything in the resident's medical record about her being encouraged to allow staff to trim her fingernails and refusing to allow them to do so. She was informed the surveyor had talked with the resident twice in the past three days (last time being earlier that morning) and both times the resident verbalized she would like the staff to trim her fingernails. The nurse indicated, if the resident was a diabetic, the nurses would have to trim the resident's fingernails. She confirmed the resident was a diabetic and in need of her fingernails to be trimmed. She was asked to assist the resident with trimming her nails and let the surveyor know if the resident refused. She was not sure why the resident's care plans did not include the need for staff to assist the resident with nail care. She stated she did not have anything to do with the care plans. On 06/30/26 at 10:33 A.M., a follow up interview with RN #160 revealed she did approach Resident #11 about assisting her with nail care and the resident allowed her to do so. The resident told her she would like to have her nails trimmed once a week moving forward. 2.) Review of Resident #17's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Bipolar disorder, depression, and anxiety disorder. She did not have any diagnoses specific to cognitive impairment such as dementia or Alzheimer's disease. Review of an optometry visit note for Resident #17 dated 03/13/26 revealed the resident was seen on that date as an established patient. She had an Electroretinography (ERG) performed that measured the electrical activity of the retina's light-sensing cells (rods and cones). The resident was indicated to have non-exudative age-related macular degeneration bilaterally in the early dry stage. She was also indicated to have hypertensive retinopathy bilaterally. An invoice indicated the resident had been previously provided with prescription glasses on 03/06/26, prior to the optometrist's visit. Review of Resident #17's quarterly MDS assessment dated [DATE] revealed the resident did not have any hearing, speech, or communication issues. She was coded on the MDS assessment as having impaired vision and had the use of corrective lenses. She was cognitively intact and was not indicated to have displayed any behaviors during the assessment reference period. Review of Resident #17's active care plans revealed she did not have a care plan in place to address her known impaired vision or use of corrective lenses. On 06/28/26 at 1:00 P.M., an observation of Resident #17 noted her to be in bed on a Notepad tablet. She had glasses on and indicated they were reader glasses her son had given her. She reported she had a pair of prescription glasses that came up missing so she was using a pair her son gave her. She confirmed she had impaired vision and was reliant on glasses to be able to read. 06/29/26 at 12:51 P.M., an interview with RN #300 confirmed Resident #11's active care plan did not include a care plan that addressed her vision impairment or use of glasses.

Based on record review, review of facility policy and interviews, the facility failed to ensure grooming/shaving were provided to dependent residents. This affected one resident (#70) of two residents reviewed for activities of daily living. The census was 79.Findings include:Review of the medical record for Resident #70 revealed an admission date of 03/30/26 with diagnoses including acute diastolic (congestive) heart failure, Type II Diabetes Mellitus without complications, schizoaffective disorder, depression, anxiety disorder, and repeated falls. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. The resident was assessed to require assistance with all activities of daily living (ADL's). Review of Resident #70's care plan dated 04/14/26 revealed personalized care with interventions including resident prefers to receive a shower. Resident #70 had an ADL self-care performance deficit related to falls, schizophrenia and depression. Interventions included provide assistance with ADL's according to need. Review of the shower schedule provided by the facility revealed Resident #70 shower days are scheduled Tuesdays and Fridays on nightshift. Review of the shower sheets revealed Resident #70 did not receive a shower or facial hair shaved per schedule on 05/29/26, 06/05/26, and 06/19/26. Review of the Certified Nursing Assistant (CNA) Point of Care (POC) documentation revealed no evidence Resident #70 received a shower on 05/29/26, 06/05/26 and 06/19/26. Further review revealed no evidence of shaving being provided since 06/16/26. Interview on 06/28/26 at 1:33 P.M. with Resident #70 and his daughter revealed she has been here visiting for three days, and he has not been shaved. He was someone who always shaved. Resident #70 stated he gets shaved when they give him a shower sometimes. Observation of Resident #70 revealed facial hair. Interview on 06/30/26 at 3:07 P.M. with the Director of Nursing (DON) verified no shower sheets for 05/29/26, 06/05/26 and 06/19/26 for Resident #70 and verifed the resident's facial hair had not been shaved. Review of facility policy titled Activities of Daily Living (ADLs), revised 08/2023, revealed the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, demonstrate a resident's ADL's are met to the best of our ability and do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: bathing, dressing, grooming, oral care, nail care, vision/hearing (glasses/hearing aides).

Based on record review, observation, interview, and policy review, the facility failed to ensure a resident with a known behavior of picking at her skin had her fingernails trimmed as part of her interventions and the facility staff identified areas of impaired skin integrity when completing weekly skin assessments. This affected one (Resident #11) of four residents reviewed for non-pressure skin conditions. They also failed to ensure a resident's hospice provider was notified when an incident occurred involving one of their hospice residents. This affected one (Resident #30) of one residents reviewed for hospice services. Findings include: 1.) Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included adult-onset diabetes mellitus, obsessive-compulsive disorder (OCD), allergic dermatitis, anxiety disorder, and Schizo-affective disorder. Review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and she was cognitively intact. She was not known to display any behaviors or reject care during her seven day assessment reference period (03/25/26- 03/31/26). She was dependent on staff for personal hygiene and transfers. Review of Resident #11's physician's orders revealed the resident had orders in place to receive Benadryl (an antihistamine) 25 milligrams (mg) by mouth (po) every 24 hours as needed for itching. She was also receiving Hydroxyzine (an antihistamine) 50 mg po every eight hours as needed for itching. The Benadryl was ordered on 06/09/26 and the Hydroxyzine was added on 06/28/26. Review of Resident #11's active care plans revealed she was at risk for impaired skin integrity related to requiring staff assistance with her activities of daily living (ADL's) and picking at her skin related to her diagnosis of OCD and dermatitis. The goals included no picking at her skin. The interventions did not include the need to assist the resident with trimming her fingernails to prevent her from causing an impaired skin integrity due to picking at her skin. Review of Resident #11's weekly skin assessments revealed the resident's skin was being checked weekly for any new areas of skin impairment. The staff was to observe the resident's body and document the appearance of her skin, temperature of her skin, skin turgor, and any new alterations in the resident's skin integrity. If no new alterations or changes in the resident's skin integrity, the skin check was complete. The facility staff documented weekly skin assessments being completed between 06/01/26 and 06/29/26, with no new areas of skin impairment indicated to have been present. Review of Resident #11's Hospice Aide Shower Sheets for the past 30 days revealed the resident's last documented bathing activity completed by the hospice aide was on 06/22/26. The hospice aide documented a visual assessment of the resident and did not note any concerns at the time. The shower sheet included a question to indicate if the resident needed her toenails cut, but it did not ask anything about fingernails. There was also no place on the shower sheet to indicate if nail care had been provided during that bathing activity. On 06/28/26 at 4:23 P.M., observations of Resident #11 noted her to be lying in bed with multiple scabbed areas skin. She had a pea sized scab on the left side of her head and multiple scabs and/ or scratches to her bilateral arms. Her fingernails were noted to be long and in need of being trimmed. An interview with the resident at the time of the observation revealed she generally liked to have her fingernails a little longer but she knew the staff were needing to keep her nails trimmed due to her having a history of picking at her skin. She reported she would be fine with the staff trimming them for her. On 06/29/2026 1:49 P.M., a follow up observation of Resident #11 noted her to be in bed watching TV. Her fingernails remained long and in need of being trimmed. Her head had been shaved to a short length and she was noted to be rubbing her head. She continued to have scabbed areas on her scalp where she had been picking at her skin. The resident reported she did not sleep well last night due to itching, but denied any itching at present. On 06/30/26 at 9:48 A.M., an interview with Resident #11 revealed her itching had improved but continued to be an issue for her. She stated the night before last she was not able to get any sleep due to itching and last night she only slept for only about three hours. She was noted to continue to have the scabbed area to the left side of her head. A scratch mark was noted to the left side of her face near her chin, along her jaw line. She continued to have multiple scabbed areas and scratches on her bilateral upper extremities. The resident's fingernails remained long on some of her fingers that extended about an inch past the end of her digits. The resident was again asked if she would be in agreement to allowing the staff to trim her fingernails. She again stated she knew she was supposed to keep them trimmed to prevent from scratching herself and would be okay with staff trimming them. She then commented she would like that if they did trim them for her. On 06/30/26 at 10:01 A.M., an interview with Registered Nurse (RN) #160 revealed Resident #11 was considered a total assist with personal care. She reported the resident was under hospice care and the hospice aide was there two times a week to do her bed baths. She was asked if she was aware of the resident having any skin issues. She reported the resident had been scratching and that was the only skin issue she was aware of. They had the resident on a Medrol (steroid) dose pack and she was receiving Hydroxyzine and Benadryl on an as needed (prn) basis. She was not sure why the resident was itching. Last week the resident had them shave her head and then she started digging at her scalp. She confirmed the resident had scabbed areas from picking at her skin that were not noted on the weekly skin assessments. They were applying lotion to her arms, but she was not sure if it was Lac-Hydrin lotion or Hydrocortisone cream. She claimed in the past week and a half, the resident was told she needed to have her nails trimmed. She further claimed the resident allowed them to do some, but not all of them. She described the resident's fingernails as being long, long then, and also dirty underneath. She denied she had documented anything in the resident's medical record about her being encouraged to allow staff to trim her fingernails and refusing to allow them to do so. She was informed the surveyor had talked with the resident twice in the past three days (last time being earlier that morning) and both times the resident verbalized she would like the staff to trim her fingernails. The nurse indicated, with the resident being diabetic, the nurses would have to trim the resident's fingernails. She confirmed the resident's fingernails were long and needed to be trimmed. She was asked to assist the resident with trimming her nails and let the surveyor know if the resident refused. On 06/30/26 at 10:33 A.M., a follow up interview with RN #160 revealed she did approach Resident #11 about assisting her with nail care and the resident allowed her to do so. The resident told her she would like to have her nails trimmed once a week moving forward. 2. Review of Resident #30's medical record revealed an admission date of 03/14/22 and diagnoses including dementia, obstructive and reflex uropathy, anemia, paroxysmal atrial fibrillation, diabetes, acute and chronic respiratory failure, bladder neck obstruction, pleural effusion, chronic diastolic (congestive) heart failure, malignant neoplasm of unspecified part of unspecified bronchus or lung, pulmonary hypertension, hypertension, and osteoarthritis. Review of Resident #30's care plan revealed a hospice care plan initiated on 01/17/25 with an intervention dated 01/17/25 that stated facility will keep hospice staff aware of significant changes in status and coordinate appropriate interventions and follow-up. Review of Resident #30's physician's orders revealed an order dated 10/21/25 to admit to a hospice for diagnosis of adenocarcinoma of lung. Review of Resident #30's progress notes revealed a note written by Licensed Practical Nurse (LPN) #454 on 05/28/26 at 5:45 P.M. stating STNA (Certified Nursing Assistant) answers call light and Res(resident) is observed on the floor in front of recliner. Res(resident) states she was transferring to her chair and went down. No redness, bruising, injuries noted at this time. VS(vital signs)-149/90, 102, 18, 97.8, 98%. Denies pain at this time. Neurological checks initiated. Left grip is greater than right grip per Res(resident)'s usual. PERRL (pupils equal, round and reactive to light). Able to move all extremities. Res(resident) educated to ask for assistance when needed. Notified CNP (Certified Nurse Pratitioner), DON (Director of Nursing), and Res(resident)'s daughter of same. Further review of Resident #30's progress notes revealed no idication the hospice provider was notified of the resident's fall. Review of Resident #30's quarterly Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status score of 15 indicating the resident was cognitively intact. Further review reviewed revealed the resident utilized a wheelchair for mobility, was dependent on facility staff for toileting hygiene, and bathing, required substantial/maximal assistance for bed mobility and transfers and was receiving hospice care. In an interview on 07/01/26 at 9:50 A.M. the Director of Nursing verified there was no documentation the hospice provider was notified of Resident #30's fall on 05/28/26. Review of the policy titled Hospice Policy, dated 05/2025, revealed the facility was responsible for monitoring the resident's status and notifying the primary care provider and the hospice of significant changes in status, new or worsening wounds, falls, signs or symptoms of a new infection or of worsening infection, pain that does not respond to the ordered non-medication and medication interventions, new symptoms or clarification of an order.

Based on record review, observation, staff interview, and policy review, the facility failed to ensure skin prevention interventions were implemented for a resident with a known pressure ulcer per the plan of care. This affected one resident (#8) of three residents reviewed for pressure ulcers. The facility census was 79.Findings include:Review of Resident #8's medical record revealed an admission date of 05/22/26 with diagnoses including chronic venous hypertension with ulcer of left lower extremity, dysphagia, down syndrome, muscle weakness, retention of urine and chronic kidney disease. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment, dated 06/06/26 revealed severe impaired cognition and he was dependent on staff for bed mobility, transfers with two staff assist, no impairment to upper or lower extremities and was at risk for pressure ulcers. Review of Resident #28's physician's orders, dated 05/27/26, revealed an order for Triad Hydrophilic wound dress external paste to buttocks three times a day and a low air loss mattress. Review of the care plan for Resident #8 dated 05/22/26 revealed he was at risk for skin integrity/pressure ulcers related to incontinence and weakness. Interventions included lift sheet on chair/bed for positioning, pressure reduction devices if ordered and turn and reposition as ordered. Further review of Resident #8's care plan dated 05/27/26 revealed he had an actual impairment to skin integrity, on 06/09/26 a stage III pressure ulcer to coccyx/buttocks with interventions including encourage no briefs in bed, low air loss mattress on bed and identify/document potential causative factors and eliminate/resolve where possible. Review of Resident #8's most recent Encore Wound Care progress note dated 06/23/26 revealed a stage III pressure ulcer to bilateral buttocks including coccyx which was present upon admission. Treatment orders included but not limited to patient should be repositioned every two hours (left side/right side/supine) and no incontinent brief while in bed. Observation and interview on 06/29/26 at 4:46 P.M. of wound care on Resident #8 with Registered Nurse (RN) Unit Manager #154 Licensed Practical Nurse (LPN) #256, Certified Nursing Assistant (CNA) # 361 and CNA #362 revealed, resident in bed upon room entry, staff stated he had a doctor's appointment this morning and returned to facility around 11:30 A.M. Observation revealed Resident #8 had two sheets, one bed pad and an incontinence brief under him while in bed. Staff stated that was from the squad when they brought him back from the appointment. LPN # 154, CNA #361 and CNA #362 verified resident has not been turned or repositioned since returning from appointment at 11:30 A.M. RN #154 verified the items underneath resident is not appropriate for wound healing. Interview on 06/30/26 at 2:06 P.M. with Encore Wound Care Nurse Practitioner (NP) #369 revealed expectations for pressure ulcer management include turning side to side, every two hours as patients tolerate, residents with air mattresses should not be wearing an incontinence brief in bed and the bare minimum between the resident and bed which should be one piece of linen. Review of the facility's policy titled Wound Management Program, updated February 2024, revealed any resident with a wound receives treatment and services consistent with the resident's goals of treatment. The goal is one of promoting healing and minimizing infection unless a resident's preferences and medical condition necessitate palliative care as the primary focus.

Based on record review and interview, the facility failed to ensure residents had appropriate justification for use of medications. This affected one (Resident #70) of six residents reviewed for medication use. Facility census was 79.Review of Resident #70's medical record revealed an admission date of 03/30/26 with diagnoses that included acute diastolic (congestive) heart failure, Type II Diabetes Mellitus without complications, schizoaffective disorder, depression, anxiety and repeated falls. Review of the physician's orders dated 04/15/26 revealed an order for Tagamet (used to treat and prevent heartburn, also used for sexually inappropriate behavior ) 200milligrams (mg) Oral Tablet one tablet by mouth two times a day for sexual behaviors. Review of Resident #70's behavior documentation from March 2026 through June 2026 revealed one indicated behavior of public sexual acts on 04/29/26. Review of Resident #70's care plan dated 04/07/26 revealed no indication of sexual behaviors. Interview on 06/30/26 at 4:05 P.M. with the Director of Nursing (DON), verified no documentation of sexual behaviors, no care plan indicating sexual behaviors to support the prescribed Tagamet. The DON stated a Certified Nursing Assistant (CNA) told her about the behaviors.

Based on record review and staff interview, the facility failed to ensure laboratory testing for a comprehensive metabolic panel (CMP) and lipid panel were obtained in the month of June 2026, as ordered by the physician. This affected one (Resident #1) of five residents reviewed for unnecessary medications. Findings include:Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included atherosclerotic heart disease (ASHD) and heart failure. Review of Resident #1's physician's orders revealed the resident was to receive Atorvastatin (a cholesterol lowering medication) 40 milligrams (mg) by mouth (po) every night at bedtime for hyperlipidemia (high cholesterol in the blood). The order originated on 04/08/26. The resident was also receiving Furosemide (a potassium depleting diuretic) 40 mg po twice a day and Potassium Chloride Extended Release (ER) 20 milliequivalents (meq) po every morning for hypokalemia (low potassium level in the blood). The physician's orders included the need to obtain a CMP (blood test that checked electrolyte levels in the blood to include potassium) every three months in the months of March, June, September, and December. She was also to have a lipid panel (blood test that measured cholesterol level in the blood) drawn every six months during the month of June and December. The lab order for routine monitoring of a CMP and a lipid panel was provided on 05/20/26. Review of Resident #1's laboratory testing results revealed her last CMP was obtained on 04/14/26. There was no evidence in the electronic medical record (EMR) of a CMP having been obtained in June 2026. Her EMR was also absent for any evidence of a lipid panel being obtained in June 2026, after it had been ordered to be checked every six months to include the month of June 2026. On 06/30/26 at 8:15 A.M., an interview with RN #160 revealed the residents' labs were drawn by the local hospital's lab services. The lab technician came every Monday through Friday to draw blood. The lab technician used to be there early in the morning, but was generally there by then (time of interview) She had not seen the lab technician in the building that day. Lab orders were entered into the computer and would be reflected on the treatment administration record (TAR) when due. The night shift nurse would look at the TAR's the night before to see who was due to a lab and would fill out a lab slip for those labs to be obtained. The lab slip would then be left at the nurses' station turned upside down. She reported the lab slips for the day had already been filled out, unless someone got missed. She denied they had any labs due that day for Resident #1. On 06/30/26 at 8:45 A.M., the facility's Director of Nursing (DON) was asked to provided a copy of any labs involving a CMP or a lipid panel that had been obtained from Resident #1. The facility's Assistant Director of Nursing (ADON) returned with a copy of the CMP that was collected on 04/14/26. She denied they had a CMP or a lipid panel that had been obtained in June 2026. She reported the resident had a CMP and a lipid panel drawn that morning. She acknowledged the surveyor had already interviewed RN #160 and it was determined that Resident #1 did not have any labs drawn that morning and did not have a lab slip filled out for her to have those labs completed. She further acknowledged the CMP and lipid panel would have been missed for that month, without the surveyor's intervention.

Based on record review and interview the facility failed to notify the state long term care ombudsman of the transfer and/or discharge of two residents. This affected two residents (#81 and #83) of four sampled for discharges/ hospitalizations. The facility census was 79.Findings include: 1. Review of Resident #81's medical record revealed an admission date of 03/28/26, a discharge date of 04/20/26 and diagnoses including encounter for other orthopedic aftercare, acquired absence of right leg above knee, unspecified asthma, diabetes, end stage renal disease, anxiety, acute on chronic diastolic (congestive) heart failure, histoplasmosis, hypertension, and major depressive disorder.Review of Resident #81's admission Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status score of 15, indicating the resident was cognitively intact. Further review of Resident #81's MDS revealed the resident utilized a wheelchair for mobility, was independent with bed mobility, and required partial/moderate assist with toileting hygiene, transfers and bathing.Review of Resident #81's progress note written by Registered Nurse (RN) #557 on 04/17/26 at 2:18 P.M. revealed the resident was experiencing more pain than normal to the surgical site in her left stump and was needing more assistance than her baseline from staff for her activities of daily living.Review of progress note written by RN#557 on 04/17/26 at 2:22 P.M. revealed the resident's physician wanted the resident directly admitted to the hospital.Review of progress note written by RN #557 on 04/17/26 at 2:56 P.M. revealed the resident had left the facility.In an interview on 06/29/26 at 8:40 A.M. Social Worker Designee (SWD) #466 verified she did not notify the state long term care ombudsman of Resident #81's transfer to the hospital.2. Review of Resident #83's medical record revealed an admission date of 04/09/26, a discharge date of 04/11/26 and diagnoses including chronic obstructive pulmonary disease, respiratory syncytial virus, chronic respiratory failure, diabetes, paroxysmal atrial fibrillation, heart failure, non-ST elevation myocardial infarction, and peripheral vascular disease.Review of Resident #83's five day MDS dated [DATE] revealed a brief interview for mental status score of six indicating the resident had severe cognitive impairment. Further review of the MDS revealed the resident utilized a wheelchair for mobility, required partial/moderate assistance for transfers and substantial assistance for toileting hygiene.Review of Resident #83's progress notes revealed a note written by Licensed Practical Nurse #456 on 04/11/26 at 3:25 P.M. that indicated the resident's spouse was at the facility to pick up the resident. The resident's spouse was offered education on encouraging the resident to remain in the facility until Monday so the facility could help set up discharge services. Resident and spouse decline and sign AMA forms (against medical advice). Resident #83 and spouse left at this time.In an interview on 06/29/26 at 8:40 A.M. Social Worker Designee (SWD) #466 verified she did not notify the state long term care ombudsman of Resident #83's discharge.

Based on observation, record review, staff interview, and facility policy review, the facility failed to maintain infection prevention and control practices when staff failed to use proper personal protective equipment while providing care for one resident (#11), with the potential to affect 13 additional residents (#1, #3, #16, #17, #19, #22, #28, #33, #39, #51, #55, #61, and #84) who received care from the same staff; and failed to ensure newly hired staff completed required two-step Mantoux/tuberculosis screening upon hire for two of 13 employee files reviewed, Social Services Director #450 and Nursing Scheduler #366. The facility census was 79. Findings Include:1: Interview with the Human Resources Director #150 was conducted on 07/01/26 from 8:00 A.M. to 8:45 A.M. regarding staffing file review, employee health requirements, and Mantoux/TB screening documentation. Review of employee health screening documentation revealed Social Services Director #450 had a hire date of 11/28/25. Review of the employee file revealed the required two-step Mantoux/TB screening was not completed until 02/10/26. During interview, Human Resources Director #150 confirmed Social Services Director #450 had a hire date of 11/28/25 and the two-step Mantoux/TB screening was not completed until 02/10/26. Human Resources Director #150 confirmed the hire date and Mantoux completion date were accurate. Human Resources Director #150 acknowledged the two-step Mantoux/TB screening was not completed timely and stated this was an issue. 2: Review of employee health screening documentation revealed Nursing Scheduler #366 had a hire date of 01/12/26. Review of the employee file revealed the required two-step Mantoux/TB screening was not completed until 02/10/26. During interview with Human Resources Director #150 on 07/01/26 from 8:00 A.M. to 8:45 A.M., Human Resources Director #150 confirmed Nursing Scheduler #366 had a hire date of 01/12/26 and the two-step Mantoux/TB screening was not completed until 02/10/26. Human Resources Director #150 confirmed the hire date and Mantoux completion date were accurate. Human Resources Director #150 acknowledged the two-step Mantoux/TB screening was not completed timely and stated this was an issue. Review of the facility policy titled Tuberculosis Control Exposure Policy, created 02/2022, revised 02/2022, and reviewed 01/2026, revealed the purpose of the policy was to institute an effective Tuberculosis (TB) control plan that included early detection for residents and staff with appropriate follow-up, isolation where necessary, and treatment of persons with active TB. Review of the policy revealed administrative measures would be taken to reduce the risk of exposure of residents and employees to people with infectious TB. Review of the procedure revealed PPD results of all employees would be maintained in employee medical files. Review of the early detection section revealed all employees at the facility would have an initial two-step Mantoux PPD on hire 3. Review of Resident #11's medical record revealed an admission date of 05/22/19 and diagnoses including morbid obesity, diabetes, chronic respiratory failure with hypoxia, anxiety disorder, schizo-affective disorder, repeated falls and a history of a multidrug-resistant organism (MDRO). Review of Resident #11's quarterly Minimum Data Set (MDS), dated [DATE] revealed the resident had intact cognition. Further review of the MDS revealed the resident had limitations in range of motion to both lower extremities and was dependent on staff for personal hygiene and transfers. Review of Resident #11's physicians orders revealed an order dated 10/06/25 for enhanced barrier precautions (EBP) due to a history of a MDRO. Review of Resident #11's care plan initiated on 10/06/25 revealed a care plan that stated Resident #11 required EBP due to a history of a MDRO. Further review of the care plan revealed the EBP should be used when preforming dressing, bathing, showering, transferring, personal hygiene, changing linens, toileting and peri-care. An observation of peri-care on 06/29/26 at 2:15 P.M. revealed care was provided by Certified Nursing Assistant (CNA) #555 and CNA #263 to Resident #11. CNA #555 assisted with positioning the resident and CNA #263 provided care, cleansing resident from front to back and utilizing a different part of the washcloth or a different wash cloth for each area cleansed. Resident #11's skin was rinsed with clear water and a clean wash cloth rinsing from front to back and utilizing a different part of the washcloth or a different wash cloth for each area and then dried using the same technique. Both CNAs completed hand hygiene prior to the procedure and wore gloves during the procedure however Resident #11 was in enhanced barrier precautions and they did not use gowns during the procedure. In an interview on 06/29/26 at 2:20 P.M. CNA #263 stated that Resident #11 did not have a catheter or intravenous access (IV) and the wound she had previously on her head was healed. CNA #263 stated that she thought the nurses had just forgotten to remove the EBP sign from the resident's room and that she did not need to be in EBP since her wound was healed. CNA #263 confirmed she did not wear a gown while caring for Resident #11. In an interview on 06/29/26 at 2:20 P.M. CNA #555 stated that she honestly did not notice the EBP sign until questioned about it by the surveyor but that she did not know of any reason for the resident to be in EBP. CNA #555 confirmed she did not wear a gown while caring for Resident #11. Review of the policy titled Enhanced Barrier Precautions Policy, revised 01/2025, revealed that Center for Disease Control (CDC) studies have shown many nursing home residents are unknowingly colonized with MDRO. The CDC has determined that by using EBP, long term care facilities can reduce the spread of MDROs. further review revealed EBP is used in conjunction with standard precautions and expands the use of personal protective equipment (PPE) to donning gown and gloves during high-contact resident care activities such as when preforming dressing, bathing, showering, transferring, personal hygiene, changing linens, toileting and peri-care.

Based on medical record review, policy review and interview, the facility failed to ensure residents received specialized therapy services as written in the plan of care. This affected one resident (#60) of three residents reviewed for specialized therapy services. The census was 77.Findings include:Medical record review revealed Resident #60 was admitted on [DATE] with diagnoses including wedge compression fracture of second lumbar vertebra, unspecified dementia, unsteadiness on feet, muscle weakness, cerebral infarction, anxiety and difficulty in walking not elsewhere classified. Review of the Physical Therapy (PT): Plan of Treatment and Orders revealed therapy services were initiated on 08/21/25. The PT plan of treatment certification periods included 09/19/25 through 10/18/25; 10/15/25 through 11/13/25, 11/14/25 through 12/06/25, and 12/06/25 through 01/04/26. The services were to be provided three to five times a week for therapeutic exercises, therapeutic activities, neuromuscular reeducation, and gait training. Review of the Occupational Therapy (OT): Plan of Treatment and Orders revealed therapy services were initiated on 08/21/25. The OT plan of treatment certification periods included 08/21/25 through 09/19/25; 09/20/25 through 10/19/25; 10/18/25 through 11/16/25; and 11/15/25 through 12/14/25. The services were to be provided three to five times a week for therapeutic exercises, therapeutic activities and self-care management training. a. Review of the OT Service Log Matrix dated October 2025 revealed Resident #60 did not receive any OT treatments between 10/03/25 through 10/12/25, 10/17/25 through 10/22/25 or 10/24/25 through 10/31/25.Review of the OT Service Log Matrix dated November 2025 revealed Resident #60 did not receive any OT treatments between 11/01/25 and 11/09/25, 11/20/25 through 11/24/25 or 11/27/25 through 11/30/25. b. Review of the PT Service Log Matrix dated October 2025 revealed Resident #60 did not receive any PT treatments between 10/07/25 through 10/13/25, 10/18/25 through 10/21/25, or 10/23/25 through 10/29/25.Review of the PT Service Log Matrix dated 11/01/25 through 11/30/25 revealed Resident #60 did not receive any PT treatments between 11/01/25 through 11/04/25, 11/06/25 through 11/08/25, 11/21/25 through 11/23/25, or 11/25/25 through 11/30/25. On 12/09/25 between 1:10 P.M. and 1:19 P.M., interview with Rehab Director #44 verified Resident #60 did not receive OT or PT services at the frequency as written in the plan of care during October 2025 and November 2025. Rehab Director #44 stated the frequency was not met due to the corporate office did not submit the insurance authorizations timely resulting in an interruption in therapy services. On 12/09/25 at 3:01 P.M., interview with Rehab Director #44 stated the facility did not have a policy related to therapy services. Rehab Director #44 stated although there was not a policy developed, it was the expectation for specialized therapies to be completed at the frequency written per plan of care. This deficiency represents non-compliance investigated under Complaint Number 2683614.

Based on observation, record review, interview, and policy review, the facility failed to ensure Resident #54 received necessary services to maintain good oral hygiene. This affected one (Resident #54) of three residents reviewed for activities of daily living (ADL) care. The facility census was 71. Findings include:Review of Resident #54's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included major depressive disorder, muscle weakness, unsteadiness on his feet, abnormalities of gait and mobility, and the need for assistance with personal care. Review of Resident #54's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. He was not known to display any behaviors, nor was he known to reject care. He was coded as being dependent on staff for oral hygiene. He was indicated to be edentulous with no natural teeth or tooth fragments noted. Review of Resident #54's care plans revealed he had a care plan in place for an ADL self care deficit. The care plan was initiated on 11/09/22 and was last revised on 09/16/25. The interventions included encouraging the resident to participate to the fullest extent possible with each interaction. The care plan did not list each ADL care out separately and was not specific to the provision of oral hygiene care. Further review of Resident #54's care plans revealed he also had a care plan in place for having oral/ dental health problems related to being edentulous. The goal was for the resident to successfully manage/ receive assistance with mouth care at least daily. The interventions included the need to coordinate arrangements for dental care. The interventions did not specifically include the provision of oral hygiene care as one of the interventions to be followed. On 11/25/25 at 2:45 P.M., an interview with Resident #54 revealed he did not receive any assistance with his oral hygiene care. He confirmed he did not have any natural teeth and did not use dentures. He stated he would have liked to be provided with mouthwash and a mouth swab to use when performing oral hygiene care. He stated he would be able to do that for himself if he had the supplies and the staff provided set up help. He denied the staff had offered any of those supplies to him. On 11/26/25 at 10:55 A.M., an interview with Certified Nursing Assistant (CNA) #177 revealed she believed Resident #54 had his own natural teeth. She reported he did not have them all, but had a few. CNA #177 stated the nursing staff provided Resident #54 with oral hygiene care, or at least sat by him so he could do his own oral care which she thought included only mouth wash for residents who had no natural teeth nor dentures. During this interview CNA #177 proceeded to go to Resident #54's room to check his mouth to see if he had any natural teeth, as she previously stated. CNA #177 verified Resident #54 was edentulous with no natural teeth or tooth fragments present and did not have the use of dentures. CNA #177 confirmed after checking in Resident #54's bathroom that there was no evidence of mouth swabs or mouthwash available for mouth care. CNA #177 asked Resident #54 if he would like her to get some supplies to do mouth care and Resident #54 stated that would be nice. CNA #177 went to the central supply room and got the resident mouth swabs and a bottle of mouthwash for him to use when receiving oral hygiene care. CNA #177 stated oral hygiene care should be provided as part of the resident's morning care. CNA #177 stated she did not know why there were no oral hygiene supplies in Resident #54's room. CNA #177 verified that prior to looking in Resident #54's mouth during the interview, she did not know he was edentulous. Review of the facility's policy on Oral Hygiene updated 11/05/24 revealed the facility recognized the importance of good oral hygiene practice to cleanse mouth, teeth, and dentures. It was to be provided to prevent infection, irritation, periodontal disease and odors. The policy only included directives for residents who had their own teeth and/ or dentures. It did not address residents who did not have any of their natural teeth (edentulous) and/ or the use of dentures. This deficiency represents non-compliance investigated under Complaint Intake Number 2665757.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview the facility failed to follow physician orders to apply ice packs several times a day to the left knee of Resident #72 who was status post left total knee replacement. This affected one (Resident #72) of three residents reviewed for admission and post-surgical physician orders. The facility census was 71. Findings Include:Findings Include:Review of the medical record for Resident #72 revealed an admission date of 10/16/25 after having a left total knee replacement on 10/13/25. Resident #72's diagnoses included diabetes, anemia, heart disease, high blood pressure and gastric reflux.Review of the initial nursing assessment completed on 10/16/25 revealed Resident #72 had a brief interview for mental status score of 14/15, meaning the resident was cognitively intact. Review of the Minimum Data Set (MDS) 3.0 assessment revealed Resident #72 was dependent for toileting, substantial assistance for dressing lower body, and dependent on applying foot wear. Review of the hospital After Visit Summary (AVS) printed on 10/16/25 at 9:14 A.M. and provided by the medical transport team to the facility on admission revealed Resident #72 was ordered post-operative care and treatment to include ice packs to operative leg several times a day 10 to 20 minutes on and 10 to 20 minutes off to decrease pain and swelling.Review of the Treatment Administration Record (TAR) for Resident #72 revealed on 10/20/25 ice packs to be applied to operative site to aide in decreasing pain and swelling. This should be done multiple times a day 10 to 20 minutes on and 10 to 20 minutes off. Place barrier, such as towel between ice and skin, four times a day for pain and swelling. The treatment was signed off as completed only once on 10/20/25 at 8:00 P.M.Further review of the medical record for Resident #72 revealed on 10/20/25 the Resident/Resident Representative requested a transfer to another skilled rehabilitation facility. On 10/21/25 Resident #72 was discharged from the facility, and his daughter transported him to another facility for further care and treatment.Interview on 11/25/25 at 9:05 A.M. with Resident #72's daughter revealed on 10/20/25 she reported to facility administration that Resident #72 had not received any ice packs or application of ice packs since arrival on 10/16/25 and it was ordered on the AVS from the hospital.Interview on 11/25/25 at 3:05 P.M. with licensed practical nurse (LPN) #125 revealed she recalled admitting Resident #72 to the facility on [DATE] between 11:30 A.M. and 12:00 P.M. LPN #125 reported that Resident #72 had a knee replacement. Interview with LPN #125 further revealed she received the AVS from the transporting team and reviewed it. LPN #125 reported she reconciled the AVS orders with the nurse practitioner around 1:30 P.M. and then entered them into the computer system. LPN #125 did not recall an order for ice pack application and stated if its not in the computer then it wasn ' t on the AVS. Interview on 11/26/25 at 3:45 P.M. with the Director of Nursing (DON) revealed she was notified by the daughter of Resident #72 on 10/20/25 that he had not received ice to operative knee since admission and the ice application was ordered on the AVS. The DON further explained that the AVS was reviewed, and an order was placed immediately, and ice application was offered to Resident. The DON could not explain why the ice application was only marked once on the treatment record as completed on 10/20/25 at 8:00 P.M. The DON further reported the facility began a self-imposed action plan on 10/22/25 due to the ice not being implemented as ordered upon admission. The deficient practice was corrected on 11/20/25 when the facility implemented the following corrective actions:-Chart audits were completed for all new admissions dated 10/01/25 through 10/22/25 and then for an additional four weeks ending on 11/20/25. The audits were completed to review resident discharge orders to the orders entered on admission to the facility for accuracy and correction if needed. Audit details included: admission orders matching the discharge orders including the Medication Administration Records and TAR orders, completion of the admission checklist, and verification of two nurses for admission orders.-All nursing staff were educated on the expected admission process, utilizing the admission checklist, and having two nurses review admission orders for accuracy.-The concern involving Resident #72 and follow-up actions taken was added to the quality assurance and performance improvement committee meeting agenda for review.As of the date of the survey on 11/26/25 no further non-compliance was identified pertaining to following admission and post-surgical physician orders. This deficiency represents non-compliance investigated under Complaint Number 2650857.

Based on observation and staff interview, the facility failed to maintain the facility in good repair and maintain a home like environment. This affected 12 of 41 resident rooms currently occupied by residents in the facility. The resident census was 70.Findings Include: On 09/18/25 tour of the facility between 9:50 A.M. and 10:20 A.M. the following environmental issues were observed: 1. room [ROOM NUMBER] behind the bed by the window, the wall was gouged and the paint peeling.2. room [ROOM NUMBER] the wall was patched and not painted in multiple places.3. room [ROOM NUMBER], 105 and 201 the ceiling was peeling and hanging down.4. room [ROOM NUMBER] by the bathroom door and corner by the dresser was gouged and scraped.5. The wallpaper was torn on both sides of the door by room [ROOM NUMBER].6. Between room [ROOM NUMBER] and room [ROOM NUMBER] the wallpaper was torn.7. room [ROOM NUMBER] the wall behind and beside the bed had gouges in multiple places.8. Baseboard was missing in the hallway by room [ROOM NUMBER] and lounge area.9. The wallpaper was off the wall in the hallway by the TV lounge in the hallway.10. The wall across from room [ROOM NUMBER] in the hallway was patched in multiple places and not painted.11. room [ROOM NUMBER] the wall was gouged behind the bed by the window. The cover was off of the metal heating unit and blinds on the window were broken12. The wallpaper was torn in the hallway by room [ROOM NUMBER]. This was verified during interview with the Director of Nursing on 09/18/25 at 1:24 P.M. This deficiency represents non-compliance investigated under Complaint Number 2614300.

Based on observation, staff interviews, and review of facility policy, the facility failed to store perishable items under sanitary conditions. This had the potential to affect all 85 residents residing in the facility. All residents were identified as receiving meals from the kitchen. Findings include: Observations of the walk in freezer on 01/21/25 at 8:18 A.M. revealed several undated/unlabeled items which were later identified by Dietary [NAME] #205 as follows: four bags of hash browns removed from their original packaging and now stored in a two-gallon plastic storage bags, a bag of tater tots removed from their original packaging which had been opened and were now stored in a two-gallon plastic storage bag, one bag of chicken tenders removed from their original packaging and now stored in a two-gallon plastic storage bag, three bags of frozen drumsticks removed from their original packaging and now stored in two-gallon plastic storage bags, five bags of Hawaiian rolls and two of which had been previously opened, one previously opened bag of cinnamon rolls which were stuck together and now stored in a two gallon plastic storage bag, one pan of lasagna that had been removed from its original packaging and now stored in a two-gallon plastic storage bag, and one two-gallon bag of hot dogs that had been previously opened and were stuck together and had ice crystals on them. Interview with Dietary [NAME] #205 on 01/21/25 at 8:27 A.M. confirmed the presence of the above listed unlabeled and undated items which had either been previously opened, removed from their original packaging without labels and dates, and/or had evidence of being re-frozen or stuck together. Review of the facility policy titled Sanitation and Food Safety: Labeling and Dating revised in January 2025 revealed that all food items in the freezers must be clearly labeled and dated to ensure food safety and quality. This included leftovers, opened foods and sealed packages removed from their original shipping box/case. All food items must be labeled with the date that they were received or opened. Sealed packages removed from their original shipping box/case must be labeled with the date that they were received. When food was transferred to a zip top bag or sealed container, the new container must be labeled with the date the food was opened or transferred.

Based on observation, staff interview, and review of the shower cleaning sheets, the facility failed to maintain a clean and sanitary shower room. This affected all 45 residents (#3, #7, #11, #13, #14, #15, #18, #19, #20, #22, #23, #25, #26, #27, #30, #35, #36, #40, #41, #42, #43, #45, #46, #47, #49, #52, #59, #61, #62, #63, #64, #67, #69, #72, #73, #75, #79, #232, #233, #234, #236, #237, #282, #332, and #334) residing on the east wing of the facility who utilized the facility's shower room. The facility census was 85. Findings include: Observation on 01/21/25 at 11:40 A.M. of the facility's East Wing shower room revealed the room hosted two shower stalls. One stall was clear while the other stall hosted several shower chairs. Along the shower wall of the second shower stall was a moderate amount of green residue. Review of the Shower Cleaning Sheet revealed housekeeping staff were to clean shower rooms on Mondays, Wednesdays, and Fridays. The cleaning involved cleaning the sink, stocking soap and paper towels, disinfecting the tub, sweeping and mopping the floors, cleaning the toilets, checking the trash, and disinfecting showers and shower chairs. Housekeeper #208 signed off that she cleaned the shower room on 01/17/25 and 01/20/25. Interview on 01/21/25 at 11:40 A.M. revealed Certified Nursing Assistant (CNA) #129 reported the green mildew had been present for a couple of months. CNA #129 went on to say she had made maintenance aware that it needed removed awhile ago, but they had not done it. Interview on 01/21/25 at 1:48 P.M. Regional Maintenance Director #220 confirmed the environmental findings and reported it appeared to be algae. He stated they recently lost their maintenance director, and several issues had been missed. Interview on 01/22/25 at 12:11 P.M. Housekeeper #208 reported she was responsible for cleaning the showers three times a week on Mondays, Wednesdays, and Fridays. She reported that since the shower stall had shower chairs present, she has not been cleaning that stall. She went on to say she expected the facility CNAs to clean it after each shower. This deficiency represents non-compliance investigated under Complaint Number OH00161280.

Based on resident interview, staff interviews, and record review, the facility failed to provide unopened mail for Resident #41. This affected one resident (#41) out of one resident reviewed for privacy. Findings included: Review of the medical record revealed Resident #41 was readmitted on [DATE] with diagnoses that included type two diabetes mellitus with diabetic neuropathy, heart disease, obstructive and reflux uropathy, conduct disorder, chronic osteomyelitis, heart failure, major depressive disorder, dementia, suicidal ideation, depression, and hypertension. Review of the annual minimum data set (MDS) 3.0 dated 09/06/24 revealed Resident #41 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15. Resident #41 had no impairment of functional range of motion in upper or lower extremities and reported no pain and received no pain medication. Review of Resident #41's admission agreement dated 02/20/19 revealed he wished to receive his mail unopened. Interview on 01/21/25 at 11:00 A.M. with Resident #41 revealed Resident #41 received a package and it was open. Resident #41 felt it should have been opened in front of him. Interview on 01/21/25 at 1:44 P.M. with Receptionist #211 revealed she worked Monday through Friday. Receptionist #211 stated that she was to go through the mail and sort it out. If the item came in a box, she would use a box cutter to slice the top open, but she would not look inside. Receptionist #211 stated she then would give the items to activities to deliver the open boxes. Interview on 01/23/25 at 10:42 A.M. with the Administrator confirmed that packages delivered to the facility should go directly to the residents, unopened. This deficiency represents non-compliance investigated under Complaint Number OH00161280.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, policy review, facility investigation review and staff interview, the facility failed to prevent a resident fall with major injury. Actual Harm occurred on 06/24/24 when Resident #14, who was identified as a fall risk, was hit by a dietary cart (used to transport resident meal trays) that was being steered by Dietary [NAME] #20, causing the resident to fall and sustain a right hip fracture. The resident was emergently transported to the hospital and admitted for surgical intervention to repair the right hip fracture. This affected one resident (#14) of three residents reviewed for falls. The facility census was 70. Findings include: Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses that included femur fracture, metabolic encephalopathy, dementia, Alzheimer's disease, and anxiety disorder. Review of the Care Plan, dated 10/13/23, revealed Resident #14 was at risk for falls related to gait/balance problems, unsteady gait, history of falls, and the use of psychotropic medications and the resident used a walker. Review of the Minimum Data Set (MDS) assessment, dated 03/08/24, revealed Resident #14 was moderately cognitively impaired and had a diagnosis of Alzheimer's disease. The assessment indicated the resident was independent with most activities of daily living (ADLs) and his mobility device was a walker. Review of a Fall Risk Assessment, dated 06/10/24, revealed the resident was at risk for falls. Review of the nursing progress note, dated 06/24/24 at 11:45 A.M., revealed Resident #14 was found lying on the floor, on his back, in the lobby. Resident #14's walker was across the lobby. Resident #14 stated he was trying to get a puzzle out of the bookshelf. A skin tear to right elbow and left hand were noted. Resident #14 complained of right leg pain. The assistant director of nursing called emergency medical services (EMS); EMS arrived at approximately 11:55 A.M. Resident #14's granddaughter was notified, and a voice mail was left for Resident #14's son. Resident #14's son called back at 12:40 P.M. and was notified. Resident #14's physician was notified at 12:15 P.M. The progress note revealed an immediate intervention was to place a bright colored sign on Resident #14's walker to remind the resident to use his walker when ambulating. Resident #14 was alert and oriented and educated to always use his walker. Review of the Incident and Accident Investigation, dated 06/24/24, (authored by Licensed Practical Nurse (LPN) #34) revealed Resident #14 sustained a fall on 06/24/24 at 11:48 A.M. when he was hit with a dietary cart by staff who could not see the resident while pushing the cart, resulting in a fall. The resident sustained a fractured right hip and multiple skin tears. The investigation further revealed the incident occurred in the hallway and the immediate actions taken following the fall was the assessment of range of motion and vital signs. The resident was unable to straighten his right, lower extremity and rotation was noted. The resident was sent to the emergency room for evaluation and treatment. A bright colored sign was placed on the walker to remind the resident to use the walker. Review of the Emergency Department (ED) Provider Note, dated 06/24/24 at 12:52 P.M., revealed Resident #14 presented with a chief complaint of a fall and stated a staff member at the nursing home accidentally struck him with a dinner cart and he fell , landing on his right hip. The resident sustained skin tears to his left hand and right arm. Review of the right hip revealed deformity, tenderness, and decreased range of motion. Minor skin tears to the left, third and fourth digits and right elbow, forearm, and hand were noted. Review of a Hospital History and Physical (H and P) report, dated 06/24/24 at 2:01 P.M., revealed Resident #14 had diagnoses including Alzheimer's disease, who presented to the emergency roiagnom on [DATE] with right hip pain following a mechanical fall. The resident stated that he was at his nursing home facility, and someone was walking by with a cart that hit him and he lost his balance and fell on his right side. The resident was found to have a right hip fracture and was admitted for an orthopedic evaluation. The pre-operative evaluation determined the resident had a moderate risk for surgery, but the final decision to take the resident to the operating room was left to the surgical and anesthesia teams. Review of a progress note, dated 06/25/24 at 9:54 A.M., revealed the interdisciplinary team met to discuss Resident #14's fall on 6/24/24. All proper notifications were made. Immediate intervention was put in place and education was provided to all staff about using two staff to move the tall dietary cart. The interdisciplinary team agreed with interventions and plan. Review of a nurse practitioner progress note, dated 07/01/24, revealed Resident #14 was seen for a hospital follow-up. The resident was hospitalized from 06/24/24 through 06/28/24 due to a right hip fracture. His hospital course included surgical repair of a closed fracture of the right hip on 06/25/24, intravenous (IV) iron therapy, and aggressive bowel regimen for constipation. The resident's pain was controlled with narcotic pain medication. Interview on 07/16/24 at 9:15 A.M. with the Administrator verified Resident #14 had a fall on 06/24/24. The Administrator revealed the resident was walking in the main lobby without his walker when Dietary [NAME] #20, who was pushing the large dietary cart, accidentally bumped into the resident with the dietary cart. The Administrator stated the facility investigation revealed the staff member only looked around one side of the dietary cart and not both sides of the cart prior to pushing the dietary cart. The Administrator stated the staff member never saw Resident #14 and when the dietary cart bumped the resident, it caused him to lose his balance and fall. The Administrator confirmed the fall caused the resident to fracture his hip/femur which required a surgical repair. The Administrator stated the facility now requires two staff to move the large dietary cart to ensure residents are not bumped by the cart. Interview on 07/30/24 at 8:39 A.M. with Dietary [NAME] #20 revealed on 06/24/24 she was transporting the food cart through the corridor between the dining room and therapy area when she made a sharp turn. Resident #10 was located by the wall on the right side of the cart and Resident #14 was standing near the puzzles on the left side of the cart. Dietary [NAME] #20 stated that she was trying to avoid bumping into Resident #10 and did not see Resident #14 at the time. Dietary [NAME] #20 stated that she felt something, stopped pushing the cart, and then heard Resident #14 yelling. Dietary [NAME] #20 stated she looked around the cart and observed Resident #14 lying on the ground, grabbing the metal cart, and he must have hit something sharp which resulted in bleeding from one of his hands. Dietary [NAME] #20 stated a nurse came and assessed the resident immediately after the incident. Dietary [NAME] #20 confirmed she could not see over the tall, metal cart while pushing it from behind. The Dietary [NAME] verified she only looked around the right side of the cart but not the left side of the cart before she hit Resident #14. On 07/30/24 at 9:50 A.M., an interview with Regional Administrator #120 revealed she was unaware of any facility policy regarding safe transportation of dietary carts prior to the incident involving Resident #14. Review of facility policy and procedures revealed the facility did not have any type of policy in place related to moving the dietary carts prior to Resident #14's fall, nor did the facility have specific education for staff regarding the movement of dietary carts prior to Resident #14's fall. The deficient practice was corrected on 06/24/24 when the facility implemented the following corrective actions: On 06/24/24 the facility initiated a Facility Self-Imposed Action Plan which included the following: On 06/24/24, Resident #14 was immediately assessed by LPN #34 on 06/28/24 at 11:45 A.M. and sent to the emergency department for evaluation. The resident was admitted and his right hip was surgically repaired. On 06/24/24, one-on-one education was provided by the Administrator to Dietary [NAME] #20 that moving forward, all tall meal carts need to be taken to/from the unit/kitchen by two staff members to ensure the hallway is clear for the cart. On 06/24/24, 46 nursing, dietary, and housekeeping staff were educated by the Administrator via in-person or over the phone, that all tall meal carts will be transported to/from kitchen by two staff members (one in front and one in back). On 06/24/24, an initial audit was completed by the DON during the supper meal, to ensure the tall meal carts were being transported to/from the kitchen/unit with two staff members. On 06/24/24, the DON initiated an audit by observation to ensure tall meal carts are being transported to/from the unit/kitchen by two staff members. Audits will be completed twice weekly for four weeks then as determined by the DON or designee. The audits began on 06/28/24. All audits will be reviewed by Quality Assessment and Performance Improvement (QAPI) during meetings held monthly and any concerns will be addressed. Two new dietary carts, shorter in design and permit visibility over the cart during transport, were approved by corporate and ordered. The new carts will replace the current tall dietary carts. No further injuries have resulted from the dietary carts since 06/24/24. This deficiency represents non-compliance investigated under Complaint Number OH00155268.

Based on closed medical record review, review of a facility fall investigation, hospital record review, review of the facility Fall policy and interviews, the facility failed to provide Resident #78 adequate assistance for transferring/ambulation with toileting to prevent a fall with major injury. This resulted in Immediate Jeopardy and Actual Harm on [DATE] when Resident #78, who was admitted to the facility for rehabilitation status post hospitalization for a left total knee replacement (on [DATE]) and who was assessed to be at moderate risk for falls sustained a fall while being assisted by one State tested Nursing Assistant, (STNA) #176 to walk from her bed to the bathroom. The resident was subsequently assessed to have dislocation to her knee (replacement) and a popliteal artery injury (an injury mainly associated with high energy injury, including knee dislocation with causes including falls and crush injuries) requiring a left above the knee amputation. The resident did not return to the facility following the incident. This affected one resident (#78) of three residents reviewed for falls. The facility census was 77. On [DATE] at 11:16 A.M. the Administrator, Regional [NAME] President of Operations #402, Director of Clinical Services #404 and Regional Clinical Support #406 were notified Immediate Jeopardy began on [DATE] when staff failed to provide adequate assistance for toileting to Resident #78 resulting in a fall with major injury. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 7:20 P.M., Licensed Practical Nurse (LPN) #100 responded to the State tested Nurse Aide (STNA) #176 yelling for help. The resident had sustained a fall and was subsequently transported to the hospital on [DATE] at 7:45 P.M. On [DATE] at 11:46 A.M., all 33 facility STNA staff, 18 Licensed Practical Nurses (LPNs), and four Registered Nurses (RN) were educated by Onshift (e-mail or text) by the Director of Clinical Services #404 on the following topics: 1. All new admissions should use a gait belt and staff assistance of two with transfer/ambulation until evaluated or screened by therapy or a nurse. 2. Residents care plans would be updated after evaluation/screen with the level of assistance needed. 3. Any staff who does not answer/not working on [DATE] would be educated prior to their next shift by Director of Clinical Services #404. On [DATE] by 2:15 P.M., an audit was completed for all in house residents by therapy staff to ensure the correct transfer status. On [DATE] at 2:15 P.M., the Director of Clinical Services #404 and Regional Clinical Support #406 updated all resident care plans related to transfer status. The facility developed a plan for the Director of Nursing/Designee to audit five times a week for four weeks on new admissions that their interview and/or observations notes support two-person assist and gait belt use were provided until the resident was evaluated by a therapist/nurse. On [DATE] a Quality Assurance (QA) meeting was held with the following staff members in attendance: Medical Director #414, the Administrator, Regional [NAME] President of Operations #402, the Director of Nursing (DON), Director of Clinical Services #404, and Regional Clinical Support #406. The facility developed a plan for the QA committee to review audit results weekly for four weeks. On [DATE] from 9:01 A.M. to 10:05 A.M., interviews with Activity Director #104, Activity Aide #110, and STNA #170, revealed they had received education to use a gait belt and the assistance of two staff members for any new admission until the resident was evaluated by therapy. On [DATE] from 9:01 A.M. to 10:05 A.M., interviews with LPN #200 and LPN #121 revealed they received education to ensure staff used a gait belt and the assistance of two staff members for all new admissions until the resident was evaluated by therapy and new interventions were to be added to the plan of care by the nurses when implemented. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #78's closed medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including left total knee replacement, diabetes with diabetic polyneuropathy, severe obesity, chronic venous insufficiency, chronic diastolic heart failure, and chronic venous hypertension with inflammation of bilateral lower extremities. The resident was admitted to the facility from the hospital for rehabilitation status post total left knee replacement (on [DATE]). The resident's height was noted to be four feet 11 inches with a weight of 207 pounds per medical record information from [NAME] Hospital. Review of the hospital physician assistant note dated [DATE] at 8:15 A.M. revealed Resident #78 had not yet been seen by physical therapy. Nursing reports Resident #78 wanted to get up to use the restroom and Resident #78 took a couple steps then requested a bedside commode due to pain. Resident #78 then required staff assistance and use of a [NAME] steady (a manual sit-to-stand transfer aid that enables one caregiver to transfer safely) to get back into bed. Review of a hospital rehabilitation therapy progress notes, written by the physical therapist dated [DATE] at 12:54 P.M., revealed the resident's transfer level of assistance required was moderate assistance: two-person assist. Resident #78 could stand with minimum of two-person assist. Resident #78 did not put weight on the left lower extremity and was unable to pick up the right lower extremity to take steps due to putting all her weight on that side. The note indicated the physical therapist was unable to assess ambulation. Review of a hospital therapy note dated [DATE] revealed Resident #78 was weight bearing as tolerated, had decreased lower extremity range of motion, decreased lower extremity strength, decreased functional mobility, impaired gait, increased fall risk, and balance deficits with pain limiting mobility. Review of a Hospital Discharge Examination, printed on [DATE] at 9:27 A.M. revealed Resident #78 was alert and in no apparent distress while sitting up in bed eating breakfast. The resident was doing fair postop day #2 from a left total knee arthroplasty. The resident's pain was controlled with the current pain regimen. She has been up with physical therapy but has not been moving very well. Review of the hospital Orthopedic Discharge Instructions dated [DATE] revealed Resident #78 had a total left knee arthroplasty on [DATE] (left) and activity was weight bearing as tolerated on operative leg and use of cane/walker during ambulation. The resident was noted to have a follow-up appointment with the surgeon in two weeks (no specific date provided). Review of the hospital Ambulance Transfer form (form provided from the hospital to ambulance company for continuity of care during transport) dated [DATE] at 12:02 P.M. revealed mobility level of assistance: Activity: in chair and the level of assistance required was four assists; at a moderate fall risk. Review of a handwritten admission report form dated [DATE] and completed by LPN #116 (report from the hospital staff to the nursing home staff) revealed Resident #78 had a left total knee replacement, left lower extremity weakness, was alert and oriented to person, place, time, and event, required ,d+[DATE] assist, and knee brace to be worn when up. Review of the facility admission assessment dated [DATE] and completed by LPN #116 revealed Resident #78 was admitted with left lower extremity weakness following a left total knee replacement. Resident #78 required limited assistance for transfers, toileting, and walking in room. Resident #78 was assessed as having unsteady gait. Review of baseline care plan dated [DATE] at 5:19 P.M. revealed Resident #78 was admitted on [DATE] for aftercare following joint replacement surgery with an anticipated short term stay at the facility. The baseline plan of care addressed activities of daily living (ADL's) indicating the resident was at risk for decline related to recent need for nursing home placement. The goal was to assist the resident to achieve desired level of ADL assist or independence. The intervention noted was therapy screen. The baseline plan of care revealed the resident was a Fall Risk/Safety Risk with a goal to minimize risk for falls. The intervention revealed to encourage call light use. The baseline plan of care also noted the resident was having current pain with an intervention to administer medication as ordered and note effectiveness. Lastly, the baseline plan of care included Therapy with a goal to identify therapy needs to maintain/improve functional status. A section for weight-bearing status was blank. Interventions under this section were also blank. Review of a nursing progress note, dated [DATE] at 4:41 P.M. and authored by LPN #116 included the resident arrived via cot at 3:30 P.M. Family was not at bedside but on the phone (did not specify which family was on the phone). Resident arrived alert and oriented (x4). The note revealed the resident denied pain. Foley catheter in place, but resident verbalizes continence of bladder before placement. Resident verbalizes continence of bowel. Resident is oriented to call light, bed alarm. No complaints or problems verbalized at this time. The note failed to contain any evidence the resident was assisted to stand/ambulate at the time of this note or that her ambulation/transfer ability was assessed. Review of a #716 Fall electronic note dated [DATE] at 7:20 P.M. and completed by LPN #100 revealed this nurse was administering medication to another resident when she heard STNA #176 yelling for help. When the nurse entered Resident #78's room, the resident was lying face down in front of the bathroom with her legs stretched out. Blood was coming from the incision to the left knee. Resident #78 stated STNA #176 was assisting her to the bathroom with her walker when her left leg gave out. The ambulance was called at 7:24 P.M. and arrived at the facility at 7:30 P.M. Resident #78 left the facility at 7:45 P.M. A corresponding nursing progress note, dated [DATE] at 11:04 P.M. and authored by LPN #100 included the same information as the #716 Fall electronic document. Review of a facility fall investigation dated [DATE] at 7:30 P.M., completed by LPN #100 and signed by the DON revealed the resident stated she was walking to the bathroom when her left leg gave out on her. The fall investigation noted the cause of the fall was the resident was ambulating to the bathroom with one assist with walker when her left leg gave out on her. A witness statement written by STNA #176 dated [DATE] at 7:20 P.M. revealed the STNA answered Resident #78's call light and Resident #78 asked for help to the bathroom. STNA #176 started to assist Resident #78 and when Resident #78 got to the bathroom door she stated honey, I can't it hurts and then Resident #78 began to fall. STNA #176 stated she had a hold of one of Resident #78's arms and helped guide her to the floor. Review of fall risk assessment dated [DATE] at 11:06 P.M. revealed Resident #78 was at moderate risk for falls. Review of the resident's medical record revealed prior to the fall that occurred on [DATE] at 7:20 P.M. she had not been assessed or physically seen by a facility physician or by staff from the facility therapy department. Review of a local hospital report (Genesis Hospital) dated [DATE] revealed Resident #78 had a knee arthroplasty completed on [DATE]. The resident had a bit of difficult recovery with therapy and moving after her surgery. She was transferred to the (skilled nursing) facility this afternoon and apparently while trying to be transferred to the bathroom she sustained a fall and the inability to ambulate. She landed directly on this knee. She was evaluated in the emergency department and identified to have dislocated total knee arthroplasty. Commuted tomography (CT) angiogram (procedure to visualize blood vessels) was obtained which revealed a popliteal injury. Physician #254 was of course called as this was my patient and again patient was two days post-op. She presents with close dislocation of the total knee arthroplasty. The CT scan reveals disarticulation of the knee with anterior translation of the tibia on the femur. There is also a popliteal artery injury and suspected also neurologic injury. After the knee was reduced a light wrap was placed on the knee as this did cause some bleeding of the incision, however there was no recovery of the pulses when assessed with the doppler. There is no recovery of the neurologic function of the foot. The resident was transferred to Ohio State University ([NAME]) Hospital as the neurovascular injury was concerning and felt to be more than what could be handled here by our vascular team. From the total knee standpoint this was something that could be dealt with in the future and revision may be necessary as obviously there was ligamentous integrity issue with this knee at this point. The neurovascular status of the lower extremity however takes precedence at this time. Post-reduction films were obtained. The knee was located and joint concentric. No obvious fractures were noted. Review of the CT ANGIO of the left lower extremity dated [DATE] revealed Clinical Indications: Popliteal entrapment syndrome suspected. (a rare condition that affects the main artery behind the knee, called the popliteal artery. In this condition, the calf muscle is in the wrong position or it's larger than usual. The muscle presses on the artery, making it harder for blood to flow to the lower leg). The left lower extremity was reduced prior to transfer to [NAME]. Post reduction x-rays were obtained showing a successfully reduced concentric knee. On presentation to the trauma bay she presented with cold left lower extremity without left popliteal, posterior tibial and dorsalis pulse signals. Compartments feel tight and there was loss of motor and sensation to the extremity. Resident #78 consented for possible fasciotomy, possible bypass, possible left lower extremity amputation, we will proceed to the operating room. A left above knee amputation was deemed necessary. Review of an [NAME] social worker progress note dated [DATE] revealed Resident #78 stated that the accident (fall) occurred because she had slipped on the floor while an aide was helping her to ambulate at the skilled nursing facility. She reported that she told the aide that she would need two people to help her, but the aide insisted that she would be able to help lift her. Review of [NAME] discharge summary dated [DATE] revealed Resident #78 was status post above left knee amputation on [DATE] and was being discharged to an in-patient rehabilitation facility. On [DATE] at 11:01 A.M., during an interview with the DON, the DON revealed STNA #176 had not been using a gait belt when assisting Resident #78 on [DATE] prior to the fall and that the facility doesn't have a policy for use of a gait belt. However, the DON indicated gait belts were available for use. When asked if a gait belt should have been used, the DON again indicated they were available for use. The DON reported Resident #78 did have a knee brace in place at the time of the incident. On [DATE] at 11:08 A.M., telephone interview with STNA #176 revealed on [DATE] she had answered Resident #78's call light and then assisted the resident to get up (to go to the bathroom). The STNA revealed the resident had her knee brace on and her walker. The STNA stated they got to the bathroom door, and the resident said her leg was hurting so she put on the resident's call light and then the resident said I can't and started going down. The STNA stated she was standing on the resident's weak side, so she assisted her to the floor and then ran out and yelled for help. The STNA verified she was not using a date belt at the time of the transfer/ambulation with the resident. There were no other staff in the room assisting with the resident's care at the time of the incident. Interviews conducted on [DATE] and [DATE] at various times during the onsite investigation with STNA #134, #148, #157, #170 and #181 all indicated gait belts should be used with all residents when transferring unless directed otherwise. On [DATE] at 3:15 P.M., a telephone interview with Physical Therapy Assistant (PTA) #212 (from Genesis Hospital therapy department) revealed following the total knee replacement on [DATE], Resident #78 required a two person assist to get from the bed to the chair and stated that was all Resident #78 really did while she was in the hospital. On [DATE] at 4:48 P.M., a telephone interview with Resident #78 revealed she had been admitted to the facility for therapy to gain additional strength to be able to go home. The resident revealed on the d. The resident stated the STNA told her, I got you, but my leg was still numb. The resident indicated the STNA didn't have a gait belt; she grabbed the back of my gown. I told her I wasn't going to make it and tried to sit back down on the bed and the walker went one way and I went the other. I fell face down and onto my knee, the STNA did not lower me to the floor. I was told to stay the way I was until the ambulance arrived and they got me onto the cot. On [DATE] at 8:25 A.M., interview with Resident #18, (Resident #78's roommate at the time of the fall on [DATE]) revealed STNA #176 had stood Resident #78 up to go to the bathroom. Resident #78 was bent over and leaning forward, and her knee brace looked loose and then dropped down. When STNA #176 bent to pull it up, Resident #78 fell forward. On [DATE] at 9:06 A.M., a telephone interview with Physician #258, the vascular surgeon from [NAME] revealed Resident #78 had a blocked artery from the fall and dislocation of the knee which probably precipitated this event (the amputation). Physician #258 revealed his intention was to try and save the extremity, however the duration of time from the injury, and it was in such bad condition and the muscle had already died , he could not. On [DATE] at 1:21 P.M., a telephone interview with Physician #254, the orthopedic surgeon who completed Resident #78's left total knee replacement (on [DATE]) revealed the injury she sustained would not have happened if she had not had the fall. When she fell it dislocated the knee causing the injury. He also revealed she was having a hard time with even ambulating before she left the hospital, that was why she was sent to the facility. The physician stated most patients go home the next day. During the interview, the physician indicated the resident required at least two persons for transfer/ambulation. On [DATE] at 2:15 P.M., during a telephone interview with LPN #116, the LPN who completed the admission assessment for Resident #78, the LPN was asked how she determined Resident #78 required limited assistance for toilet use and transfers. The LPN stated she completed an interview with the family and resident, and also conducted an observation. She stated she had Resident #78 stand, and she used a walker and a gait belt, and she took a couple steps. She revealed she also had two STNAs present in the room with her at the time. The LPN stated she felt the resident required one to two staff to assist, but at the time she evaluated her, she only needed one. There was no indication during the interview as to how it would be determined or who would determine what level of assistance the resident would need to transfer/ambulate (one or two staff) until the time she was evaluated/assessed by therapy staff. On [DATE] at 10:05 A.M. a telephone interview with One [NAME] RN/Clinical Coordinator #214 from Genesis Hospital revealed at the time of discharge from the hospital on [DATE], Resident #78 required a forward wheeled walker and the assistance of two staff for transfers/ambulation. On [DATE] the facility provided a written statement from LPN #116, dated [DATE]. The statement indicated I received report from Genesis hospital, during that report I was told by the nurse overseeing [Resident #78's] care that she was a x1 assist. I was also told by the same nurse that the nursing staff at Genesis had had her up and ambulating and she performed well. This statement did not address why the same nurse documented on the handwritten hospital admission report the resident was a one to two assist. There was no statement from LPN #116 on [DATE] at the time of the incident. On [DATE] from 4:51 P.M. to 5:11 P.M. telephone interview with Resident #78's daughter revealed she was not present with the resident at the time she arrived to the facility on [DATE] from the hospital, however she did get to the facility at approximately 4:,d+[DATE]:45 P.M. The daughter indicated she stayed at the facility for approximately an hour to an hour and 45 minutes and during that time period, three staff members had come into the resident's room to weigh the resident. The daughter indicated the resident was weighed in bed and did not get out of bed during the weighing process. Resident #78, was also present during this call and was asked if she had been out of bed or if she had stood/taken steps/walked with staff following her admission prior to the incident when she fell . The resident denied being out of bed prior to when she fell . The resident again reported she fell while being helped to the bathroom by one STNA and the STNA didn't have a gait belt. When asked what the resident's ambulation status had been in the hospital prior to admission, the resident's daughter indicated she was not aware the resident had been walking in the hospital prior to the nursing home admission and stated that was part of the reason why she was being transferred to the nursing home (for therapy). The daughter revealed staff had reported to her during her visit that no one from therapy was in the facility at that time, stating he had already left for the day so the resident would not been seen on this date. The daughter indicated she was unaware when therapy would start for the resident. The resident's daughter indicated she had left the facility to go home and hadn't been gone very long when she got a call that there had been an incident (the daughter indicated she was still driving at the time the call came to her). The daughter stated the call had come on [DATE] at 7:36 P.M. She stated she turned around and went straight to the hospital, arriving there between 7:40 P.M. and 7:45 P.M. and indicated the resident was in x-ray when she arrived to the hospital. Review of the Fall Policy dated ,d+[DATE] and revised ,d+[DATE] revealed it was the policy of the facility to assure proper fall risk and implementation of interventions to attempt to prevent or reduce falls/accidents and injuries related falls. Facility staff worked with the resident/resident representative to determine risk factors for falls and appropriate interventions that promote independence while reducing the risk of falls/injuries from falls. This deficiency represents non-compliance investigated under Compliant Number OH00149311.

Based on record review, interview, policy review and manufacturer guideline review the facility failed to ensure guidelines were followed related to the re-insertion of a gastrostomy tube. This affected one resident (Resident #5) of one resident reviewed for tube feeding. Actual harm occurred when Resident #5 developed a [DIAGNOSES REDACTED] perforation related to [DIAGNOSES REDACTED] ulceration secondary to pressure necrosis from a prolapsed percutaneous endoscopic gastrostomy tube (PEG ) replacement balloon. The facility identified one resident with a tube feeding. Findings include: Review of Resident #5's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the hospital records dated 11/10/17 revealed the resident had a PEG ( tube passed into the resident's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate or because of difficulty swallowing). The records did not indicate the size of the tube inserted but did instruct the resident to contact physician if the tube became blocked and unable to be flushed with warm water. Review of the (MONTH) (YEAR) physician orders [REDACTED]. The tube was used for medication administration and for bolus feeding if the resident's meal intake was less than 50 percent. The resident also had 200 cubic centimeter (cc) water flushes four times a day and 120 cc water flush before and after all bolus feedings. The PEG tube site was to be cleansed daily with normal saline and covered with a split 4 x 4. Review of the Nurse Progress Notes dated 04/09/18 at 10:37 A.M. revealed Licensed Practical Nurse (LPN) #4 went to flush the resident's PEG tube per order. The tube was noted to be clogged. The LPN attempted to unclog the tube with a declogger but it was ineffective. Twenty cubic centimeter of solution was removed from the balloon and the PEG tube was removed. A 20 french gastrostomy tube with a 20 cc balloon was inserted. Thirty cubic centimeters of normal saline was inserted into the balloon. Placement was verified with air bolus and aspiration. The dressing to the site was changed and the resident tolerated well. The tube was flushed with 200 cc of water per orders. No distress was noted. Further review of the Nurse Progress Notes revealed on 04/16/18 at 6:15 A.M. the resident was noted to have a large coffee ground emesis at that time. A foul odor was present. The resident's husband was notified. At 6:45 A.M. the resident's husband contacted the facility and requested the resident be sent to the hospital for an evaluation. Review of the brief summary of hospital course dated 04/23/18 revealed the resident was admitted to the hospital for a pneumoperitoneum secondary to [DIAGNOSES REDACTED] perforation related to [DIAGNOSES REDACTED] ulceration secondary to pressure necrosis from prolapsed PEG replacement balloon. Surgery had initially been consulted and recommended a possible bowel resection with definite placement of a jejunostomy tube (surgical creation of an opening through the skin at the front of the abdomen and the wall of the upper part of the small intestine) and intraperitoneal drains. However, surgery made it known the patient may never completely recover after the operation and that there were significantly high risks of perioperative mortality. The family opted against surgical intervention and requested to pursue supportive care with antibiotics and monitor for improvement. The resident was taken to upper endoscopy and the gastrostomy tube bulb was decompressed and removed and a regular PEG tube was placed per gastrointestinal. A repeat CT scan was obtained and showed the [DIAGNOSES REDACTED] perforation had healed. The resident was to return to the facility and take 10 days of antibiotics. On 03/28/19 at 9:41 A.M. interview with the resident's spouse revealed the resident was hospitalized in (MONTH) of (YEAR) due to the resident's bowel being perforated during a PEG tube replacement. Further interview revealed the resident remained in the hospital for a few days before returning to the facility. On 03/28/19 at 2:06 P.M. interview with LPN #4 revealed she did contact the resident's physician to notify him the tube was clogged and received an order to change the tube. LPN #4 stated it was difficult to recall the incident since it had almost been a year and verified the medical record did not contain an order for [REDACTED].#4 verified she over-inflated the 20 cc balloon and stated it was protocol to over-inflate the tube balloon. On 03/28/19 at 2:24 P.M. interview with Physician #200 revealed he was Resident #5's primary care physician as well as the facility medical director. Physician #200 stated he was notified the resident's PEG tube had come out and needed replaced. The physician stated he gave the order to change the tube since it wasn't a newly placed PEG tube. Further interview revealed the original tube probably had a mushroom and when the mushroom was removed and replaced with a tube with a fluid filled balloon, the stomach could have pushed the tube through the stomach lining causing a perforation. Physician #200 stated he could not attest to the nurse's technique for insertion since he was not present at the facility during the replacement of the tube. Lastly the physician expected to be called each time the tube would need replaced. On 03/28/19 at 3:10 P.M. interview with Registered Nurse (RN) #73 verified the recommendation for balloon inflation of a 20 french gastrostomy tube was 20 cc of fluid. The RN verified LPN #4 did not follow manufacturer guidelines related to the tube and over-inflated the balloon. Further interview revealed the facility did not complete an investigation related to the incident and the facility should have completed an investigation since the resident was hospitalized shortly after a procedure was completed in the facility. Review of the gastrostomy feeding tube with y-ports manufacturer guidelines (not dated) revealed to not exceed the recommended balloon inflation volume. For a 20 french gastrostomy tube the balloon size was 20 cc. Assess balloon inflation daily by withdrawing 3-5 cc of water from the inflation lumen. If the water contained gastric content, the balloon had been damaged and the catheter must be replaced. If the water did not contain gastric content, reinject the water. Review of the un-dated tube feeding policy revealed a physician's orders [REDACTED]. If the tube was dislodged staff were to follow the physician's orders [REDACTED].

Based on record review, review of the physician's standing orders, review of the ambulance transport report, review of hospital records, and physician and staff interview, the facility failed to ensure one resident (Resident #80) who received scheduled insulin received appropriate monitoring of blood sugars to prevent [DIAGNOSES REDACTED]. Actual harm occurred when Resident #80, who received scheduled NPH insulin twice a day for three days without blood glucose monitoring, became unresponsive and was sent to the hospital and found to have a blood sugar level of 24 milligrams/deciliter (normal fasting blood sugar range 70-110) requiring treatment with intravenous [MEDICATION NAME]. This affected one of three residents reviewed for unnecessary medications. Findings include: A review of Resident #80's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #80's admission orders [REDACTED]. The resident also had orders to receive [MEDICATION NAME] (an oral hypoglycemic used to lower blood sugar levels) 10 milligrams (mg) by mouth (po) twice a day and [MEDICATION NAME] (oral hypoglycemic) 1000 mg po twice a day for diabetes mellitus. The admission orders [REDACTED]. A review of Resident #80's Medication Administration Record [REDACTED]. He also received the oral hypoglycemics ([MEDICATION NAME] and [MEDICATION NAME]) twice a day as ordered through the evening dose on 08/11/18. The MARs showed no evidence of the resident having a FSBS completed to monitor his blood sugar while receiving his diabetic medications. A review of Resident #80's nurse's progress note for 08/12/18 revealed the state tested nursing aides (STNA) were unable to arouse the resident for breakfast around 8:30 A.M. They attempted to arouse him again at 8:45 A.M. with no responses. The nurse on duty verified he was not responding to verbal stimuli or a sternal rub. Vital signs were checked as part of the nurse's assessment but the nurse did not obtain a blood sugar level by a finger stick as part of her assessment. The community ambulance was called at 9:05 A.M. and they responded to transport the resident to the hospital at 9:20 A.M. A review of the ambulance transport report dated 08/12/18 revealed the ambulance company responded for a possible stroke. The secondary complaint was unresponsiveness. Vital signs obtained by the ambulance personnel did not include a blood sugar. The narrative note indicated they were dispatched to the facility for an unresponsive resident with a possible stroke. The ambulance personnel was informed Resident #80's history only included pneumonia and a recent cardiac stent. His paperwork also indicated an aortic aneurysm. There was no evidence of the facility informing the ambulance personnel of the resident having diabetes requiring insulin and oral hypoglycemics. A review of a hospitalist history and physical dated 08/13/18 revealed Resident #80 presented to the hospital with a facial droop and confusion. On admission, his glucose was 24 milligrams/deciliter (mg/dl). Resident #80 was given intravenous (IV) [MEDICATION NAME] to raise his blood glucose level. He remained in the hospital until 08/16/18. Upon his return, he was no longer receiving [MEDICATION NAME] and his NPH insulin was ordered to be given at 20 units sq twice daily. FSBS were ordered to be checked twice a day before insulin administration. A review of Resident #80's physician's standing orders revealed FSBS were to be completed per in house protocol two days a week fasting and at 5:00 P.M. if the resident had a [DIAGNOSES REDACTED]. On 09/24/18 at 4:35 P.M., an interview with Physician #10 via phone revealed he would have recommended Resident #80's FSBS be checked twice a week if he was in good control. He stated he would have liked the facility to check it around the time he was first admitted and then twice weekly thereafter. He reported he also would have expected the nurse to check his blood sugar on 08/12/18 when the resident was found unresponsive as part of her assessment and workup for the resident's altered mental status. On 09/24/18 at 4:55 P.M., an interview with the Director of Nursing (DON) confirmed Resident #80 was on scheduled NPH insulin and oral hypoglycemics upon his admission without orders to monitor his blood glucose levels with FSBS. She confirmed the nurse who admitted the resident should have clarified the need to obtain FSBSs with the physician since he was receiving scheduled insulin. She stated physician standing orders were to obtain a FSBS twice a week unless the resident was on sliding scale insulin. She also agreed the nurse should have obtained a FSBS when Resident #80 was found unresponsive on 08/12/18 as part of her assessment with his altered mental status. The DON indicated the nurse suspected the resident was having a stroke as he had left sided facial drooping. She acknowledged there was ample time to obtain a FSBS while awaiting the ambulance to arrive as part of the assessment of the resident's vital signs. The DON verified Resident #80's blood sugar was 24 mg/dl when he was checked at the hospital. The DON acknowledged the blood glucose level was dangerously low and could have resulted in the resident's death if not identified by the hospital and [MEDICATION NAME] administered via IV.

Based on closed clinical record review, review of laboratory blood test results, review of hospital documentation, policy review, review of the Physician Desk Reference (PDR) 2015 Edition Nurse's Drug Handbook and staff interview, the facility failed to ensure laboratory testing and clinical monitoring of cardiac medication ([MEDICATION NAME]), administered for [MEDICAL CONDITION], was completed as ordered by the physician for Resident #1. This resulted in a significant change and an Immediate Jeopardy in the resident's medical condition when on [DATE] at approximately 10:10 P.M., Resident #1 was found unresponsive with her pupils fixed and dilated. The resident's blood pressure was ,[DATE] and a heart rate was difficult to obtain. The resident was transferred to the hospital where she was assessed to have a critically high toxic [MEDICATION NAME] blood level. The resident expired at the hospital. This affected one (Resident #1) of seven residents reviewed for [MEDICATION NAME] medication therapy. The facility census was 91. On [DATE] at 4:45 P.M. Corporate Registered Nurse (RN) #20 and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when the facility failed to obtain a [MEDICATION NAME] blood level for Resident #1 as ordered by the physician. On [DATE] at approximately 10:10 P.M., Resident #1 was found unresponsive, transferred to the hospital and was assessed to have a toxic [MEDICATION NAME] blood level. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective measures: · On [DATE], the DON completed a review of all six medical records of the current residents (Residents #11, #57, #58, #63, #22 and #75) who received [MEDICATION NAME] medication therapy. The records were reviewed and audited for physician orders, laboratory testing orders, review of when the next laboratory testing was ordered and review of the medication administration record. Another review was completed on [DATE] by the DON. · On [DATE], Corporate RN #20 initiated in-service training for the 23 Registered Nurses (RN) and Licensed Practical Nurses (LPN) which included education related to missing laboratory draws, laboratory notification and falls. As of [DATE], six of 23 nursing staff had not received the training. However, a plan was in place to ensure all staff received training. · On [DATE], interview of five licensed nurses (RN #5, LPN #6, LPN #7, LPN #8 and LPN #9) revealed all were knowledgeable regarding [MEDICATION NAME] administration/monitoring, and signs and symptoms of [MEDICATION NAME] toxicity and verified they had recently received training. · On [DATE], review of the medical records for Residents #11, #57, #58, #63, #22 and #75 revealed laboratory testing for the monitoring of [MEDICATION NAME] had been completed as ordered. Although the Immediate Jeopardy was removed on [DATE] the deficiency remains at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) as six of 23 professional nursing staff had not received formal re-education regarding obtaining ordered laboratory blood draws. All staff had not been educated regarding the clinical signs/symptoms of [MEDICATION NAME] toxicity and the facility had not initiated a policy and procedure related to the administration of [MEDICATION NAME]. Findings include: Review of Resident #1's closed medical record revealed the resident was admitted to the facility on [DATE] following a hospitalization for hip replacement surgery. The resident had [DIAGNOSES REDACTED]. Review of the resident's admission physician orders [REDACTED]. Review of skilled assessment notes during the resident's stay from [DATE] through [DATE] revealed the resident was alert but confused. Review of a nursing progress note dated [DATE], revealed Resident #1 was seen by the physician. Following the physician visit, a new order was received for a [MEDICATION NAME] level and a complete blood panel to be completed in one week. The physician also ordered the anti-depressant medication, [MEDICATION NAME] 15 milligrams once a day at night time and a multivitamin every day. Review of a dietary progress note, dated [DATE] revealed Resident #1's weekly weight was 116 pounds which reflected a five pound weight loss in the past week. The note reflected the resident's intake remained poor and the resident voiced a history of gastrointestinal reflux disease (GERD). Review of dietary progress notes dated [DATE], revealed Resident #1's daughter questioned if nutritional supplementation had been offered to the resident and was concerned about the resident's poor appetite. The daughter was informed that multiple supplements had been offered and that staff would continue to offer alternate food choices and encouragement when needed. On [DATE], Resident #1's blood pressure medication, [MEDICATION NAME] was decreased from 10 milligrams to five milligrams daily. A corresponding physician's progress note revealed her [MEDICATION NAME] was decreased due to the tendency to become a nonspecific beta blocker (drugs that slow the heartbeat, lessen the force with which the heart muscle contracts and reduce blood vessel contraction in the heart, brain and throughout the body) at high doses. There was no mention of the resident's [MEDICATION NAME] medication at that time or follow up related to the ordered laboratory testing that should have been completed on this date. Review of the social service progress note, dated [DATE], revealed the resident had mood complaints of feeling down, depressed, trouble sleeping and poor appetite. Review of the dietary progress note, dated [DATE], revealed a 14 day assessment was completed. The note indicated the resident's oral intake remained less than desirable. Resident #1's current body weight was 116 pounds which again reflected a five pound weight loss since admission. A nursing progress note, dated [DATE] revealed Resident #1 was seen by the physician and a new order was received to decrease the resident's potassium chloride (K-Dur) from 20 milliequivalents (meq) to 10 meq. K-Dur is a medication used to prevent or to treat low blood levels of potassium. Review of the corresponding physician progress notes [REDACTED]. There was no mention of the resident's [MEDICATION NAME] medication or follow up of the laboratory testing ordered to have been completed on [DATE]. On [DATE], Resident #1 was seen for an outside appointment with the orthopedic physician. The orthopedic physician ordered [MEDICATION NAME][MEDICATION NAME](oral disintegrating tablet) 4 milligrams (mg) by mouth every eight hours as needed for nausea and vomiting. Resident #1 received the [MEDICATION NAME] on [DATE] (twice); [DATE] and [DATE]. However, there was no documentation that the resident was experiencing nausea and/or vomiting in the nursing progress notes. On [DATE], review of the dietary assessment revealed the resident displayed episodes of confusion at times. The resident's current body weight was 114 pounds which reflected a 6.8 pound weight loss since admission. On [DATE], review of the physician progress notes [REDACTED]. There was no mention of the resident's [MEDICATION NAME] medication or follow up of the laboratory testing ordered to have been completed on [DATE]. Speech Therapist #22 also noted therapy attempted a cognitive screen; however the resident presented with increased lethargy and required multiple cues to arouse. The resident was oriented to the month, day and year, but required choice cues to orient to the name of the building. The screen was discontinued due to increased fatigue and decreased attention. Nursing progress notes dated [DATE], revealed physical therapy staff called the nurse to the resident's room due to complaints of dizziness upon sitting up on the bedside. On [DATE] Certified Nurse Practitioner (CNP) #23 visited the resident related to the complaints of dizziness and also for right ankle pain. CNP #23 noted the resident had osteopenia and [MEDICAL CONDITION] of the right ankle and was started on Calcium with Vitamin D. No new orders related to the dizziness were noted. Additionally, there was no mention of the resident's [MEDICATION NAME] medication or follow up of the laboratory testing ordered to have been completed on [DATE]. Review of a fall assessment/situation, background, assessment, recommendation (SBAR) revealed on [DATE] at 1:00 P.M. Resident #1 was found face down on the floor in her room. The resident was assessed to have a hematoma to the forehead. The resident stated she was grabbing for a drink on her table and fell forward. The physician was notified and the note indicated Resident #1 would be monitored. Record review revealed a corresponding nursing progress note, completed as a late entry on [DATE] at 3:15 P.M., which also reflected the fall had occurred. The next entry in the nursing progress notes, authored by LPN #21 and dated [DATE] at 11:26 P.M., revealed on [DATE] at approximately 10:10 P.M., Resident #1 was found by nursing staff unresponsive but breathing. Her pupils were fixed and dilated, heart rate was difficult to obtain and the blood pressure was ,[DATE]. The physician was notified and an order was given to transfer the resident to the emergency room for an evaluation. Resident #1 did not return to the facility and subsequently expired at the hospital on [DATE]. On [DATE] at 12:56 P.M., interview with RN #33 revealed the [MEDICATION NAME] laboratory test, ordered on [DATE] was not obtained and should have been completed on [DATE]. RN #33 also verified the resident was admitted to the hospital on [DATE] for [MEDICATION NAME] toxicity and [MEDICAL CONDITION]. Review of hospital documentation, dated [DATE] revealed Resident #1 was admitted to the hospital with [REDACTED]. Resident #1 went into [MEDICAL CONDITION] en-route to the hospital from the facility. Review of hospital documentation notes revealed Resident #1 was admitted to the hospital status [REDACTED]. The laboratory results at the hospital on [DATE] revealed Resident #1's potassium level was critically high at 11 mmol/L (normal range was 3.5 mmol/L-5.00 mmol/L). The hospital records also indicated Resident #1's [MEDICATION NAME] level was critically high toxic at 4.0 ng/mL (normal range is 0.8 ng/mL-2.0 ng/mL). Resident #1 expired at the hospital on [DATE]. On [DATE] at 12:14 P.M. interview with the DON revealed the facility did not have a policy and procedure related to the administration of [MEDICATION NAME] including the monitoring for signs or symptoms of [MEDICATION NAME] toxicity. Additionally, the DON revealed there was no routine monitoring of resident's apical pulse related to the administration of the [MEDICATION NAME] medication. On [DATE] at 4:28 P.M. interview with CNP#23 who saw the resident on [DATE] revealed she did not review the resident's [MEDICATION NAME] therapy or follow up to review why laboratory testing was not completed as ordered on [DATE] to check the resident's [MEDICATION NAME] level. Attempts to reach the Physician #24, who was the resident's physician as well as the facility medical director, on [DATE] were unsuccessful. Review of the Physician Desk Reference (PDR) 2015 Edition Nurse's Drug Handbook, pages ,[DATE] revealed to monitor for signs/symptoms of severe sinus [MEDICAL CONDITION], [MEDICATION NAME] toxicity and other adverse reactions. Information contained in the section patient counseling revealed to instruct to contact physician if nausea/vomiting, persistent diarrhea, confusion, weakness or visual disturbances occur. Advise that symptoms of having too high of doses may be difficult to recognize symptoms such as weight loss, abdominal pain and behavioral disturbances may be signs of [MEDICATION NAME] toxicity. A suggestion contained in the patient counseling section of the PDR included to monitor and record heart rate and blood pressure daily. This deficiency substantiates Complaint Number OH 290.

Based on observations, medical record review, staff interview, and review of the facility policy on skin care, the facility failed to ensure that residents who developed pressure sores received the necessary treatment and services to promote healing as treatments were not obtained timely and measurements of the areas were not done timely. This affected two of two residents reviewed with pressure ulcers (Residents #26 and #68). The facility identified two residents residing in the facility with pressure ulcers. There were 98 residents residing in the facility at the time of the survey. Actual harm occurred to Resident #26 who had an increase in size of a pressure sore on the sacrum and developed additional multiple Stage II pressure sores on the left buttock after treatment was not provided. Findings include: 1. Review of the medical record for Resident #26 revealed the resident was admitted to the facility 01/28/11 and had [DIAGNOSES REDACTED]. Review of weekly skin assessments revealed that on 09/14/11 the resident was assessed as not having any pressure sores. On 09/20/11 the resident was admitted to the hospital with [REDACTED]. On 09/29/11 the resident was readmitted to the facility. Review of skin alteration records revealed that Resident #26 was readmitted to the facility with pressure sores. However, there was no evidence the areas were assessed or measured until 10/05/11 (seven days after readmission). On 10/05/11 the resident was noted to have a Stage II area measuring 0.7 cm by 0.5 cm with a depth of less than 0.1 cm on the coccyx. The wound bed was red with skin around the wound pink. (Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. ) The resident was also noted to have a Stage II pressure sore measuring 0.6 cm by 0.2 cm by less than 0.1 cm deep on the sacrum. On 10/19/11 the resident was again admitted to the hospital for treatment of [REDACTED]. On 10/20/11 a skin inspection tool documented the resident had open areas noted on the sacrum and coccyx. However, there was no further description of the areas, no measurements of the areas, and no staging of the pressure sores. There was no evidence that a treatment of [REDACTED]. On 10/25/11 a physician's order was obtained for a [MEDICATION NAME] dressing to the open area at the coccyx. The dressing was to be changed on Tuesday and Friday. There was no evidence the open areas on the coccyx and sacrum were measured until 10/26/11 (six days after readmission). On 10/26/11 a nurses note documented that a skin inspection was completed. Two open areas were noted on the coccyx which had reddish/yellow wound beds. The areas measured 2 cm by 0.7 cm and 1.7 cm by 0.5 cm. No depth was documented although the areas were noted to be open. No stages of the wounds were documented. The resident was also noted to have developed two new pressure sores on the left buttock which had reddish purple wound beds and margins of rolled skin. The areas were noted to be 0.7 cm by 0.7 cm and 0.6 cm by 1.6 cm. No depth was documented and no stages were documented. There was no evidence the pressure ulcers were staged until 10/31/11 (11 days after readmission). On 10/31/11 skin alteration records indicated the resident had a pressure ulcer on the coccyx measuring 1.5 cm by 0.5 cm. There was a question mark under stage and depth. Interview with Registered Nurse (RN) #100 on 11/09/11 at 11:25 A.M. revealed that she put question marks as the area was unstageable as she could not see the wound bed. On 11/07/11 the pressure sore on the coccyx was noted to be a Stage III measuring 1 cm by 0.2 cm by 0.1 cm. (Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. ) On 10/31/11 a skin alteration record indicated the pressure sore on the sacrum was a Stage II and measured 1 cm by 0.4 cm by less than 0.1 cm deep. On 11/07/11 the area on the sacrum was a Stage II and measured 1.5 cm by 0.5 cm by less than 0.1 cm deep. On 10/31/11 the first area on the left buttock was noted to be a Stage II measuring 1.5 cm by 1 cm by less than 0.1 cm deep. On 11/07/11 the first area on the left buttock had a question mark under stage and measured 0.5 cm by 1.2 cm with a question mark under depth. The wound bed was noted to be yellow. On 10/31/11 the second area on the left buttock was noted to be Stage II and measured 1 cm by 1 cm by less than 0.1 cm deep. On 11/07/11 the second area on the left buttock was noted to be a Stage II and measured 1 cm by 0.4 cm by less than 0.1 cm deep. On 11/08/11 hospice was consulted for this resident. Observations on 11/09/11 at 8:35 A.M. revealed Resident #26 in bed on her right side. The resident was noted to have [MEDICAL CONDITION] of her lower extremities. The resident had an occlusive dressing on the coccyx dated 11/09/11. The skin around the dressing was pink. The resident's buttocks were noted to be excoriated. Interview with RN #100 on 11/09/11 at 11:25 A.M. confirmed that Resident #26's pressure sores were not assessed and measured until 10/05/11 after being readmitted on [DATE]. She confirmed that after being readmitted on [DATE] there was no treatment provided to the open areas until 10/25/11 and no measurements until 10/26/11. She confirmed the pressure sores were not staged until 10/31/11. 2. Review of the medical record for Resident #68 revealed the resident was admitted to the facility 09/10/10 and had [DIAGNOSES REDACTED]. Review of weekly skin assessments revealed that on 10/14/11 the resident was assessed as not having any pressure sores. A weekly skin assessment on 10/21/11 documented the resident had a superficial abrasion to the left outer ankle measuring 0.5 centimeters (cm) by 0.2 cm. (No stage of the pressure ulcer was identified). The wound bed had a brown scab and the surrounding skin was fleshtone. Record review revealed there was no evidence the physician was notified of the area or that a treatment for [REDACTED]. On 10/28/11 physician's orders were obtained for heel protectors to both feet and to cleanse the left outer ankle with normal saline, pat dry, apply skin prep, apply a large bandaid, and change daily and as needed. Review of nurses notes revealed that on 10/28/11 it was documented the resident's left outer ankle had a dried brown scab with surrounding skin pink. There was a scant amount of drainage from the center of the wound. (Again there was no stage of the pressure ulcer identified). Review of a skin alteration record revealed that Resident #68 developed a pressure ulcer on the left outer ankle on 10/28/11. (Even though a weekly skin assessment identified the area on 10/21/11). The first measurement of the area on the skin alteration record was 10/31/11. On 10/31/11 the resident was noted to have a Stage II area measuring 0.5 cm by 0.4 cm with a depth of less than 0.1 cm. It was noted to have a scant amount of yellow exudate with a pink wound bed. Skin around the wound was noted to be red. (Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. ) On 11/07/11 the area was noted to be a Stage II measuring 0.3 cm by 0.3 cm with no depth identified. A brown thin scab was noted with the skin around the wound red. Observations on 11/09/11 at 10:00 A.M. revealed Resident #68 to have a 0.3 cm by 0.3 cm superficial Stage II open area on the left outer ankle. Skin around the wound was red. Interview with RN #100 on 11/09/11 at 10:30 A.M. confirmed the wrong date of onset had been put on the skin alteration record as the area had developed on 10/21/11. She confirmed that although the area developed on 10/21/11, the physician was not notified and a treatment to the area was not obtained until 10/28/11. She further confirmed the area on the left outer ankle was not staged until 10/31/11. (Ten days after the area developed). 3. Review of the facility policy titled The Skin Care Management System (undated) revealed that an assessment of skin integrity would be completed on each resident upon admission by completing a head to toe physical assessment of skin condition. Residents admitted with skin impairments would have appropriate interventions implemented to promote healing, a physician's order for treatment, and wound location and characteristics documented in the medical record. In addition, a skin alteration record for pressure ulcers would be completed (this form included a space for stage of the pressure sore, measurements, and description of the pressure sore). The policy further stated that pressure ulcers were to be measured and staged weekly. This certification deficiency substantiated Complaint Number OH 008.