Every finding on record at Continuing Healthcare at Willow Haven

Based on observation, medical record review, facility investigation review, interviews and Hoyer lift user instructional guide review, the facility failed to ensure a safe transfer when mechanical lifts were not maintained in good repair. This affected one resident (#40) of three residents reviewed for mechanical lift use. The facility census was 62. Findings Include:Review of the medical record for Resident #40 revealed an admission date of [DATE] with the latest readmission date of [DATE]. Diagnoses included chronic respiratory failure with hypoxia, atrial fibrillation, diabetes mellitus, obesity, congestive heart failure, chronic obstructive pulmonary disease, anxiety disorder, osteoarthritis, dependence on supplemental oxygen, angina pectoris, depression, overactive bladder, constipation, pain, anemia, hyperlipidemia, gastro-esophageal reflux disease and hypertension. Review of the care plan dated [DATE] revealed the resident had an activity of daily living (ADL) self-performance deficit related to shortness of breath, limited mobility, cardiac diagnoses, dyspnea and obesity. Interventions included to assist with mobility as needed and Hoyer lift (a medical device designed to safely transfer individuals with limited mobility from one surface to another) for transfers. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the progress note dated [DATE] at 6:49 P.M. revealed during a transfer with the mechanical lift, an equipment malfunction occurred while the resident was being lifted resulting in being lowered onto the bed. The resident's arm made contact with the nearby wall during the incident. The resident was assessed immediately following event and was able to move affected extremity without pain, difficulty, or noted limitation. No acute distress was observed. Resident monitored for any changes in condition. Review of the medical record revealed no documentation of follow up from the incident. Review of the facility's investigation dated [DATE] with no time documented revealed the resident was being transferred to bed via Hoyer lift when the Hoyer tipped with resident over her bed. The resident put her left arm up to the wall and the Hoyer hit the light cover and broke it. The incident documented the resident was not injured. The facility removed the Hoyer from use and placed in the maintenance room. Review of the staff statement from Certified Nursing Assistants (CNA) #184 dated [DATE] revealed herself and CNA #123 was transferring the resident into bed with Hoyer number three and when the resident got over the bed it tipped and she hit the side of the wall. On [DATE] at 9:30 A.M., an interview with Licensed Practical Nurse (LPN) #108 revealed Hoyer number three was not steering correctly due to one of the wheels. The LPN revealed Resident #40 was being transferred using Hoyer number three and when she was over her bed the Hoyer lift tipped over and she hit the wall. She revealed the Hoyer also hit the light cover over her bed and broke it. On [DATE] at 10:53 A.M., an interview with CNA #122 revealed Hoyer number three was very hard to steer and she preferred not to use that lift. She revealed she had only had to use the lift, a couple of times, and it made her nervous. On [DATE] at 11:28 A.M., observation of Licensed Practical Nurse (LPN) #108 and CNA #113 transfer Resident #40 from her bed to power wheelchair revealed the resident's sling was under her. CNA #113 placed the Hoyer lift with the legs closed under the bed and hooked the sling to the Hoyer lift bar. CNA #113 lifted the resident up off the bed and moved the resident to her power wheelchair while LPN #108 steadied the resident in the sling. CNA #113 opened the legs and both staff members positioned the resident in her chair. Review of the maintenance log revealed an entry dated [DATE] for Hoyer number three indicating, Hoyer #3 needs fixed. It is a safety concern. The leg is broken and sways. On [DATE] at 9:54 A.M., an interview with the Regional Maintenance Director (RMD) #200 verified Hoyer lift number three was taken out of service and Maintenance Director (MD) #158 had worked on the lift and whatever he did, it was steering without difficulty. The RMD #200 revealed the lift was removed from service and was in his mechanical shop but he was unable to find anything wrong with the lift. Review of the Hoyer lift User Instruction Manual, dated 2014 revealed all Hoyer products are designed for minimum maintenance, however some safety checks and procedures are required. A schedule of daily tasks are detailed below. Make sure the lift moves freely on its castors and make sure the legs open and close correctly. This deficiency represents non-compliance investigated under Complaint Number 3034577.

Based on observation and interview, the facility failed to ensure storage of resident toileting equipment was maintained in a manner to prevent the potential spread of infection. This affected one resident (#40) of six sampled residents. The facility census was 62. Findings Include:On 06/09/26 at 10:12 A.M., an observation of Resident #40's bathroom revealed a peach bariatric bedpan and a gray fracture bedpan laying on the floor under the resident's sink without a protective barrier. On 06/09/26 at 11:15 A.M., an observation of Resident #40's bathroom revealed the peach bariatric bedpan and the gray fracture bedpan laying on the floor under the resident's sink without a protective barrier. On 06/09/26 at 11:35 A.M., an interview with Licensed Practical Nurse (LPN) #108 verified the peach bariatric bedpan and the gray fracture bedpan was not store in a manor to prevent the potential spread of infection. On 06/09/26 at 2:30 P.M., an interview with Assistant Director of Nursing (ADON) #172 who functions as the facility's Infection Preventionist revealed the facility had no policy on how bedpans should be store but should be stored in a plastic bag off the floor. This deficiency represents non-compliance investigated under Complaint Number 3034577.

Based on record review, staff interview, and policy review, the facility failed to ensure medical records were complete and accurate when the nursing staff failed to document the continency status and meal consumption percentages of residents in their electronic medical records (EMR's) on each of the three shifts daily and when they occurred. This affected seven (Resident #7, #8, #13, #24, #58, #70, and #71) of seven residents reviewed. Findings include: Review of Resident #7's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia, epilepsy, hallucinations, delusional disorder, anxiety disorder, major depressive disorder, muscle wasting and atrophy, constipation, anemia, hyperlipidemia (high cholesterol) dysphagia (difficulty swallowing),and a history of a traumatic brain injury.Review of Resident #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had minimal difficulty hearing and clear speech. He was able to make himself understood and was able to understand others. His cognition was moderately impaired and mood indicators were present to include a poor appetite. His height was 75 inches, but no weight had been recorded, and any history of a significant weight loss (SWL) was unknown at the time. Review of Resident #7's care plans revealed he had an active care plan in place for being at risk for malnutrition that originated on 04/03/25. He had a history of an unplanned SWL due to refusals of meals when having UTI's. He had refused all facility supplements when attempted and was refusing to be weighed more frequently. The goals were for the resident to consume adequate energy to avoid significant, unplanned weight changes and for his intake to remain at least 50-75% of most meals. The interventions included the need to monitor and evaluate his meal percentage intake via meal intake records and observation.Review of Resident #7's meal intakes recorded for the past 30 days (03/10/26- 04/06/26) revealed not all three meals served each day were being recorded under the point of care history for amounts eaten in the electronic medical record (EMR) under the task tab. There were no meals recorded for any of the three meals served to the resident on 03/20/26, 03/22/26, 03/26/26, or on 03/27/26. Only one of three meals served to the resident were recorded on 03/25/26 and 04/05/26. Only two of the three meals served to the resident were recorded on 03/11/26, 03/13/26, 03/18/26, 03/19/26, 03/21/26, 03/29/26, and 04/03/26. Only 14 of those 30 days were all three meals recorded that had been served to the resident to reflect the amount of the meal that he had consumed. 2.Review of Resident #8's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included central cord syndrome at unspecified level of the cervical spine, post-laminectomy syndrome, cervical disc disorder w/ myelopathy, chronic obstructive pulmonary disease, anxiety disorder, Vitamin D deficiency, nutrition deficit, muscle weakness, pain, constipation, muscle spasms, depression, anemia, and hemiplegia and hemiparesis following CVA (stroke) affecting left non-dominant side. Review of Resident #8's significant change MDS assessment dated [DATE] revealed the resident had adequate hearing and clear speech. He was able to make himself understood and was able to understand others. His cognition was moderately impaired. He was dependent on staff for eating and toilet hygiene. He was always incontinent of his bladder and his bowel continence was not rated. His height was 66 inches and his weight was 119 pounds. No known SWL was noted and he was indicated to be on a therapeutic diet.Review of Resident #8's active care plans revealed the resident had a care plan in place for being at risk for malnutrition. He was known to have a SWL of 7.2 pounds/ 5.4% loss from his hospital weight likely due to fluid fluctuations. He was not accepting supplementation and the facility was trying a Magic Cup for the resident. The interventions included the need to monitor his intake and record every meal. He also had a care plan in place for bowel and bladder incontinence that was initiated on 08/04/25. The staff were to assist the resident with toileting as needed and to check the resident as requested for incontinence. Review of Resident #8's meal intakes for the past 30 days (03/08/26- 04/05/26) recorded under the task tab of the EMR revealed not all meals served to the resident were being recorded in the medical record. No meal intakes were recorded for any of the three meals served on 03/12/26, 03/23/26, and 04/05/26. Only two of the three meals were recorded on 03/08/26, 03/11/26, 03/15/26, 03/18/26, and 03/29/26. Review of Resident #8's Urinary Control/ Frequency Point of Care History for the past 30 days (03/08/26- 04/05/26) revealed the staff were to mark if the resident was continent, incontinent, or did not void on each of the three shifts daily. There was documentation missing to indicate what his continence status was on a particular shift or a particular day during that 30 day period. There was no continence status recorded for the resident on any of the three shifts on 03/12/26, 03/18/26, 03/23/26, or 04/05/26. His continence status was only documented on one of the three shifts on 03/08/26, 03/09/26, 03/11/26, 03/13/26, 03/14/26, 03/15/26, 03/28/26, 03/29/26, and 03/31/26. His continence status was only documented on two of the three shifts on 03/10/26, 03/16/26, 03/17/26, 03/19/26, 03/20/26, 03/21/26, 03/22/26, 03/24/26, 03/25/26, 03/26/26, 03/27/26, 04/01/26, 04/02/26, 04/03/26, and 04/04/26. His continence status was only recorded for all three shifts once during that 30 day period occurring on 03/30/26. On 04/06/26 at 12:02 P.M., an interview with Regional Clinical Support #500 indicated it was expected that the nursing staff recorded the amount of a meal a resident consumed for all three meals served each day. They were also to indicate on each of the three shifts, if a resident was continent, incontinent, or did not void. He confirmed the computer software program they used broke it down into three separate shifts. Even though the nursing staff may work 12 hour shifts, they were to record that information on all three shifts (days, afternoons, and nights). 3.Review of Resident #13's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, adult-onset diabetes mellitus, muscle wasting and atrophy, abnormalities of gait and mobility, diarrhea, constipation, muscle weakness, major depressive disorder, anxiety disorder, pain, muscle spasms, and chronic kidney disease- stage 3.Review of Resident #13's quarterly MDS assessment dated [DATE] revealed the resident did not have any communication issues. Her cognition was moderately impaired and she was not known to display any behaviors or reject care. She was dependent on staff for toileting hygiene and was always incontinent of bowel and bladder. Review of Resident #13's active care plans revealed she had a care plan in place for being incontinent of her bladder related to a decreased awareness of need and dementia. The care plan was initiated on 07/03/25. The interventions included checking and changing her as requested for incontinence. Review of Resident #13's Urinary Control/ Frequency documentation under the Point of Care History found under the task tab for the past 30 days (03/08/26- 04/06/26) revealed the resident's continency status was not documented on each of the three shifts daily as it should have been. Her continence status was not documented for any of the three shifts on 03/0926, 03/14/26, 03/16/26, 03/21/26 or on 04/04/26. Her continency status was only documented on one of the three shifts on 03/08/26, 03/11, 03/12, 03/13, 03/15, 03/22, 03/23, 03/25, 03/28, 03/29, 04/03, and 04/05/26. Her continence status was only documented on two of the three shifts on 03/10/26, 03/17, 03/18, 03/19, 03/20, 03/24, 03/26, 03/27, 03/30, 03/31, 04/01, and 04/02/26. There were none of the days reviewed where her continence status was indicated to have been recorded for all three shifts during that 30 day time period. 4.Review of Resident #24's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included COPD, bipolar disorder with psychotic features, morbid obesity, heart failure, major depressive disorder, and hypertension. Review of Resident #24's quarterly MDS assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to display any behaviors nor was she known to reject care. She was dependent on staff for toileting hygiene and was coded on the MDS as being frequently incontinent of bowel and bladder. Review of Resident #24's active care plans revealed she had a care plan in place for being incontinent related to impaired mobility. The interventions included the need to assist the resident with toileting and to provide incontinence care as needed. Review of Resident #24's Urinary Control/ Frequency documentation for the past 30 days (03/08/26- 04/05/26 revealed the resident's continency status was not being recorded for each of the three shifts daily as it should have been. Her continence status was not documented for any of the three shifts occurring on 03/09/26, 03/24/26, and 03/31/26. Her continence status was only documented on one of the three shifts on 03/12/26, 03/13, 03/14, 03/15, 03/17, 03/18, 03/19, 03/23, 03/25, 03/28, 03/29, and 04/05/26. Her continence status was only documented on two of the three shifts on 03/08/26, 03/10, 03/11, 03/16, 03/20, 03/21, 03/26, 04/01, 04/02, 04/03, and 04/04/26. There was only three days during the past 30 days that the staff documented the resident's continence status on each of the three shifts and that was on 03/22/26, 03/27/26, and 03/30/26.5.Review of Resident #58's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a periprosthetic fracture around her internal prosthetic right hip joint, extrapyramidal movement disorder, muscle wasting and atrophy, muscle weakness, abnormalities of gait and mobility, colostomy status, history of falls, depression, insomnia, Post Traumatic Stress Disorder (PTSD), bipolar disorder, and hypertension.Review of Resident #58's admission MDS assessment dated [DATE] revealed the resident did not have any communication issues and she was cognitively intact. No behaviors or rejection of care was noted. She was dependent on staff for toilet hygiene and toilet transfers. She was coded on the MDS as being frequently incontinent of bladder. Review of Resident #58's active care plans revealed she had a care plan in place for being at risk for skin impairment. The interventions included the need to provide incontinence care as needed. Review of Resident #58's Urinary Control/ Frequency documentation under the task tab of the EMR for the past 30 days (03/08/26- 04/06/26) revealed the staff were not consistently documenting the resident's continence status on each of the three shifts daily. Her continence status was not documented for any of the three shifts on 03/11/26, 03/12, 03/18, 03/23, and 04/05/26. Her continence status was only documented on one of the three shifts occurring on 03/09/26, 03/13, 03/14, 03/15, 03/21, 03/28, 03/29, 03/31, and 04/03/26. Her continence status was only documented on two of the three shifts on 03/08/26, 03/10, 03/16, 03/19, 03/24, 03/25, 03/26, 03/27, 04/01, and 04/04/26. There were only five days out of the 30 reviewed where the resident's continency status was documented on all three shifts and those days were 03/17/26, 03/20, 03/22, 03/30, and 04/02/26. 6.Review of Resident #70's closed medical record revealed she was admitted to the facility on [DATE]. She was discharged on 03/05/26. Her diagnoses included acute on chronic diastolic heart failure, adult-onset diabetes mellitus, muscle wasting and atrophy, abnormalities of gait and mobility, morbid obesity, muscle weakness, COPD, overactive bladder, retention of urine, and constipation.Review of Resident #70's Medicare 5 Day MDS assessment dated [DATE] revealed her short and long term memory were intact. She was marked as having a modified independence for cognitive skills for daily decision making. She was not known to display any behaviors and she was not known to reject care. She was dependent on staff for toilet hygiene but toilet transfers were marked as not being applicable. She was always incontinent of bowel and bladder. Review of Resident #70's active care plans revealed she had a care plan in place for being at risk for skin impairment. The care plan included the intervention to provide the resident with incontinent care and to use barrier cream after each incontinence episode. Review of Resident #70's Urinary Control/ Frequency documentation under the task tab of the EMR from 02/20/26 thru 03/05/26 revealed the facility staff were not consistent documenting the resident's continence status on each of the three shifts daily as they should. Her continence status was not documented on any of the three shifts on 02/21/26 or 02/26/26. Her continence status was only documented on one of the three shifts occurring on 02/20/26, 02/22, 02/24, 02/27, 02/28, 03/01, and 03/02. Her continence status was only documented on two of the three shifts during that 14 day period on 02/23/26, 02/25, 03/03, 03/04, and 03/05/26. Her continence status was not documented on all three shifts on the same day for any of those 14 days reviewed. 7.Review of Resident #71's medical record revealed he was admitted to the facility on [DATE]. He remained in the facility until his discharge on [DATE]. His diagnoses included unspecified dementia, a history of a stroke, adult-onset diabetes mellitus, depression, unspecified protein-calorie malnutrition, muscle weakness, difficulty walking, gastroesophageal reflux disease, and constipation. Review of Resident #71's admission MDS assessment dated [DATE] revealed he had no communication issues and his cognition was moderately impaired. Set up/ clean up assistance with eating. His height was 68 inches and his weight was 175 pounds. He was not known to have had a SWL. Review of Resident #71's active care plans revealed he had a care plan in place for being at risk for malnutrition. The care plan was initiated on 12/30/25. The goals were for the resident to maintain his weight and to consume at least 50- 75% of most meals. The interventions included the need to monitor his intake and record every meal. Review of Resident #71's physician's orders revealed he was on a carbohydrate controlled diet with regular texture and thin liquids. He was to be up in his chair for all meals. Review of Resident #71's meal intakes recorded from 12/30/25 thru 01/17/26 revealed the facility staff were not consistently recording the percentages of meals the resident was consuming. None of the three meals served to the resident were recorded on 01/02/26, 01/09/26, 01/11/26, or 01/16/26. Only one of three meals served were recorded for 12/31/25, 01/03/26, 01/04/26, 01/12/26, and 01/17/26. Only two of three meals served were recorded on 01/01/26, 01/08/26, and 01/15/26. There were only seven days where all three meals had been recorded to reflect what percentage of the meal the resident consumed, while he was in the facility. On 04/06/26 at 4:30 P.M., an interview with the facility's Administrator and Regional Clinical Support # 500 confirmed meal intakes were not consistently being recorded to reflect the percentage of the meal each of the three residents consumed for all three meals served each day. No additional meal intakes were provided to show evidence the residents' plan of cares were being followed in regards to the recording of meal intakes for each meal served. They also confirmed the residents' continence status were not being documented on each of the three shifts daily as they should have been. Review of the facility's policy on Nutritional Documentation Guidance last reviewed in June 2025 revealed daily meal documentation was to be completed by the facility's direct care staff. Under the documentation guidelines, the nursing assistants or the licensed nurses were to observe meal intakes and document them in the facility's computer software program (PointClickCare) under the point of care.Review of the facility's policy on Compliance/ Ethics: Records and Documentation revised August 2025 revealed it was the facility's policy for accurate and complete record keeping and documentation, as it was critical to virtually every aspect of the facility's operations. It was the policy of the facility that all documentation should be timely, accurate, and consistent with applicable professional, legal, and facility guidelines and standards. That included all aspects of the facility's documentation, including resident assessments and care plans, and clinical records. The following deficiency was issued relative to incidental findings that were discovered during this complaint investigation completed on 04/06/26.

Based on record review, interview, and policy review the facility failed to ensure a resident representative was notified of a change in condition. This affected one resident (Resident #7) of eight residents reviewed for notification of change. The facility census was 69.Findings include: Record review revealed Resident #7 re-admitted to the facility on [DATE] with diagnoses including epilepsy, dementia, chronic kidney disease, pressure ulcer of left buttock, transient ischemic attack, anxiety, major depressive disorder, hypertension, and dysphagia (difficulty swallowing).Review of Resident #7's progress note dated 02/20/26 at 2:04 P.M. revealed Resident #7 complained of pain to the right nephrostomy tube insertion site. Area continues to be warm to touch, red in color and small amounts of drainage noted. Preliminary lab results of the nephrostomy tube site received. Med one notified of same, new orders received for doxycycline (antibiotic) 100 milligram (mg) twice a day (BID) for seven days. Resident notified of same and agrees with new orders. Call light and fluids in reach.Review of Resident #7's record revealed no documentation of the resident's Power of Attorney (POA) being notified of the resident's change in condition and new orders on 02/20/26.Record review revealed a progress note dated 02/22/26 at 9:15 A.M. revealed Resident #7's wound culture (from the right nephrostomy tube insertion site obtained on 02/19/26) resulted positive for methicillin- resistant staphylococcus aureus (MRSA) and the resident was placed on contact isolation precautions for seven days.Review of Resident #7's record revealed no documentation of the resident's Power of Attorney (POA) being notified of the resident's change in condition (positive culture for MRSA and contact precautions) on 02/22/26.Review of Resident #7's quarterly Minimum Data Set (MDS) Assessment completed on 03/04/26 revealed a brief interview for mental status (BIMS) score of 08 indicating moderate cognitive impairment. Further review revealed the resident was dependent for toileting, showering, transfers, and mobility.Review of Resident #7's progress note dated 03/05/26 at 9:36 A.M. revealed the resident's indwelling urinary catheter was changed per request due to the resident complaining of lower abdominal pain and lower back pain. #18 French indwelling urinary catheter was placed. 550 milliliters of urine retrieved from the catheter after the change, urinalysis sent and nurse practitioner aware.Review of Resident #7's medical record revealed no documentation of Resident #7's POA being made aware of the resident's change in status on 03/05/26.Interview on 03/18/26 at 8:00 A.M. with Resident #7 revealed the resident wanted his daughter (POA) notified of changes and the facility should know this as it should be in the record. Interview on 03/17/26 at 8:13 A.M. with Nurse #95 revealed if there was a new medication order or change in condition, the staff would notify the resident's representative if the resident was not alert and oriented. Nurse #95 stated Resident #7 had a daughter who was his POA and was very involved in making decisions. Nurse #95 verified the resident's POA should have been notified of his new medication orders and change in condition but was not notified.Review of facility policy reviewed June of 2025 titled Notification of Change in Condition revealed the nurse will inform the resident, resident's physician, and if known notify the resident's legal representative or resident representative when there is a significant change in the resident's physical, mental, psychosocial status and need to alter treatment including discontinuing existing form of treatment due to adverse consequences, or to commence a new form of treatment, and abnormal lab results. Upon notification of the resident, physician and if known the resident's legal representative or resident representative documentation will be entered into the resident's record reflecting exchange of information.This deficiency represents non-compliance investigated under Complaint Number 2707660.

Based on record review, staff interview, and policy review, the facility failed to ensure meal intakes were monitored and recorded for every meal, as per the plan of care. This affected three (Resident #7, #8 and #71) of three residents reviewed for nutrition/ weight loss. Findings include: 1.Review of Resident #7's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia, epilepsy, hallucinations, delusional disorder, anxiety disorder, major depressive disorder, muscle wasting and atrophy, constipation, anemia, hyperlipidemia (high cholesterol) dysphagia (difficulty swallowing),and a history of a traumatic brain injury. Review of Resident #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had minimal difficulty hearing and clear speech. He was able to make himself understood and was able to understand others. His cognition was moderately impaired and mood indicators were present to include a poor appetite. His height was 75 inches, but no weight had been recorded, and any history of a significant weight loss (SWL) was unknown at the time. Review of Resident #7's care plans revealed he had an active care plan in place for being at risk for malnutrition that originated on 04/03/25. He had a history of an unplanned SWL due to refusals of meals when having UTI's. He had refused all facility supplements when attempted and was refusing to be weighed more frequently. The goals were for the resident to consume adequate energy to avoid significant, unplanned weight changes and for his intake to remain at least 50-75% of most meals. The interventions included the need to monitor and evaluate his meal percentage intake via meal intake records and observation.Review of Resident #7's physician's orders revealed he was to receive a regular diet, with regular texture, and thin liquids. He was also receiving Remeron 15 milligrams by mouth every night for the treatment of depression and to help stimulate his appetite. Review of Resident #7's recorded weights revealed he has had a SWL as his weights had reduced from 190 pounds on 10/08/25 to 175 pounds on 04/02/26. He had refused to be weighed in the months of February and March 2026 resulting in his SWL not being identified until he agreed to be weighed on 04/02/26. Review of Resident #7's meal intakes recorded for the past 30 days (03/10/26- 04/06/26) revealed not all three meals served each day were being recorded under the point of care history for amounts eaten in the electronic medical record (EMR) under the task tab. There were no meals recorded for any of the three meals served to the resident on 03/20/26, 03/22/26, 03/26/26, or on 03/27/26. Only one of three meals served to the resident were recorded on 03/25/26 and 04/05/26. Only two of the three meals served to the resident were recorded on 03/11/26, 03/13/26, 03/18/26, 03/19/26, 03/21/26, 03/29/26, and 04/03/26. Only 14 of those 30 days were all three meals recorded that had been served to the resident to reflect the amount of the meal that he had consumed. 2.Review of Resident #8's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included central cord syndrome at unspecified level of the cervical spine, post-laminectomy syndrome, cervical disc disorder w/ myelopathy, chronic obstructive pulmonary disease, anxiety disorder, Vitamin D deficiency, nutrition deficit, muscle weakness, pain, constipation, muscle spasms, depression, anemia, and hemiplegia and hemiparesis following CVA (stroke) affecting left non-dominant side. Review of Resident #8's significant change MDS assessment dated [DATE] revealed the resident had adequate hearing and clear speech. He was able to make himself understood and was able to understand others. His cognition was moderately impaired. He was dependent on staff for eating. His height was 66 inches and his weight was 119 pounds. No known SWL was noted and he was indicated to be on a therapeutic diet.Review of Resident #8's active care plans revealed the resident had a care plan in place for being at risk for malnutrition. He was known to have a SWL of 7.2 pounds/ 5.4% loss from his hospital weight likely due to fluid fluctuations. He was not accepting supplementation and the facility was trying a Magic Cup for the resident. The interventions included the need to monitor his intake and record every meal.Review of Resident #8's meal intakes for the past 30 days (03/08/26- 04/05/26) recorded under the task tab of the EMR revealed not all meals served to the resident were being recorded in the medical record. No meal intakes were recorded for any of the three meals served on 03/12/26, 03/23/26, and 04/05/26. Only two of the three meals were recorded on 03/08/26, 03/11/26, 03/15/26, 03/18/26, and 03/29/26. On 04/06/26 at 12:02 P.M., an interview with Regional Clinical Support #500 indicated it was expected that the nursing staff recorded the amount of a meal a resident ate for all three meals served that day. He did not provide any documentation for the resident's missing intakes for the missing meals indicated above. 3.Review of Resident #71's medical record revealed he was admitted to the facility on [DATE]. He remained in the facility until his discharge on [DATE]. His diagnoses included unspecified dementia, a history of a stroke, adult-onset diabetes mellitus, depression, unspecified protein-calorie malnutrition, muscle weakness, difficulty walking, gastroesophageal reflux disease, and constipation. Review of Resident #71's admission MDS assessment dated [DATE] revealed he had no communication issues and his cognition was moderately impaired. Set up/ clean up assistance with eating. His height was 68 inches and his weight was 175 pounds. He was not known to have had a SWL. Review of Resident #71's active care plans revealed he had a care plan in place for being at risk for malnutrition. The care plan was initiated on 12/30/25. The goals were for the resident to maintain his weight and to consume at least 50- 75% of most meals. The interventions included the need to monitor his intake and record every meal. Review of Resident #71's physician's orders revealed he was on a carbohydrate controlled diet with regular texture and thin liquids. He was to be up in his chair for all meals.Review of Resident #71's meal intakes recorded from 12/30/25 thru 01/17/26 revealed the facility staff were not consistently recording the percentages of meals the resident was consuming. None of the three meals served to the resident were recorded on 01/02/26, 01/09/26, 01/11/26, or 01/16/26. Only one of three meals served were recorded for 12/31/25, 01/03/26, 01/04/26, 01/12/26, and 01/17/26. Only two of three meals served were recorded on 01/01/26, 01/08/26, and 01/15/26. There were only seven days where all three meals had been recorded to reflect what percentage of the meal the resident consumed, while he was in the facility. On 04/06/26 at 4:30 P.M., an interview with the facility's Administrator and Regional Clinical Support # 500 confirmed meal intakes were not consistently being recorded to reflect the percentage of the meal each of the three residents consumed for all three meals served each day. No additional meal intakes were provided to show evidence the residents' plan of cares were being followed in regards to the recording of meal intakes for each meal served. Review of the facility's policy on Nutritional Documentation Guidance last reviewed in June 2025 revealed daily meal documentation was to be completed by the facility's direct care staff. Under the documentation guidelines, the nursing assistants or the licensed nurses were to observe meal intakes and document them in the facility's computer software program (PointClickCare) under the point of care. The following deficiency was issued relative to incidental findings that were discovered during this complaint investigation completed on 04/06/26.

Based on closed record review, interview, and policy review the facility failed to prevent significant medication errors. This affected one resident (Resident #72) of eight residents reviewed for medications. The facility census was 69.Findings include: Review of Resident #72's closed medical record revealed an admission date of 02/26/18 and discharged on 12/24/25 with diagnoses including type 2 diabetes, major depressive disorder, anxiety, blindness of one eye, cognitive impairment and chronic obstructive pulmonary disease.Review of Resident #72's physician orders revealed an order dated 12/16/25 for lorazepam (antianxiety medication also known as Ativan) oral tablet 0.5 milligram (mg) give 0.5 tablet (the order was to give 0.5mg 1/2 tablet) by mouth every eight hours as needed for anxiety for 14 days. Target behaviors of restless, yelling out, combative.Review of Resident #72 care plan dated 09/20/23 and revised 04/10/25 revealed the resident had a behavior problem. Interventions include administration of medications as ordered. The resident uses anti-anxiety medications related to anxiety disorder, interventions include administration of anti-anxiety medications as ordered by the physician.Review of Resident #72 medication administration record (MAR) for December 2025 revealed lorazepam oral tablet 0.5 milligram (mg) give 0.5 tablet by mouth was ordered and documented as administered by Registered Nurse (RN) #401 on 12/16/25 at 9:18 P.M. Review of Resident #72's progress note dated 12/17/25 at 5:26 A.M. authored by nurse #401 revealed the nurse recognized, at that time, a medication error was made with lorazepam. Review of Resident #72's progress note dated 12/17/25 at 5:27 A.M. authored by Assistant Director of Nursing (ADON) revealed Nurse #401 notified ADON of medication error regarding Resident #72 receiving 0.5mg of Ativan (lorazepam) instead of 0.25 mg.Interview on 03/17/26 at approximately 2:15 P.M. with the ADON confirmed Nurse #401 administered the wrong dose of lorazepam to Resident #72 as she administered 0.5 mg of lorazepam instead of 0.25 mg (half of a 0.5 mg tablet). Two attempts were made during the onsite investigation to reach RN #401 however; no return contact was provided.Review of undated facility policy titled Medication Administration revealed prior to and during administration, the nurse must observe the five rights of medication administration the right patient, right dose-verify the dosage on the medication administration record, check the doctor's original order if there is a concern or question, right time, right route, right drug.This deficiency represents non-compliance investigated under Complaint Number 2707660.

Based on record review, observation, interview, and policy review the facility failed to ensure residents received diets per orders to meet the resident's needs. This affected one resident (Resident #7) of three residents reviewed for nutrition. The facility census was 69.Findings include:Review of Resident #7's medical record revealed a re-admission date of 02/08/25 with diagnoses including epilepsy, dementia, chronic kidney disease, pressure ulcer to the left buttock, anxiety, major depressive disorder, and dysphagia (swallowing difficulty). Review of Resident #07 orders revealed an order placed on 02/03/26 for large protein portions at meals, cut meats/ entrees to bite sized for wound healing.Review of Resident #7's quarterly Minimum Data Set (MDS) Assessment completed on 03/04/26 revealed a brief interview for mental status (BIMS) score of 08 indicating moderate cognitive impairment. Further review revealed the resident was dependent for toileting, showering, transfers, and mobility. The resident also required set up/clean up assistance for eating.Review of Resident #7 at risk for malnutrition and or dehydration care plan related to a past medical history of seizures, dementia, stage 3 chronic kidney disease, dysphagia, history of unplanned significant weight loss, refusal of facility supplementations, intakes and weights fluctuating significantly, frequently poor appetite, refusals of weights with large protein portions to ensure high protein intakes, the resident has had multiple episodes of skin breakdown so high protein diet to guard against reoccurrences. Strongly refuses Juven, Prostat, supplementation was dated 02/08/26 Interventions included monitoring and evaluating meal percentage intake via meal intake records and observations, provide meals per physician diet orders, provide feeding and dining assistance as needed.Interview on 03/18/26 at 8:00 A.M. with Resident #7 revealed he had concerns with the dietary department. The resident shared the kitchen was always messing up his food and it doesn't seem like anyone cares to do anything about it. Resident #7 stated it was hard for him to eat some foods because he doesn't have teeth. Further interview revealed the resident told the staff what he liked and didn't like to eat and it would be on his meal ticket but the facility still served the wrong stuff. Observation of the breakfast meal on 03/18/25 at 8:24 A.M. revealed Resident #7 was served a tray with one piece of ham (whole), one piece of bread and a small portion of scrambled eggs. Review of the resident's meal ticket, located on his breakfast tray, stated cut food into bite sized pieces highlighted in pink and the ticket also indicated large protein portions.On 03/18/26 at 8:24 A.M. interview with certified nursing assistant (CNA) #33 confirmed the resident's meal ticket said the resident's food was to be cut into bite sized pieces and contain large protein portions however, the resident's ham and bread were not cut into bite sized pieces and the resident didn't receive large portions of his protein which was ham and eggs. Review of facility policy titled Portion Sizes dated September 8th of 2021 revealed large portions are one and a half times the standard portion unless otherwise indicated on the meal ticket. The following deficiency was issued relative to incidental findings that were discovered during this complaint investigation completed on 04/06/26.

Based on observation, interview, record review, and policy review the facility failed to ensure infection control interventions were implemented related to maintenance of a nephrostomy collection bag. This affected one resident (Resident #7) of one residents reviewed for nephrostomy maintenance. The facility census was 69. Findings include: Record review revealed Resident #7 re-admitted on [DATE] with diagnoses including epilepsy, dementia, chronic kidney disease, pressure ulcer of left buttock, transient ischemic attack, anxiety, major depressive disorder, hypertension, and dysphagia. Review of Resident #7's physician orders revealed an order placed on 01/29/26 for enhanced barrier precautions every shift for prevention due to indwelling urinary catheter, nephrostomy tube, and wound (right nephrostomy insertion site with methicillin resistant staphylococcus aureus) (MRSA). Further review revealed the resident was ordered ceftriaxone (antibiotic) one (1) gram intramuscular (IM) every day for five days for a urinary tract infection (UTI) that was completed on 03/13/26.Review of Resident #7's quarterly Minimum Data Set (MDS) Assessment completed on 03/04/26 revealed a brief interview for mental status (BIMS) score of 08 indicating moderate cognitive impairment. Further review revealed the resident was dependent for toileting, showering, transfers, and mobility. The resident had an indwelling catheter (nephrostomy tube) and was frequently incontinent of bowel. Resident #7's care plan completed on 03/04/26 revealed the resident required enhanced barrier precautions related to a nephrotomy site to reduce the potential of spreading multi-drug resistant organisms. Observation on 03/18/26 at 8:20 A.M. revealed Resident #7's nephrostomy bag was laying on the floor, on the right side of the resident's bed. Interview and observation on 03/18/26 at 8:33 A.M. with certified nurse assistant (CNA) #33 confirmed the resident's nephrostomy bag was lying on the floor. The CNA stated previously there was a basin under the nephrostomy bag to prevent it from touching the floor but she was unsure what had happened to it, as she had been off for a few days. Review of facility policy titled infection control prevention program dated December of 2019 revealed it is the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Residents have a right to reside in a safe environment that promotes health and reduces the risk of acquiring infections. The following deficiency was issued relative to incidental findings that were discovered during this complaint investigation completed on 04/06/26.

Based on observations, review of purchase order history and interviews, the facility failed to ensure water temperatures in the shower rooms were at the appropriate temperature. The facility also failed to ensure a shower, sink, exhaust fan, and ceiling light were working appropriately and in good repair. This had the potential to affect 56 residents residing on Units 200, 300, 400 and 500. Facility census was 76.Findings include: Review of the printed orders from Amazon, provided by Maintenance Direct #295, revealed a shower valve was ordered to replace a bad valve for the 200-hall shower room on 11/12/25. An additional order dated 12/02/25 revealed a vacuum breaker was ordered for the 200-hall shower room. An observation on 12/30/25 at 8:57 A.M. revealed there was no water when the hot water handle in the sink in the 400-hall shower room was turned on.An interview on 12/30/25 at 8:59 A.M. Certified Nursing Assistant (CNA) #246 verified the shower room on the 200-hall sprayed water out of the pipes and was not working properly so residents requested to be showered on the 400 or 500 halls. CNA #246 verified the water temperature in the shower rooms on the 400 and 500 halls were always cold. An observation on 12/30/25 at 8:59 A.M. of the 200-hall shower room revealed a medical glove over the pipes coming out of the wall and went to the shower head. Water was observed dripping into the glove even though the shower was turned off.An interview on 12/30/25 at 9:00 A.M. Maintenance Director #295 verified parts had been ordered and delivered for the 200-hall shower room, but he did not have time to fix the shower and wasn't sure when the repairs would be done because he also had other repairs to complete. Maintenance Director #295 stated at first the shower on the 200-hall did not have hot water, so a shower valve was ordered. Then water started spraying out of the pipes coming out of the wall, so another part was ordered on 12/02/25. An additional interview and observation at 9:55 A.M. with Maintenance Director #295 verified the ceiling exhaust fan cover was missing and there was clear liquid that appeared to be water and brown colored stains in the ceiling light cover in the 200-hall shower room. Maintenance Director #295 verified he did not check water temperatures in the shower rooms. An interview on 12/30/25 at 10:00 A.M. Maintenance Director #295 verified there was no water when the hot water was turned on in the sink in the 400-hall shower room. An interview on 12/30/25 at 10:20 A.M. Maintenance Director #295 verified the water in the 400-hall shower room was 101 degrees Fahrenheit (F) and was not at an appropriate temperature for residents to use for bathing/showers.An interview on 12/30/25 at 10:25 A.M. Maintenance Director #295 verified the water in the 500-hall shower room was 102 degrees F and was not at an appropriate temperature for resident use for showers. This deficiency represents non-compliance investigated under Complaint Number 2692752.

Based on medical record review, review of a self-reported incident, facility investigation review, interview and policy review, the facility failed to complete a thorough investigation related to an allegation of misappropriation. This affected one resident (#78) of three residents reviewed for misappropriation. The facility census was 76.Findings include: Review of the medical record for Resident #78 revealed an admission date of 08/14/25 with diagnosis including chronic obstructive pulmonary disease, anxiety disorder anemia, hypothyroidism, depression, chronic respiratory failure, and dependence on supplemental oxygen. Review of the resident's personal inventory from admission did not include an Apple watch. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 out of 15 points, which indicated intact cognition.Review of Self-Reported Incident (SRI) Tracking Number 266105 and facility investigation dated 10/07/25 revealed the category of the allegation was misappropriation. The SRI revealed Resident #78 had stated her Apple watch was missing from her room. Additionally, employee statements which indicated multiple employees had seen the Apple watch in Resident #78's room prior to 10/07/25. One of the employee statements revealed Resident #78 had a locator app on her cell phone to track the Apple watch. Resident #78 had been in the local hospital on [DATE] and 09/30/25 and returned to the facility on [DATE]. The SRI also stated the facility was doing laundry off site during the timeframe of the watch being reported missing. Furthermore, the investigation did not contain documentation of communication with the hospital staff to determine if Resident #78 left her Apple watch at the hospital. There was also no evidence the off-site laundry services were contacted to determine if the watch was found in laundry from the facility. Further review revealed no evidence the resident's location app was used to track her watch and no documentation to support police involvement and lastly, no evidence of interviews with like residents or residents who live on the same unit as Resident #78 to determine if they had knowledge of anything with the watch or if they had been impacted by allegations of misappropriation. Review of an instant message dated 10/07/25 at 1:30 P.M., and printed from the Administrator's computer during the onsite survey, revealed she had sent communication to the laundry service regarding Resident #78's missing Apple watch but there was no evidence of follow-up communication. Review of the missing items log for the month of October 2025 revealed Resident #78's Apple watch was not on the missing items log. Interview on 12/30/25 at 2:07 P.M. with the Administrator revealed she was not sure if Resident #78's son called the police or not but confirmed no police had come to the facility regarding Resident #78's missing Apple watch. The Administrator stated the Apple watch was not on Resident #78's inventory of personal effects. The Administration verified that staff do not always update the inventory of personal effects when a resident receives a new item. The Administrator stated they did try the locator app on Resident #78's phone, but the watch must have been dead, and they could not locate the watch and verified there was no documentation to indicate they had checked the app locator on Resident #78's phone. The Administrator verified there was no documentation of communication with hospital staff regarding the resident's missing watch and no statements from other residents, especially residents who lived in the same area to determine if they had knowledge of the missing watch or if they had missing items. Review of the facility abuse policy dated as reviewed on 05/2025 stated residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. Additionally, the investigation section of the facility abuse policy dated as reviewed on 05/2025 stated the person investigating the incident should generally take the following actions: interview the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. If there are no direct witnesses, then the interviews may be expanded. If the allegation involves abuse/neglect, interview other residents, as appropriate, to determine if they may have been affected by the accused staff member or resident. Interview other health care professionals, as appropriate, and document all interviews. Review all relevant medical reports/records, as applicable. Evidence of the investigation should be documented in accordance with Quality Assurance (QA) protocols. Furthermore, the follow up section of the facility abuse policy dated as reviewed on 05/2025 stated whether the incident/allegation is substantiated or unsubstantiated the Administrator and/or Director of Nursing (DON) or designees will: ensure involved resident ' s plan of care is reviewed and revised, as appropriate, consistent with the results of the investigation; determine if modifications to existing policies and procedures are needed to prevent similar events from occurring in the future as applicable; staff training, if appropriate, as determined by the results of the investigation; and implement other measures as deemed necessary by the investigation. This deficiency is an incidental finding discovered during the complaint investigation.

Based on record review, interview and review of facility's medication administration policy, the facility failed to ensure medical records were accurate and complete regarding the administration of controlled substances. This affected two (Resident #55 and #56) of 25 residents reviewed for medication administration. The facility census was 74. Findings include:1. Review of the medical record for Resident #56 revealed an admission date of 04/08/25 with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, weakness, acquired absence of left leg above knee, muscle weakness, depression, and chronic kidney disease.Review of the care plan dated 09/09/25 revealed the intervention to give analgesics as ordered by the physician and to monitor/document for side effects.Review of a physician order dated 10/31/25 revealed the order for Hydrocodone-Acetaminophen 5-325 milligrams (mg) (opioid pain medication) one tablet by mouth every eight hours as needed for moderate to severe pain.Review of Resident #56's Individual Patient Controlled Substance Administration Record revealed Hydrocodone-Acetaminophen 5-325 mg one tablet was administered on 11/19/25 at 10:50 P.M. Review of Resident #56's Medication Administration Record (MAR) revealed no documentation of the administration of Hydrocodone-Acetaminophen 5-325 mg, one tablet, on 11/29/25 at 10:50 P.M. There was a discrepancy between the Controlled Drug Record and the MAR.Observation of medication cart on 12/04/25 at 10:35 A.M. with Registered Nurse (RN)/Unit Manager #134 confirmed Resident #56's MAR did not contain documentation of the administration of Hydrocodone-Acetaminophen 5-325 mg, one tablet, on 11/29/25 at 10:50 P.M.Interview on 12/04/25 at 10:35 A.M. with the Assistant Director of Nursing (ADON) confirmed Resident #56's Individual Patient Controlled Substance Administration Record revealed Hydrocodone-Acetaminophen 5-325 mg one tablet was administered on 11/19/25 at 10:50 P.M.; however, his MAR revealed no documentation of the administration of Hydrocodone-Acetaminophen 5-325 mg, one tablet, on 11/29/25 at 10:50 P.M. The ADON stated the facility would follow up with the nurse who failed to document the medication administration on the MAR.2. Review of the medical record for Resident #55 revealed an admission date of 08/06/21 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type two diabetes mellitus, transient cerebral ischemic attack, hypertension, pain, unspecified, other chronic pain, atrial fibrillation, hypothyroidism, and hyperlipidemia. Review of the care plan for Resident #55 revealed an intervention to administer all medications as ordered. Review of the November 2025 MAR of Resident #55 revealed an order for Oxycodone HCl oral tablet 5 mg (opioid pain medication) give half a tablet by mouth three times a day for breakthrough pain. Review of the MAR revealed the Oxycodone was given on 11/10/25 for the bedtime dose but was marked as an error on the narcotic count sheet. Additionally, two narcotic sheets titled Individual Patient Controlled Substance Administration Record-30 dose for Resident #55 had no date of the narcotic received, no amount of the narcotic, no amount sent of narcotic, and no signature of the person receiving the narcotic. Interview on 12/04/25 at 11:36 A.M. with Licensed Practical Nurse (LPN) #136 verified there was a 11/10/25 bedtime dose of Oxycodone for Resident #55 which was marked as given on the MAR and not signed out on the narcotic count sheet. LPN #136 verified there was no signature for when the narcotics were received, no date received, no amount received, no amount sent for two of the narcotic sheets for Resident #55. Interview on 12/04/25 at 12:26 P.M. with the ADON confirmed the 11/10/25 bedtime dose of Oxycodone for Resident #55 was given per the MAR, but the narcotic count sheet had the Oxycodone crossed out in error which would indicate the Oxycodone was not given. Additionally, the ADON confirmed there was no received signature, no date received, no amount received, and no amount sent on two drug narcotic count sheets for Resident #55. Review of the facility policy Controlled Medication Storage and Accountability, dated 04/2018, a controlled medication accountability record is prepared when receiving inventory of a Schedule II medication. Accountability record necessity for Scheduled III, IV, or V medications will depend on state regulations or decision of the center. The following information is completed: name of resident, prescription number, name, strength (if designated), and dosage form of medication, date received, quantity received, and name of person receiving medication. At each shift change or when keys are transferred, a physical inventory of all Schedule II, including refrigerated items, is conducted by two licensed nurses or per state regulation and is documented of the controlled substances accountability record or verification of controlled substances count report. Any discrepancy in controlled substance medication counts is reported to the Director of Nursing (DON) immediately. The DON or designee investigates and makes every reasonable effort to reconcile all reported discrepancies while nurses remain on duty. The DON, in a report to the Administrator, documents irreconcilable discrepancies. This deficiency represents non-compliance investigated under Complaint Number 2619077.

Based on staff schedule review, payroll-based journal review, facility assessment review, policy review and interview, the facility failed to ensure adequate staffing to meet the needs and staffing as identified in the facility assessment. This had the potential to affect all residents residing within the facility. The census was 68. Findings Include: Review of the Facility Assessment Tool revised 03/24/25 revealed the facility average daily census was 69 to 78 residents. The facility staffing plan was based on the resident population and their varying needs for care and services, the general approach to help the facility gauge sufficient staff to assist in meeting the needs of the residents at any given time involves various factors including: The range of facility staff that may be needed to gauge sufficient qualified staff available to meet each resident's needs may be based on resident AOL acuity, medical complexities, behavioral/psychosocial needs of the residents, and the ebb and flow of day/night routine needs to name a few. This data can be obtained from sources such as the MOS, clinical observations, chart/physician order review, various facility reports, collaboration with other vendors/services such as therapy, behavioral/mental health, and direct care staff input to name a few. The facility may adjust positions and staffing needs as necessary to meet the needs of an aggregate of residents or the overall resident population at any time. Estimated range of licensed nurses providing direct care staff was three to four on day shift and two to three on night shift. Nurse Aides required was five to eight on day shift and four to six on night shift. Other licensed nursing personnel (e.g. those with administrative duties included the DON, ADON and unit manager). Determination of staff assignments can involve many factors such as the number of residents on each hall/unit/community, AOL acuity, medical complexities, specialty community, load of medication/treatment administration, behavioral/psychosocial needs, observations, and staff input. The facility encourages direct care staff to work in one or two areas of the facility for continuity of care and services. Those staff that float throughout the facility tend to desire a change in routine and are more flexible with care and services. Review of staff assignments is an ongoing process as resident conditions change, admissions, discharges, and changes in overall resident population. Changes may occur by shift, day, week or month as the resident population can change very quickly. Review of the second quarter (2025) Payroll-Based Journal revealed the facility had low weekend staffing, did not meet the criteria for registered nurses daily for eight consecutive hours and had a one-star rating for staffing. Review of the Staffing Schedules and Detailed Hour/Time Punch Detail reports dated January 2025 through August 2025 for the below dates revealed the following licensed staffing shift needs were not met: a. No fourth Certified Nurse Aide (CNA) on 02/09/25 between 11:00 P.M. and 3:00 A.M.b. No fourth CNA on 03/08/25 between 7:00 P.M. and 3:00 A.M.c. No third Licensed Nurse on 03/29/25 between 3:00 P.M. and 7:00 P.M.d. No fourth CNA on 04/20/25 between 7:00 P.M. and 5:00 A.M.d. No third Licensed Nurse on 06/16/25 between 3:30 P.M. and 7:00 P.M b. No second Licensed Nurse on 06/22/25 between 7:00 P.M. and 11:00 P.M.c. No fourth CNA on 08/06/25 between 12:00 A.M. and 3:00 A.M. During the course of the survey between 08/11/25 and 08/21/25, interview with five employees who wish to remain anonymous stated there was not enough staff to meet the needs of the residents timely. On 08/11/2025 between 1:54 P.M. to 2:04 P.M., interview with Resident #46 revealed the facility does not have enough staff on the weekends of both nurses and nurse aides. Resident #46 stated she used to be a Certified Nurse Aide (CNA) and knows what they should be doing. Resident #46 stated she can do most things for herself but there are those at the facility that cannot. On 08/12/25 at 6:34 A.M., interview with CNA #185 stated the facility does not always have adequate staffing and if someone call offs, management does not come in to cover. The staff working just does the best they can. There is not always a housekeeper on the weekends and rooms do not get cleaned. On 08/12/25 at 6:59 A.M., interview with CNA #112 stated the facility runs short of help frequently and depending on who is working determines if things all get done or not. Management does not come in to help and staff try to do room checks every two hours but sometimes they are late. On 08/12/25 between 9:05 A.M. and 9:24 A.M., interview with Family #204 revealed the facility does not have enough staff to ensure residents are checked frequently. Family #204 stated concerns have been brought to members of the management team and nothing is done. Sometimes call lights are on for 30 minutes without being answered because they are all busy. Rooms are not cleaned and items that need fixed are reported but not fixed timely. Family #204 stated in June 2025 a concern was reported regarding an air conditioner and it was still leaking and had not been fixed. On 08/12/25 at 12:13 P.M., interview with Maintenance Director (MD) #173 revealed the electronic work order system included a 08/05/25 request to hook up a television for Resident #80. MD #173 stated he had been focusing on the fire and did not get to it until 08/11/25 as he was the only maintenance man for the facility. On 08/19/25 at 10:08 A.M., interview with Housekeeping/Laundry Manager #113 revealed on the weekends there was only one housekeeper. The facility was down a person so all the rooms do not get cleaned. On 08/21/25 between 10:29 A.M. and 10:41 A.M., interview with the Director of Nursing (DON) verified the facility assessment staffing range of staff needed to provide adequate care and services for residents residing within the facility included licensed nurses providing direct care three to four on day shift and two to three night shift and the nurse aides (CNA) five to eight (CNA) for day shift and four to six CNA on the night shift for the facility. The DON stated they should never be under the minimum number of staff needed and it was her expectation on-call nursing management staff should come it to cover any part of the shift that was needed. The DON verified the above listed shifts with staffing concerns. On 08/21/25 between 8:32 A.M. and 8:50 A.M. interview with the DON stated the following: the facility currently does not have a nursing waiver. Staffing is based on resident care needs and census. Two of the five halls have higher acuity due to the residents require more assistance e.g. hoyer lifts, feeding, two person assists, etc. If the staffing numbers exceed the needs and census, nursing staff was sent home. The DON stated the minimum staffing for direct care nursing day shift was three nurses and night shift was two nurses for the full 12 hour shift (7a-7p/7p-7a). The minimum CNA's were five on day shift and four on night shift. The DON stated it should 'never' go below the above numbers and if it did, it would be her expectation that management staff or the on-call nursing manager would come in to cover that shift. On 08/21/25 at 1:47 P.M., interview with the Administrator revealed the facility continued to be hiring to fill vacant positions. The Administrator stated the facility did not have a Staffing Policy as they use their budget to determine staffing levels. This deficiency represents non-compliance investigated under Complaint Number 2569206.

Based on payroll-based journal review, staffing schedule review, policy review and interview, the facility failed to provide eight hours of consecutive registered nurse (RN) hours per day. This had the potential to affect all 68 residents residing within the facility. Findings include: Review of the Payroll-Based Journal second quarter 2025 revealed the facility did not meet the requirement of having a RN for eight consecutive hours daily. Review of the Facility Assessment Tool revised 03/24/25 revealed the facility average daily census was 69 to 78 residents. The facility staffing plan was based on the resident population and their varying needs for care and services, the general approach to help the facility gauge sufficient staff to assist in meeting the needs of the residents at any given time involves various factors. Review of the Staffing Schedules dated January 2025 through July 2025 revealed there was no consecutive eight hour RN coverage on the following dates: 01/18/25, 01/19/25, 02/01/25, 02/02/25, 03/16/25, 04/12/25, 04/13/25, 04/19/25, 04/20/25, 04/26/25, 05/04/25, 05/10/25, 05/11/25, 05/18/25, 05/25/25, 06/07/25, 06/08/25, 06/14/25, 06/15/25, 06/22/25, 06/29/25, 07/20/25 and 07/27/25. On 08/13/25 at 8:35 A.M., interview with the Director of Nursing (DON) stated the facility was not able to accept residents with central lines, TPN or orders for IV therapy more than twice a day due to the availability of a RN and/or an IV trained Licensed Practical Nurse. The DON verified the facility currently had the following direct care RN's: one on nights and 2 PRN (as needed) and the facility wound nurse: however, she was currently on a medical leave of absence. On 08/18/25 at 10:05 A.M. interview with the Assistant Director of Nursing (ADON) verified there was no RN coverage for eight consecutive hours on the following dates: 01/18/25, 01/19/25, 02/01/25, 02/02/25, 03/16/25, 04/13/25, 04/19/25, 04/26/25, 05/10/25, 06/07/25, 06/08/25, 06/14/25, 06/15/25, 07/20/25 and 07/27/25. On 08/19/25 at 8:25 A.M., interview with ADON verified there was no RN coverage for eight consecutive hours on 04/12/25, 04/20/25, 05/04/25, 05/11/25, 05/18/25, 05/25/25, 06/22/25 and 06/29/25. On 08/21/25 between 8:32 A.M. and 8:50 A.M. interview with the DON stated there has been a shortage of RN coverage in the past, as well as, currently and the concern was primarily on the weekends. On 08/21/25 at 9:59 A.M., interview with the DON verified the facility continued to be unable to meet the requirement of having a RN for eight consecutive hours per day/seven days a week. The DON stated the facility had done the following trying to find RN's: a facility self-initiated action plan through their quality assurance program to address the need of RN staff earlier this year and had hired two of four RN's interviewed between 01/09/25 and 08/06/25. One Certified Nurse Aide transitioned to an RN position after passing her nursing boards and was scheduled to start on the schedule in September 2025. The facility had posted the RN positions on the company website, social media (unsure which one) and job fairs but have not been able to fill the positions. The DON stated RN's do not want to work in long term care facilities anymore since COVID-19. On 08/21/25 at 1:47 P.M., interview with the Administrator stated the facility did not have a Staffing Policy and the facility uses their budget to determine staffing.

Based on observation, manufacturer review, policy review and interview, the facility failed to maintain a safe and sanitary kitchen. This had the potential to affect all 68 residents that received food from the kitchen. Findings include: 1.On 08/11/25 between 8:20 A.M. and 8:45 A.M., initial observation of the kitchen revealed Dietary Aide #111 and Dietary [NAME] #128 were preparing and serving breakfast meals. Dietary [NAME] #128 was observed serving an omelet that was dark brown and overcooked. Dietary [NAME] #128's hairnet did not encase all of her hair in the front and both sides. Dietary [NAME] #128 verified the above and she stated she was new to the position. Observation of the reach-in refrigerator revealed no temperature was displayed on the thermometer. Water was observed leaking in the same reach-in refrigerator. The reach-in refrigerator contained a gallon of whole milk, 13 glasses of chocolate milk and three additional cafeteria-style trays each containing glasses of apple juice, cranberry juice and fruit punch. The chocolate milk and juice glasses were covered with plastic lids and saran wrap. Water was leaking from the top portion of the reach-in refrigerator onto beverages ready for meal service. The chocolate milk glasses were sitting in water that filled the cafeteria-style trays. A metal serving pan was observed sitting on top of the chocolate milk glasses without any water in it. At the time of the observation, Dietary [NAME] #128 verified the observation and Dietary Aide #111 stated the reach-in refrigerator had been not working correctly for several weeks and had been leaking water. Dietary Aide #111 also verified the thermometer was not working, stated she would let someone know and then positioned the metal serving pan to the back of the shelf stating the pan should catch the leaking water now. Further observations of the kitchen revealed the stove and kitchen hood had heavy grease build-up and dust trendils along the hood, metal piping and fan screening. The dust trendils were long and were observed moving back and forth as the cook was cooking. There was also heavy food debris along the gas pipes, outlets and serving cart beside and behind the stove. The above was verified by Dietary Aide #111 at the time of the observation. On 08/13/25 at 9:25 A.M., interview with Regional Culinary Director #195 verified the stove and kitchen hood grease and dust trendils remained stating it was to be cleaned on today. 2.On 08/11/25 at 12:40 P.M., observation revealed Pest Control Employee (PCE) #197 entered the kitchen without a hat or hairnet. Regional Culinary Director #195 was in the dietary office next to the kitchen entrance doors and was informed of the observation. RCD #195 verified the observation on 08/11/25 at 12:44 P.M. and stated PCE #197 was going to the dry storage room which was on the other side of the kitchen. 3. On 08/14/25 between 7:00 A.M. and 7:52 A.M., observation with Dietary [NAME] #180 of the prep and steam table revealed a red bucket containing water and cloth on the lower shelf of the steam table. Dietary [NAME] #180 tested the quaternary solution in the red bucket and it tested at 150 ppm (parts per million). Observation of the GFS poster labeled Sanitizer Test Procedure that was posted above the prep station revealed the Quaternary should be a 200 ppm test paper reading and test results must be within the range shown. Observation of the dishwash station revealed an 4-plug size electrical box with electrical wires with two sets of red wire nuts/cap remained with one corner resting on the floor under the dishwashing station. There was no cover protecting the electrical wires except for the wire nuts. The above was verified by Dietary [NAME] #180 at the time of the observations and stated maintenance had informed him the electrical wires were no longer in use or connected to electricity. Review of the undated policy: Cleaning Standards revealed food contact surfaces, non-food contact surfaces, equipment, pans and utensils must be kept clean at all times. This includes but not limited to free of grease deposits, food residue, dust and other soil accumulation/debris. Sanitizer buckets to maintain clean equipment and work areas include: sanitizer solution is in appropriate concentration (use test strip to determine this and solution is changed at least every four hours. Production, storage and service equipment to be cleaned and sanitized as required as recommended by the manufacturer. Review of the undated policy: Use and Storage of Digital and Unit Thermometers revealed all thermometers must be used, stored, calibrated and maintained in a manner that ensures accuracy, hygiene, and compliance with safety standards. Faulty or uncalibrated thermometers must be discarded or repaired promptly to prevent risks to resident health and safety. This deficiency represents non-compliance investigated under Complaint Number 2569206.

Based on review of the facility surety bond, review of fund balance form, and interview the facility failed to ensure the surety bond had not lapsed. This affected 42 residents (Resident #11, #12, #13, #15, #16, #17, #19, #22, #23, #26, #27 (two accounts), #2 (two accounts), #28, #29, #31, #33, #34, #3, #39, #40, #5, #42, #43, #45, #47, #48, #49, #51, #52, #54, #8, #55, #10, #58, #59, #60, #61, #62, #65, #64, #9 (two accounts), and #67 out of 68 residents identified as having a resident funds account. Findings Include:Review of resident funds balance form dated [DATE] revealed there was 45 accounts for 42 residents (Resident #11, #12, #13, #15, #16, #17, #19, #22, #23, #26, #27, (two accounts), #2 (two accounts), #28, #29, #31, #33, #34, #3, #39, #40, #5, #42, #43, #45, #47, #48, #49, #51, #52, #54, #8, #55, #10, #58, #59, #60, #61, #62, #65, #64, #9 (two accounts), and #67 totaling $28,884.44. Review of the surety bond dated [DATE] revealed the surety bond was effective from [DATE] and expired on [DATE]. There was no documented evidence the facility had renewed this surety bond or entered into a new surety bond. Interview on [DATE] at 11:00 A.M. with the Administrator confirmed the surety bond had expired on [DATE]. The Administrator reported corporate had reported the facility was changing companies, however there was no evidence the facility had a current surety bond. Interview on [DATE] at 4:27 P.M., with Corporate Staff Member #199 confirmed the facility did not change companies and decided to renew the surety bond with the previous company. The bill was paid today ([DATE] at 1:27 P.M.).

Based on observation, policy review and interview, the facility failed to maintain a clean and sanitary physical environment, failed to ensure a homelike dining experience and failed to ensure adequate supplies/linens were available for resident use. This affected 16 residents observed eating in the main dining room (Resident #2, #3, #6, #8, #15, #18, #19, #20, #25, #28, #29, #31, #44, #45, #47, and #52), three resident's (#9, #69 and #80) air conditioner unit, nine resident rooms (Resident's #2, #6, #8, #18, #19, #45, #47, #65 and #80) and had the potential to affect all 68 residents residing within the facility. 1.On 08/11/25 between 11:28 A.M. and 11:35 A.M., observation and interview with Resident #59 revealed upon entering the room the floor was sticky causing your shoes to make a snapping noise as you walked across the floor. Interview with Resident #59 at the time of the observation revealed she was unaware what was on the floor that made the entire floor sticky and she said it had been that way for a day or so. The resident's waste paper basket was overflowing with trash and the resident's privacy curtain was observed to have a brown and white substance scattered on it. Observation of the resident's bathroom revealed the floor was sticky and the caulking around the base of the toilet was stained with a brown/black substance. The above was verified by Certified Nurse Assistant (CNA) #132 and Housekeeping #137 at the time of the observation. Review of the Housekeeping Log revealed staff check marked rooms as they were cleaned/floors mopped/etc. Review of the Housekeeping Log dated 08/09/25 and 08/10/25 revealed Resident #59's room had not been cleaned/floors mopped/trash emptied. On 08/19/25 at 9:56 A.M., interview with Housekeeping Manager #113 revealed housekeeping was not able to get everything done on the weekends due to only having one housekeeper. The Housekeeping Log was to help keep track of what rooms were cleaned and what rooms still needed to be cleaned. Housekeeping Manager #113 stated during the week she helps out but she does not work weekends normally. The facility was currently looking for another housekeeper to hire. 2. On 08/11/25 between 12:30 P.M. and 12:41 P.M., observation of the main dining room lunch meal revealed a contracted pest control employee (Orkin) was observed entering the main dining room while Resident #2, #3, #6, #8, #15, #18, #20, #25, #28, #29, #31, #44 and #52 were eating lunch. Pest Control Employee #197 was observed spraying a chemical substance along the base of two doors in the activity/dining room. Pest Control Employee #197 then walked over to the sink area, opened the cabinet beneath the sink, removed a used glue mouse trap and discarded the trap. Pest Control Employee #197 removed a new glue trap and placed it under the sink. Pest Control Employee #197 then entered the kitchen and was observed entering the kitchen without a hairnet. At the time of the observation, Regional Culinary Manager (RCM) #195 was informed of the observation and entered the kitchen. RCM #195 verified the Pest Control Employee was in the kitchen without a hairnet during meal service. RCM #195 verified it was not appropriate or homelike to spray pest chemicals during the resident meal service. Review of the pest control Invoice/Service Ticket dated 08/11/25 revealed no activity was detected and preventative treatment for target pests was performed. Treatment included PT Fendona Pressurized Insecticide. Review of the material Safety Data Sheet for PT Fendona Pressurized Insecticide dated 03/16/21 revealed aspiration hazards included the insecticide may be fatal if swallowed and entered the airways. General safety and hygiene measures included to keep away from food, drink and animal feeding stuff. 3. Medical record review revealed Resident #9 was admitted on [DATE] with diagnoses including Parkinson's disease, dystonia and cachexia. On 08/12/25 at 9:20 A.M., observation of Resident #9's room (209-B) revealed the fall mat was cracked and not a cleanable surface, the air conditioning unit (AC unit) was dripping water from the AC unit vent onto a bath blanket placed on the floor. The AC unit was observed with black debris/mildew pooling on the vents and dripping onto the floor. The resident's upper portion of the bed was positioned away from the wall and a bath mat was observed on the floor below the AC unit. The resident had a cork board hanging on the wall below the AC unit that had cards and pictures pinned to it. The cork board was observed to have dried black stains extending from the top to the bottom on bilateral sides of the cork board approximately one to three inches in width. At the time of the observation, interview with Family #204 revealed the facility was notified of the leaking air conditioner unit at the beginning of summer and it was still leaking. Family #204 stated he had come in to visit and Resident #8's pillow was soaked from the AC unit above her bed dripping onto the bed and black debris/mold was on the slats of the AC unit and on her bed linens. Family #204 stated it has not been fixed and pointed to the cork board hanging beneath the AC unit and the black stained areas on both sides from the AC unit. There was also a bath blanket on the floor between the wall and the resident's bed that had dried water stains and grey/black splattered areas. The drywall and baseboard along the floor was observed to be black and the baseboard was pulling away from the drywall. Family #204 stated he was concerned that the black mold would make Resident #9 sick. 4. Observation of the environment on 08/11/25 between 10:36 A.M. and 1:27 P.M. revealed the following: - room [ROOM NUMBER] with Resident #2 had the left side of the bed against the wall. There was paint scraped off in an approximate eight foot area of the wall exposing the drywall. The floor of the resident's room had was dark and dirty with paper and debris on the floor. The floor had no shine. - room [ROOM NUMBER] with Resident #45 the floor was dull, dirty with dark streaks on the floor. - room [ROOM NUMBER] Resident #19 one third of his headboard was broken off. Interview 08/11/25 at 11:05 A.M. with Resident #19 revealed his headboard sounded like a gun went off when it broke a couple weeks ago. It was still not replaced. -room [ROOM NUMBER] with Resident #6 the back wall of his room was scraped up in an approximate eight foot section. His floor was darken and dull. -room [ROOM NUMBER] with Resident #47 the floor was dull and soiled. - room [ROOM NUMBER] with Resident #18 his bed was against the wall. There was an approximately three by two foot area, on the wall he would be looking at if he rolled on his right side, where the paint was scraped off exposing the drywall. - room [ROOM NUMBER] with Resident #8 the floor was dirty. There was also a cup, a [NAME] box, mail, and pencil sharpener on the floor. On 08/11/25 between 2:43 P.M. and 2:54 P.M. Licensed Practical Nurse #179 verified the dirty floors, damaged walls and headboard. Interview on 08/19/25 at 10:08 A.M. with Housekeeping Staff #113 said on the weekends there is only one housekeeper. We are down a person. She said not every room gets cleaned on the weekends. Review of the list of rooms cleaned over the weekend of 08/09/25 and 08/10/25 revealed rooms [ROOM NUMBERS] were described on the list of observation and not cleaned by housekeeping on 08/09/25 or 08/10/25. In addition rooms 205, 302, 413, 501, 502, 503, 504, 505, 506, 507, 508, 509, 510, 511, and 512 were not cleaned over the weekend due to one housekeeper only working. 5. Observations included: - On 08/11/25 at 10:36 A.M. Resident #2 had a pillow behind her head without a pillow case on it. - On 08/11/25 at 11:07 A.M. it was noted Resident #19 had a heel boot on the floor that was heavily soiled with dry drainage. He was on a special air mattress. The blue cover of the air mattress was heavily soiled with white flakes and dried debris. He had a pillow under his head without a pillow case on it. Verified at the time of the observations with Licensed Practical Nurse (LPN) #179. Interview on 08/12/25 at 10:39 A.M. with Central Supply/Medical Records #127 staff they run out of supplies at times such as medium and large gloves. The corporation likes them to use Tri-State because their prices are lower on some things. However, they are not reliable for delivery. Sometime they come on Monday, Tuesday, or Wednesday. She orders three cases each of medium, large and extra large gloves and usually only have extra large left. She tried to keep two cases of wet wipes in the office for emergencies. She does not put them in the central supply room so they are not used daily. Wipes are not kept in rooms. She came in on a Saturday and bought gloves locally and brought them in. She bought three or four boxes at Walmart. We were not out of gloves completely. There were still extra large gloves in the building. They can also borrow from sister facilities. There may be ten (10) boxes floating around in the halls for the 68 residents. Staff will put a medium box on one side of the hall and a box of large on the other side of the hall. The supply room had one box of extra large in the supply room. She had eleven boxes in her office, of extra large. There are no wet wipes on the shelf. She has one full box of 50 wipes and a partial box in her office. She thinks a nurse has a key to get in her office if she needs to get the wet wipes or the extra large gloves. They are not put on the shelf. She manages the supplies like the person taught her who she took the job over from a few months ago. Interview on 08/13/25 at 12:46 P.M. with Licensed Practical Nurse (LPN) #108 and Central Supply #127 revealed there were two boxes of tissues left in the facility until the next shipment next Tuesday, in six days). There were no medium or large gloves. There was one box of extra large gloves in the supply room. They indicated they ran out of laundry even before the fire. On 08/13/25 at 1:04 P.M. observation revealed Resident #2 had no gloves in her room and needed assistance with a large bowel movement. Interview on 08/13/25 at 1:10 P.M. Housekeeping #137 revealed they have run out of toilet paper and paper towels. She had no tissues left to place in rooms. She indicated there is a new person in the central supply position. They have not had enough supplies gloves, toilet paper, Kleenex, paper towels, and linens the last three months. On 08/13/25 at 1:14 P.M. it was noted Resident #18 wanted a tissue and there were no tissues in his room. Observation of seven rooms on 400 hall on 08/13/25 at 4:12 P.M. revealed two of seven rooms had a box of gloves. Some almost empty. Rooms 403, 404, 408, 409, and 412 did not have a box of gloves. Interview with CNA #185 on 08/12/25 at 6:34 A.M. stated the facility does not stock gloves or incontinence products in the rooms. States most nights only have maybe one box per hallway. No longer can get to extra supplies including linen. Hall 2 had no gloves when she started her shift last night (08/11/25). Cant take the one box in and out of rooms so what are you supposed to do. On 08/12/25 at 6:59 A.M., interview with CNA #112 stated the facility runs short of help frequently and depending on who is working determines if things all get done or not. Management does not come in to help and try to do the required checks every two hours but sometimes they are late. States the facility runs out of linens and gloves and never have large briefs. The briefs they provide the residents do not always fit them so they just lay them out on the bed because it would cut into their skin if they closed the tabs. Interview on 08/13/25 at 4:22 P.M. with LPN #108 revealed they are encouraged to use soap and water for pericare. They keep wet wipes in the office for emergencies. If they are on the shelf they would use them instead of soap and water. We have run out of gloves that are not extra large. The good sizes are gone. She has had complaints from aides that there are no gloves. The rooms have glove holders with them but no gloves in the holders. They complain frequently about the lack of gloves. 6. Tour of the linen cart and four linen rooms on 08/12/25 between 4:10 P.M. and 4:35 P.M. revealed: Hall 1 linen closet had three washcloths and no bath towels, Hall 2 linen closet had 1 washcloth. Hall 3 linen cart had three towels and two washcloths. Hall 4 linen closet had four washcloths and three towels. Hall 5 linen closet had seven washcloths and no towels. Licensed Practical Nurse (LPN) #179 accompanied the surveyor on the tour and verified the linen count of 17 clean wash clothes and six clean towels in the facility for 68 residents. Interview on 08/12/25 at 4:38 P.M. with Certified Nurse Aides (CNA) #105 and #132 revealed they do run out of washcloths and towels The facility wants them to use soap and water and wash clothes for pericare not wet wipes. They do have wet wipes in housekeeping office for emergency. They do not keep wet wipes in central supply. They also do not have enough gloves in medium and large. They run out. Also, verified they run out of gloves in medium and large and spend a lot of time hunting for gloves because boxes of gloves are not kept in rooms. Interview on 08/12/25 at 4:19 P.M. with Housekeeping/Laundry Supervisor #113 revealed the linens are being washed and dried at a sister facility. She will drop off the soiled linen and personals when she leaves work and pick them up clean in the morning between 7:30 A.M. and 8:00 A.M. What linen is out is what they have until after 8:00 A.M. in the morning. She said she does have some washcloths and hand towels in her office that have not been put out. She included she asks for more linens and they get removed from requisitions due to budget. There were blankets, towels and washcloths approved last week due to the laundry dryer fire and loss of items in the dryer. 7. Interview on 08/12/25 at 12:15 P.M. with Laundry #140 included she was told they did not have enough washcloths and towels. On Monday and Tuesday morning especially there are not enough towels and washcloths. If the stains do not come out of linen they take the linen out of circulation. They tally the linen they take out of production, make a list and requisition more. They have to wash and dry linens and personals. It takes an hour in the washer and a half hour in the dryer. The wash load is split in two and dried half at a time since there was only one functioning dryer. The linen is then folded and brought out to the floor. She will put nothing but towels and washcloths in the washer first thing Monday and Tuesday morning because they are always short those mornings maybe due to less production on the weekends. Since the laundry fire they are sending everything to a sister facility. Facility staff are working after hours there to wash the linens. The clean is then brought back to the facility sorted and distributed. Interview on 08/13/25 at 8:52 A.M. with Laundry/Housekeeping #113 revealed the company formula/par level for washcloths was three washcloths per resident per day, She calculated that with a 67 census she should have 201 washcloths per day. When she did inventory she had nine clean washcloths in the facility. She received 350 washcloths on 08/05/25 and so she put those in circulation on 08/12/25. She did not know where the washcloths for peri care would come from. The facility identified 43 current incontinent residents. Incontinence care is to be provided every two hours. Incontinence care requires three washcloths at a minimum. Three washcloths times 12 incontinence care a day would require 36 washcloths per incontinent resident. Forty three incontinent resident receiving pericare every two hours would need 36 washcloths for pericare a day. Multiply by 43 residents would equal 1548 needed per day for incontinence care. If the 67 residents Laundry #113 identified as a current census used two wash clothes a day for bathing, face washing, etc. that would be a total of 134 washcloths for bathing for a total 1682 washcloths needed a day. Using the facility formula of three washcloths per resident per day the total would be 1759 washcloths need per day instead of the 201 washcloths the corporation identified as a par level. On 08/14/25 at 1:54 P.M. interview with the Administrator, Licensed Practical Nurse (LPN) #179, Registered Nurses (RN) #193 and #194, the Director of Nursing, and Culinary Director #195 verified the corporation wants staff to cleanse residents with washcloths for pericare. They verified the facility would not have enough washcloths to provide care for incontinent residents utilizing washcloths as the corporation prefers. They verified they did not have enough linen, gloves and tissues on hand to provide resident care. 8. a. Interview on 08/11/25 at 11:34 A.M. with Resident #65 included she asked to have her television mounted. She reported it and was told it was on the list. Review of the TELLS maintenance requisitions revealed a request on 04/23/25 to mount Resident #65's television. b. Review of Resident #80's record revealed a 08/04/25 admission with diagnoses including fracture fifth vertebrae T-11 to T-12, end stage renal disease, dependence on renal dialysis (hemodialysis), Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, dysphagia, hypertension, hypocalcemia, and depression. Interview on 08/12/25 at 8:46 A.M. with Resident #80 revealed the television did not work when she arrived, 08/04/25. They did not give her a new one until 08/11/25. Her air conditioner is dirty and smells musty. She said maintenance came in and cleaned it 08/11/25. Observation revealed the front half of the air vents appear to have been wiped off. The back half of the air conditioner vents were soiled dark with dirt/dust. The air conditioner did smell musty when blowing air. Interview on 08/12/25 at 12:13 P.M. with Maintenance #173 verified the TELLS report revealed an entry on 08/05/25 that the resident needed a television. He indicated he was focusing on the fire and then had to find a television so she did not receive a working television until 08/11/25. He also looked at her air conditioner and swept the debris out of the vents of debris. He verified the vents were not clean on the air conditioner and he said he will need to teach housekeeping how to pop out the vents and clean them. Interview on 08/19/25 at 12:06 P.M. with the Administrator revealed they buy televisions for skilled. She thinks residents are taking facility televisions home. She just bought two this weekend. The Administrator revealed maintenance told her he did not know about the air conditioner not working until 08/11/25. 9. Observation on 08/20/25 at 2:17 P.M. revealed Resident #69's air conditioner had visible whitish clumps of lint/dust in the air conditioner vents. There was a puddle of water on the floor under the air conditioner. There was a steady drip coming out of the air conditioner onto the floor. On 08/20/25 at 2:20 P.M. Licensed Practical Nurse #179 verified the air conditioner was dirty and leaking. The deficiency substantiates Complaint Numbers 2588814, 2584767, 2583878, and 2569206.

Based on medical record review, observation, interview, and policy review, the facility failed to ensure dependent residents were assisted with nailcare and shaving. This affected four residents (#2, #5, #10 and #19) of seven residents reviewed for activities of daily living. The census was 68. Findings Include:1. Review of Resident #2's medical record revealed a 07/12/25 admission with diagnoses including fracture of left femur, vascular dementia, hypertensive heart disease, congested heart failure, depression, muscle wasting and atrophy, abnormalities of gait and mobility, weakness, history of falling, anxiety disorder, Vitamin B deficiency, chronic stage III kidney disease, gastroesophageal reflux disease, disorientation, hypertension, spondylolisthesis lumbar region, and cardiac murmur.Review of a 07/19/25 Quarterly Minimum Data Set (MDS) Assessment revealed the resident was severely impaired for daily decision making and needed substantial/maximum assist for personal hygiene.Review of the resident record included a plan of care dated 08/05/25 activity of daily living self-care performance deficit related to the resident's confusion, dementia, femur fracture, weakness, and recent surgery.Observation on 08/11/25 at 10:36 A.M. of Resident #2 revealed the resident was sitting in her room in a recliner. Resident #2's fingernails on her right hand were long all with dark debris except for the pinky finger. Her left hand, her thumb, and middle finger had long nails with dark debris under the nailbeds.Interview on 08/11/25 at 2:39 P.M. with Licensed Practical Nurse (LPN) #179 verified the resident had long fingernails with debris under the nailbeds.Review of the facility Activities of Daily Living (ADL) policy (updated 02/2024 and approved 05/2025) included activity of daily living services are directed toward the goal of promoting the highest practicable physical, mental and psychosocial functioning of the resident. Activity of Daily Living plans of care may be implemented as appropriate. 2. Review of Resident #10's medical record revealed a 08/24/23 admission and 05/08/25 readmission admission with diagnoses including chronic obstructive pulmonary disease, cervical disk degeneration, chronic peripheral venous insufficiency, need for assistance with personal care, lack of coordination, type 2 diabetes mellitus, intervertebral disc degeneration, lower extremity pain, polyneuropathy, cramps and spasm, hypotension, contracture of muscle multiple sites, insomnia, chronic pain, hyperlipidemia, vitamin D deficiency, deaf nonspeaking, obstructive and reflux uropathy, peripheral vascular disease , benign neoplasm of right adrenal gland, full incontinence of stool, seasonal allergies, open angle glaucoma, anxiety disorder, hypertension and dysphagia.Physician orders did not include any orders related to activities of daily living or positioning. Review of Certified Nurse Aide (CNA) TASK documentation revealed no mention of nail care.Review of the 07/16/25 Annual MDS revealed the resident was independent for daily decision making, had bilateral upper extremity impairment, utilized a wheelchair, and was dependent for personal hygiene. The resident had a plan of care dated 07/23/25 Activity of Daily Living Self Care Performance Deficit related to Chronic Obstructive Pulmonary Disease, disc degeneration, contractures, weakness, and impaired mobility. He will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. The resident has limited physical mobility related to contractures of bilateral upper extremities. Requires moderate to maximum assistance with most functional mobility and ADL performance. Declines any splinting or formal range of motion. Will allow staff to perform cleaning and nail trimming only.Observation on 08/11/25 at 1:27 P.M. of Resident #10 revealed bilateral hand contractures. The fingernails on his left hand were long with debris under the nailbeds He did not have a mechanism in place to protect the palms of his hands from the fingernails of his contracted fingers. The fingernails were making and indentation on his palm.On 08/11/25 at 2:48 P.M. interview with LPN #179 verified the resident's contracted fingers, positioned his fingernails to dig into his palm. Further verified the fingernails were long and soiled.3. Review of Resident #19's medical record revealed a 07/17/24 readmission with diagnoses including lymphedema, dysphasia, anemia, proximal atrial fibrillation, acquired absence of left toes, chronic kidney disease stage three, venous insufficiency, chronic diastolic congestive heart failure, hyponatremia, hyperlipidemia, benign prostate hyperplasia, bladder neck obstruction, type two diabetes, severe protein calorie malnutrition, vitamin D deficiency, chronic respiratory failure, chronic kidney disease and disorder, Parkinson's disease and major depressive disorder. The resident had a plan of care dated 03/25/24 Activity of Daily Living (ADL) self care deficit related to impaired mobility, impaired balance, chronic abdominal wound, diabetic mellitus, morbid obesity, Parkinson's, chronic respiratory failure and Bell's Palsy.Review of the 06/10/25 Quarterly Minimum Data Set Assessment revealed the resident was independent for daily decision making, had bilateral lower extremity functional impairment, was dependent for personal hygiene, did not walk or transfer, and needed substantial/maximum assistance to roll left and right. The resident was at risk for developing pressure ulcers, had pressure reducing devices, and ointments applied other than feet. The resident received insulin, antianxiety, antidepressant, anticoagulant and hypoglycemic medications. Observation on 08/11/25 at 11:07 A.M. revealed the resident was unshaven. He had long fingernails bilaterally that were heavily soiled with dark debris bilaterally.Interview on 08/11/25 at 11:08 A.M. with the resident revealed they do not offer to shave him. His sister shaved him last. Further, learned the staff does not trim or clean his fingernails. Observation and interview on 08/11/25 at 11:09 A.M. with LPN #179 verified Resident #19 was unkept and unshaved. His fingernails were long bilaterally with dark debris under the nailbeds.4. Review of Resident #5's medical record revealed a 07/14/25 readmission with diagnosis including metabolic encephalopathy, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, major depressive disorder, bipolar disorder, constipation, muscle weakness and atrophy, sepsis, vitamin D deficiency, pain, cyst of kidney, osteoarthritis of hip, irritable bowel syndrome with diarrhea, hypertension, retention of urine, dysphagia, anxiety, and hypercholesterolemia. A 12/06/21 plan of care had the resident at risk for declines/fluctuations in activity of daily living ability related to impaired mobility, metabolic encephalopathy, anxiety, bipolar disease, dyspnea, chronic obstructive pulmonary disease, weakness, chronic respiratory failure, and needs encouraged to get out of bed.Review of the 07/20/25 Minimum Data Set Assessment included the resident was moderately impaired for daily decision making. The resident needed some help with self care. The resident was set up for eating, and oral hygiene. Resident #5 received continuous oxygen therapy. Observation and interview on 08/11/25 at 12:05 P.M. with Resident #5 revealed her fingernails were long and dirty. The resident said she doesn't get her nails cleaned or cut. All fingers on her right hand had debris under the nailbeds. Her left hand had debris under her index finger and thumb. Interview on 08/11/25 at 2:54 P.M. with LPN #179 verified the resident's fingernails were long and soiled.This deficiency represents non-compliance investigated under Complaint Numbers 2588814, 2569206.

Based on medical record review and interview the facility failed to ensure medical records were complete and accurate. This affected four residents (#48, #72, #77, and #80) of 27 resident records reviewed.Findings Include: 1.Closed record review revealed Resident #72 was admitted to the facility on [DATE] from another long-term facility. The resident admission diagnoses included malignant neoplasm of right and left female breast, atrial fibrillation, anemia, hyperlipidemia, hypocalcemia, anxiety, insomnia, essential hypertension, constipation, psoriasis, osteoporosis, chronic kidney disease, pain, use of anticoagulants, and difficulty walking. The resident expired in the facility on [DATE]. Review of Resident #72's altered cardiovascular status/related to hypertension, atrial fibrillation initiated [DATE] and revised [DATE] to monitor/documented/report to physician as need any signs and symptoms of coronary artery disease: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in capillary refill, color/warmth of extremities. Review of Resident #72's progress notes dated [DATE] at 2:50 P.M. revealed the resident was absent of vital signs at this time. A second nurse arrived to [NAME] at this time. The medical director was notified. The family at bedside. Further review of the resident medical record revealed no evidence change of condition or events that led up to the resident's death on [DATE]. Review of a typed statement authored by the Director of Nursing (DON) dated [DATE] revealed on [DATE] during morning meeting the staff were told nursing needed help with Resident #72. I, the Assistant Director of Nursing (ADON), the unit manager and Administrator all responded. Upon entering the room, the resident was noted to be hypoxic in recliner, oxygen was started as the resident was sats were high 60%. The crash cart was in room as the resident was a full code. Oxygen brought the resident sats to high 80's. When asked staff stated they were walking her to bathroom when she got weak and unsteady, so they sat her in the recliner and called for help. One nurse had already called 911 and the Administrator called the family to update the family. Family stated the resident was a do not resuscitate (DNR). The ADON went to the computer to pull a signed code status from the hospital records. The squad arrived and was updated on code status and left. Family arrived at same time and was taken to the resident's room. Family at bedside requested to keep resident comfortable but did not want morphine at this time. Stating it was okay with oxycodone to keep her comfortable. Physician aware, new orders obtained for oxycodone, code status updated approx. 11:25 A.M. Administrator stayed in room with family at that time. This DON checked in on resident and family and noticed resident with labored breathing, bilateral feet were starting to mottle. This DON spoke in depth to family about possibly starting morphine to keep resident comfortable and explained reasons why. Family agreeable to start morphine. Unit manager talked to physician for morphine orders around 2:00 P.M. At approximately 2:50 pm the resident was absent from vitals. Family was at beside. Interview on [DATE] at 8:11 A.M., with the DON confirmed there was no documentation evidence in the medical record of the resident change of condition leading up to the resident's death including vital signs, oxygen orders, and signed code status for DNR. The DON reported she had written a statement on [DATE] to provide to the surveyor explaining events and change of condition that led up to resident's death. Interview on [DATE] at 10:09 A.M. ,11:37 A.M., 12:20 P.M., and 4:25 P.M., with Corporate Regional Nurse (CRN) #193 confirmed there was no documented evidence of change of condition leading up to the resident death in the medical record. The staff did not document vital signs or received signed orders for oxygen or DNR code status. The funeral home sent over the cause of death was arteriosclerotic cardiovascular diseases. 2. Review of Resident #48's medical record revealed a [DATE] admission with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure, Obstructive sleep apnea (OSA), diabetes, asthma, hemiplegia, and anxiety disorder. Physician orders included a [DATE] order for Non-invasive home ventilator (Trilogy machine) Settings: AVAPS-AE Breath Rate: Auto Inspiratory time: N/A Sigh: off mouthpiece ventilation: NO PS min-5 comment-20 PS max-20 comment-25 EPAP min-5 EPAP max:15 AVAPS rate: 5 max pressure: 35 VT Target: 500 heated humidifier with mask, a [DATE] order for routine cleaning of trilogy supplies day shift every Sunday, [DATE] order to wipe Trilogy mask in the mornings after removal and change oxygen supplies every night shift on Sunday. Interview on [DATE] at 11:45 A.M. with Resident #48 revealed she has a bipap machine and mask but they are not putting it on her as it is broken. On [DATE] at 2:49 P.M. interview with Licensed Practical Nurse (LPN) #179 revealed part of the gel came off of the Trilogy mask and they could not get a good seal. Another mask was ordered. Observation at the time of the interview revealed there was an unopened box on the top of the resident's cabinet. LPN #179 looked at the box but did not open it. The outside of the box did not identify what was inside the box. Observation at the time of the interview verified the bipap machine on the bedside table had a mask that was not contained in a bag for sanitation. Interview on [DATE] at 6:01 P.M. with the resident included she wore the Trilogy two nights ago. Last night it beeped and so she did not wear it. She did not wear it for about a month because of the mask not fitting. The Trilogy mask was lying on the bedside table not contained in a bag. Interview on [DATE] at 7:00 P.M. with LPN #108 revealed she ordered the new mask on [DATE] and it was delivered on [DATE]. Interview on [DATE] at 7:02 P.M. with LPN #179 verified the mask was in the unopened box on top of the resident's cabinet she looked at on [DATE]. The box did not identify what was in the box. Review of the Treatment Record revealed the device was marked as applied at night on [DATE], [DATE], [DATE], and [DATE] when the seal on the old mask was broken. This documentation is inaccurate as a new mask was ordered [DATE], was received [DATE] but not opened until [DATE]. Interview on [DATE] at 12:03 P.M. with LPN #179 verified the resident had the Trilogy machine signed off as being applied to the resident when the mask was broken and it would have just beeped because of the bad seal. LPN #179 verified the mask was not applied as indicated on the treatment sheet [DATE], [DATE], [DATE] or 08/10 /25 after the new mask arrived and was not opened for use until [DATE]. 3. Medical record review revealed Resident #80 was admitted on [DATE] with diagnoses including end stage renal disease, dependence on dialysis. Review of the dialysis Progress Note dated [DATE] revealed Resident #80 was ordered two new medications including calcium acetate (phosphate binder) 667 milligrams (mg) with the first bite of each meal. The physician order was not transcribed until [DATE]. Review of the electronic Medication Administration Record revealed calcium acetate 667 milligrams (mg) was ordered on [DATE] to be administered with the first bite of the meal. The medication was documented as being unavailable for administration except for three doses on [DATE] and two doses on [DATE]. Review of the record revealed no evidence calcium acetate 667 (mg) was available to be administered while Resident #80 was a resident at the facility. On [DATE] at 12:15 P.M., interview with the Director of Nursing verified the facility did not receive any calcium acetate 667 (mg) as ordered from either the pharmacy or the dialysis center; therefore, Resident #80 did not receive the medication between [DATE] and [DATE]. The DON verified the electronic Medication Administration Record indicated Resident #80 had received three doses of calcium acetate on [DATE] and two doses of calcium acetate on [DATE]; however, the DON verified this was not accurate due to the calcium acetate was never received at the facility. 4. Medical record review revealed Resident #77 was readmitted on [DATE] with diagnoses including diabetes mellitus. Review of the electronic Physician Orders dated [DATE] revealed to administer lispro insulin per sliding scale intramuscularly (IM) before meals for diabetes. Review of the electronic Medication Administration Record dated [DATE] revealed Resident #77 was administered five doses of lispro insulin IM between [DATE] and [DATE]. Review of the National Institutes of Health: lispro insulin revised [DATE] revealed the insulin was to be administered subcutaneously. On [DATE] at 2:23 P.M., interview with Registered Nurse #193 verified Resident #77's lispro insulin order was inaccurate for the route of administration.

Based on medical record review, observation, interviews, and policy reviews the facility failed to ensure enhanced barrier precaution (EBP) were implemented/maintained and infection control practices were maintained during incontinence care. This affected three residents (#1, #32, and #42) of four residents observed on 100-unit for EBP and two residents (#20 and #77) of two residents observed for incontinence care. Findings Include: 1. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including gastrostomy tube. Review of Resident #32' EBP plan of care dated 07/23/25 revealed to use appropriate EPB when performing the following care: dressing, bathing, showering, transferring, hygiene care, changing linen, toileting, and peri care. Dispose of EBP in the appropriate containers. Review of Resident #32 current orders revealed no evidence of orders for EBP. Interview and observation on 08/11/25 at 10:32 A.M., of Resident #32 revealed the resident had a gastrostomy tube. The resident reported staff flush the tube, however they do not wear gowns when providing direct care or flushing the tube. There was no evidence of EBP sign in the room or personal protective equipment (PPE) outside the room. Interview and observation on 08/11/25 at 11:09 A.M., with Licensed Practical Nurse (LPN) #108 confirmed resident #32 should have been on EBP for her gastrostomy tube. The LPN confirmed if a resident was in EBP there should be a sign in the room above the resident bed, a PPE basket hanging outside the room on the wall, and a signed order for resident on EBP. LPN #108 confirmed Resident #32 did not have a sign or a basket outside the room to alert staff that the resident was in EBP or a signed order. 2. Observation and interview on 08/11/25 at 11:11 A.M., with LPN #108 revealed Resident #42 was in EBP because he had a urinary foley catheter. The LPN confirmed there was no evidence of a sign above the residents' bed nor a basket outside the door. LPN #108 reported the sign was hung above the roommate's bed in error instead of Resident #42's bed and the basket had broken and she had requested a new basket. 3. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, diabetes, bacteremia, and skin alterations. Review of Resident #1's EPB plan of care dated 06/26/25 and revised 08/12/25 revealed to dispose of EBP in the appropriate container, do not use EBP outside resident rooms such as hallways, common areas, and dining rooms, use appropriate EPB when performing the following care: dressing, bathing, showering, transferring, hygiene care, changing linen, toileting, and peri care. Treatment for wounds and utilize proper hand hygiene. Observation on 08/11/25 at 11:10 A.M., with LPN #108 revealed two Certified Nursing Assistants (CNA's) were providing care to Resident #1 with no PPE in place. Dirty linens were noted on the floor not in a bag. The two CNAs reported to LPN #108 they didn't think they were required to wear PPE since they were not providing wound care. LPN #108 provided education to the CNAs. Interview on 08/11/25 at 11:22 A.M., with LPN/infection preventionist (IP) #179 confirmed resident with EBP should have a sign above the bed, orders, and a basket outside the room with PPE equipment. Review of the facility's policy and procedure titled Enhanced Barrier Precautions (EBP) dated 04/2018 and revised 01/2025 revealed EBP are indicated for residents with any of the following: Infections or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply or wound and indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. For residents who EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, hygiene care, changing linens, changing briefs or assisting with toileting, device care, and/or wound care. The gown and gloves used for each resident during high-contact resident care activities should be removed and discarded after each resident care encounter and hand hygiene should be performed. An EBP isolation sign would be placed near the resident's room identifying the PPE required during high contact care activities. 4. Observation on 08/19/25 at 2:00 P.M., of incontinence care with CNA's #100 and #132 for Resident #20 revealed staff had already had the supplies ready and the resident positioned for incontinence care. Staff explained procedure to the residents. The two CNAs unfastened the resident's brief and rolled the brief down between her legs. CNA #100 placed soap on a washcloth and wiped down the middle of labia and then changed positions on the washcloth and then wiped the right outer thigh crease and then the left outer thigh crease. She repeated the procedure for the rinse and dry. The CNA confirmed she did not cleanse the right and left side of the inner labia. CNA #100 reported she was not trained to spread the labia apart and wash both sides of the labia just to cleanse down the center. Review of the skills checklist undated for perineal care revealed to use a soapy washcloth to wash the front perineum to include the genital and skin fold areas of the groin. There were no instructions on how to cleanse the perineal area. Review of the incontinence care policy 04/18 and revised 01/06/25 revealed to clean area with perineal wash or with mild cleanser and pat dry. There were no instructions on how to cleanse the perineal area. Interview on 08/19/25 at 3:11 AM with the LPN/IP #179 reported the perineal care skilled checklist did not include detail instruction on how to cleanse the perineum area. Interview on 08/20/25 at7:22 A.M. with the Director of Nursing (DON) confirmed the policy and competency did not include specific instructions on how to cleanse the perineal area. The DON reported her expectation would be the labia should have been cleansed in the middle and then the labia should have been spread apart and cleansed right and then left. 5. Medical record review revealed Resident #77 had multiple admissions to the facility and was most recently admitted on [DATE] with diagnoses including peripheral arterial disease, diabetes mellitus, bilateral below the knee amputations (BKA) and multiple wounds. Review of the census revealed the resident was discharged to the hospital on [DATE] with a diagnosis of encephalopathy and returned to the facility on [DATE]. Review of the Wound Care re-consultation visit for wound care services dated 08/14/25 revealed multiple wounds including a Stage III pressure ulcer to the coccyx present on admission measuring 3.5 (cm) in (l) by 4.9 (cm) in (w) by 0.2 (cm) in depth (d). The wound bed was 100% granulation with scant serous drainage. Education was provided on the importance of offloading to promote wound healing and maintaining proper hygiene to support wound healing including to keep the wound site clean and dry, avoiding contamination and the importance of adhering to prescribed treatments and dressing changes to prevent infection was emphasized. On 08/19/25 between 4:15 P.M. and 5:01 P.M., observation of incontinence care revealed licensed practical nurse (LPN) #131 and certified nursing aide (CNA) #107 were observed washing their hands and applied gloves. CNA #107 gathered incontinence supplies, positioned the resident in bed and removed the tape from the incontinence brief. The resident was observed to have been incontinent of urine and CNA #107 washed the resident's penis, groin and up under the scrotum. LPN #131 and CNA #107 rolled the resident onto his left side exposing the buttock and coccyx. An unstageable pressure ulcer irregular in shape was observed to be 75% covered with slough with scant drainage. CNA #107 proceeded to cleanse the groin under the scrotum, and wiped across the rectum and over the lower aspect of the Stage III pressure ulcer. CNA #107 then using the same gloved hands grasped a clean wash cloth and rinsed the resident in the same order. CNA #107 and LPN #131 rolled the resident over onto his right side and LPN #131 using the same gloved hands placed her thumb on various areas of the peri-wound and wound center then applied triad cream around the wound perimeter but not the wound bed. The resident was then repositioned on his back, incontinence brief applied and head of bed raised to 30 degrees. LPN #131 removed her gloves, washed her hands and stated she was going to notify the physician of the wound due to a change in the appearance of the wound. CNA #107 changed the linens on the resident's bed and then removed her gloves and washed her hands. CNA #107 verified the above observation on 08/19/25 at 4:45 P.M. and LPN #131 verified the above observation on 08/19/25 at 5:01 P.M. and stated she had messaged the physician and was awaiting a response. This deficiency represents non-compliance investigated under Complaint Number 2583878, 2588814, 2569206.

Based on observation, record review, review of manufacturer guidelines and interview, the facility failed to ensure an exit door, clothes dryer, air conditioner and refrigerator were maintained. This had the potential to affect all 68 residents in the facility. The census was 68.Findings Include:1.Review of an elopement investigation dated 05/19/25 revealed the facility determined the 100 hall door was not locked as the key panel indicated.Interview on 08/21/25 at 8:51 A.M. with Maintenance Staff #173 revealed the 100 hall exit door is an Advantage 500 DE System. It was not connected to a Wanderguard system. The door at the end of the 100 hall had a key pad. The door was hardwired with a battery back up. The doors had a red and green light on the keypad. Red means locked and green open. The door was pushed to see if it opened during weekly door checks. Prior to the elopement the door was last checked on 05/15/25. Maintenance Staff #173 said the day of the elopement the door keypad was showing red. However, when the door was pushed, it opened. He said they looked and the back up battery was corroded. (The battery was last changed 11/20/24). It must have still had enough power to make the light red but not enough for the magnet to lock the door. Also, the electricity to the door failed. They had been trying to find out why the door wasn't consistently working. They were getting another used part in this Friday, three months and three days since the elopement. They had been conducting daily door checks since the elopement.Review of the Installation Manual for Advantage 500 DE System dated 05/16/11 revealed on page 6 only a Qualified Service Technician should work on Secure Care System. Secure Care does not authorize, and strongly recommends against, any installation or field replacement of software, parts or products by untrained contractors or facility staff. Such work can be hazardous, can render the system ineffective and will void any Secure Care warranty or liability that might otherwise relate to the system. Page seven included Warning: even slight modifications to the system or changes in the operating environment may cause secure care's system to malfunction, The only way to assure that secure care's system has been installed, set up, tested, supported, maintained and repaired correctly is to have a qualified service technician do the work.Interview on 08/21/25 at 12:21 P.M. with Regional Maintenance #200 revealed initially the corroded battery was replaced on 05/19/25. The door alarmed and locked. On 05/22/25 the door opened when checked even though the red light was on. Maintenance #200 said he had a transformer for the magnetic box on top of the door. He replaced the transformer and the door locked for about a month (06/20/25) and then the door was found to open again even though it indicated alarmed with a red light on the door. He then replaced a transformer in the ceiling with a stronger one that went to the key box. The door had been locked since. The door was in emergency mode. It runs off the 9 volt battery and converts it to a 12 volt. The doors were also on a generator. It was riding on the battery temporary. When staff did the checks it was operating off of the battery. He had changed two transformers because they were getting weak. He was getting in a used Printed Circuit Board (PCB ) part coming this Friday. He verified he was not a Qualified Secure Care Technician. He said he could call a technician but believed he knew how to fix the door even though if had been over three months since the incident. He had not had an outside entity come in to check the door. 2.Interview on 08/12/25 at 12:15 P.M. with Laundry/Housekeeping #140 revealed the laundry only had one functioning dryer prior to the fire. She stated a load of laundry was dried half at a time. So, the wash was not able to be dried all at once. She indicated if the air conditioning worked in the laundry it was very little.Interview on 08/21/25 at 11:32 A.M. with Maintenance #173 included the second dryer in the laundry had been broken since October 2024. He looked at it to see what was wrong with it. The dryer was not getting power. The dryer was so old that Regional Maintenance #200 told him they could not find the part. He did not know why the facility hadn't bought another. He verified the air conditioning had not been working since he arrived two years prior. It was set up for central air and the system was too old to get a new part.Interview on 08/21/25 at 1:55 P.M. with the Administrator revealed she thought they were trying to get parts for the clothes dryer. She included she thought the second dryer and air conditioner had not worked since she started a couple years ago. She included she had not tried to order a new dryer. 3.On 08/11/25 between 8:20 A.M. and 8:45 A.M., observation of the reach-in refrigerator revealed water was leaking in the same reach-in refrigerator that included a gallon of whole milk, 13 glasses of chocolate milk and three additional cafeteria-style trays each containing glasses of apple juice, cranberry juice and fruit punch. The chocolate milk and juice glasses were covered with plastic lids and saran wrap. Water was observed on top of the chocolate milk lids and the glasses were sitting in water that filled the cafeteria-style trays. A metal serving pan was observed sitting on top of the chocolate milk glasses without any water in it. At the time of the observation, Dietary [NAME] #128 verified the observation and Dietary Aide #111 stated the reach-in refrigerator had been not working correctly for several weeks and had been leaking water. Dietary Aide #111 positioned the metal serving pan to the back of the shelf stating the pan should catch the leaking water now.Review of the TELLS maintenance request revealed no request to fix a leaking refrigerator in the kitchen.Interview on 08/21/25 at 11:22 A.M. with Maintenance Staff #173 revealed a lot of the work he does not get on a TELLS request. He is told in the halls things that need completed. He included he had known the refrigerator was leaking for a couple weeks. He needs to clean/fix the condensation drain and has not gotten to it yet. When asked, he confirmed he was the only maintenance man for the facility. He does have a regional maintenance staff that will assist.This deficiency represents non-compliance investigated under Complaint Numbers 2588814, 2584767, 2583878, and 2569206.

Based on record review, review of the facility's timeline and related investigation, review of staff education records, resident interview, staff interview, and policy review, the facility failed to ensure nursing staff were adequately trained and knowledgeable on the use of Negative-Pressure Wound Therapy (NPWT) (wound vac) and were able to maintain, monitor, and intervene appropriately when complications arose. They also failed to implement a physician's order to obtain a CT scan and refer a resident to a surgeon when he showed signs of an infected abdominal wound. This affected one resident (#10) of one resident reviewed for wound vac therapy management. Harm occurred on 07/03/24 for Resident #10, who had a history of abdominal wall infections, when he displayed possible signs of infection in an abdominal wound, and the wound physician ordered a CT scan of his abdomen and a referral back to his surgeon. The facility failed to make the referrals as ordered. Resident #10 had complications related to the use of a wound vac and a facility nurse failed to adequately intervene or notify the wound physician of the complications they were having with his wound vac. His wound vac began to leak the evening of 07/07/24 and the wound drainage progressively increased through the night saturating draining from his abdominal wound. By morning, the area around his abdominal wound became red, hard, and warm to touch with complaints of mild to severe abdominal pain. Resident #10 was transferred to the hospital and hospitalized between 07/08/24 and 07/17/24 requiring two separate incisions and drainage to debride the abdominal abscess and to remove a foreign body. Findings include: Review of Resident #10's medical record revealed he was admitted to the facility with an initial admitted [DATE]. His diagnoses included a cutaneous abscess of the abdominal wall, sepsis, gastrostomy malfunction, morbid obesity, and an infection due to a bariatric procedure. Review of Resident #10's physician's orders revealed he had an order in place to maintain NPWT to the left flank at 125 mmHg continuous with the need to check the placement and function every shift. The order had been in place since 06/19/24. He also had an order to change the NPWT dressing to the left flank every Monday, Wednesday, and Friday. That order had been in place since 06/19/24. Review of Resident #10's wound visit note dated 07/03/24 revealed he was seen by Wound Physician #100 on 07/03/24 as a routine weekly visit. The wound physician assessed the resident's non-healing surgical wound of the left flank and indicated it had a large amount of exudate coming from the wound. His treatment order continued to include the implementation of NPWT every Monday, Wednesday, and Friday, while applying 125 mmHg on a continuous basis. Under the comments, the wound physician indicated only one piece of white foam was to be used. The comments also indicated the output of the wound vac had increased. He requested that the facility please get a CT scan of the abdomen to evaluate for an abscess at the left flank. He also wanted them to re-consult surgery regarding the left flank wound due to increased drainage. The order for both the CT scan and the re-consult with surgery order had been written on 07/03/24 at 5:01 P.M. Resident #10's medical record was absent for any evidence of the CT scan being ordered/ scheduled or that the surgeon had been contacted for a re-consult as was ordered by the wound physician. Review of Resident #10's nurses' progress notes revealed a nurse's note by Licensed Practical Nurse (LPN) #120 dated 07/08/24 at 10:29 A.M. that indicated the nurse went in to change the resident's wound vac and his wound vac was noted to be turned off and not intact. The resident was observed by the nurse to be lying in a puddle of drainage. When the nurse assessed the resident's left flank, it was noted to be very swollen, red, and warm to touch. The resident stated he had mild to severe pain to the surrounding area. Physician #135 was in the building and gave an order to send the resident to the emergency room (ER) for further evaluation. Review of a Discharge Summary note by Physician #135 revealed Resident #10 was discharged to the ER for an abdominal wall abscess. He had a history of a PEG tube dislodgement with necrotizing fasciitis, abscess of abdominal wall, and severe sepsis. The history of the present illness indicated the resident had a marked increase in abdominal wall edema and he was discontinued from the use of the wound vac. The wound of his abdomen was a non healing abdominal wound. Evidence of recurrence. Management was beyond the scope of the skilled nursing facility and would need imaging and possible incision and drainage (I&D). Review of an ER provider report dated 07/08/24 revealed Resident #10 was seen for an open wound of the abdominal wall. He presented for a wound check and had an abnormal CT of the abdomen. He had a non-healing wound to his upper abdomen and he had an increase of purulent bloody drainage. The ER report indicated the resident was supposed to be using a wound vac, but it was not applied yesterday evening per report from Emergency Medical Services (EMS) personnel. The resident reported persistent abdominal discomfort as a 7 on a scale of 0 to 10. Review of the hospital history and physical (H&P) dated 07/08/24 revealed Resident #10 had a history of necrotizing fasciitis and an abdominal wall abscess. He presented to the hospital with a small open wound in the left flank area with purulent drainage. CT scan showed a persistent gas fluid pocket in the superficial aspect of the left abdominal wall surrounding a non-radiopaque foreign body, such as a retained surgical sponge. He was admitted with a recurrent left flank abdominal wall abscess. Review of a surgical consult by Surgeon #150 dated 07/08/24 revealed he saw Resident #10 for a left flank wound being warm and firm with purulent drainage coming from a small open wound. CT scan obtained on 07/08/24 revealed concern for a retained foreign body in the abdominal wall. An abdominal assessment showed mild tenderness to the left flank with erythema and induration. A small wound to the left flank was present with malodorous drainage. The results of the CT scan obtained on 07/08/24 revealed a foreign body measuring 14 cm in length by 1 cm in width and a 10 cm cranio-caudal diameter. The impression from the CT scan was a persistent gas fluid pocket in the superficial aspect of the left abdominal wall surrounding the non-radiopaque foreign body, such as a retained sponge. The assessment/ plan indicated left flank/ abdominal wall abscess and small wound remained to the left flank though most of it was closed over. CT scan revealed what appeared to be a retained sponge from most likely a previous wound vac dressing. It would need to be removed and likely a debridement of the abdominal wound. The CT scan and abdominal exam revealed a foul smelling abscess, a healing wound that most likely had a retained sponge from his wound vac care near the undermined cavity that was grossly infected, needed to be removed and the area debrided. Review of the operative note by Surgeon #150 dated 07/09/24 revealed his pre and post operative diagnosis was a foreign body. A palpable cavity fluid collection was opened using a skin incision under general anesthesia with a large amount of purulent thick fluid that not entered, but cultures were obtained. A second incision was taken down to the large fibrous cavity where the foreign body was identified and removed. Findings of the foreign body revealed a retained large white vac sponge. Review of a skin grid non-pressure wound assessment, dated 07/17/24, revealed Resident #10's left flank wound was assessed upon his return to the facility. The wound that originated on 05/11/24 and was a surgical wound deteriorated from when it was last assessed (07/03/24) and measured 27 cm x 13 cm x 2 cm. Tunneling was not present, but undermining was noted between 6-12 o'clock and at 3 cm. A large amount of serosanguinous drainage was noted, was free of any odors and free of signs of infection. The decline in the wound was related to surgery while in the hospital. Review of the facility's timetable of the events pertaining to Resident #10's wound vac and it's related complications revealed the events began when the resident was seen by Wound Physician #100 on 07/03/24 and ordered a CT scan to be completed and to follow up with the resident's surgeon due to increased drainage in his wound vac. Due to it being a holiday, the CT scan was going to be scheduled on 07/08/24. On 07/08/24, the resident's dressing was noted to have come off with a large amount of drainage. The nurse went in to assess the drainage due to the wound vac dressing being scheduled to be changed. The nurse noted redness and excessive drainage. The nurse immediately notified the nurse practitioner and the physician of the concern. The physician (Physician #135) was in the facility, assessed the resident, and requested that the nurse place an ABD over the wound and to send the resident to the ER. The nurse sent the resident to the ER and the ER noted a foreign body in the wound via a CT scan. During the debridement of the wound, they discovered it was white foam from the wound vac dressing. An interview with the nurse revealed she did not remove the white foam before sending the resident to the hospital due to Physician #135 stating to place an ABD dressing over the wound and to send the resident out. As a result of the incident, all nurses were educated on timely treatment when a wound vac was leaking and completing a full assessment of the wound before sending to the ER. The transport scheduler was educated on pulling the order listing report and attempting to make appointments the next business day after the order was received. Review of email correspondence from the involved employees (obtained as part of the facility's related investigation that went along with their timeline) revealed accounts of the incident were provided by the nurse and the aide that were on duty for the night shift on 07/08/24, when Resident #10's issues with his wound vac started. An email from LPN #222 sent 07/10/24 at 9:52 A.M. revealed on the early morning of 07/08/24, she was notified of red drainage from Resident #10's wound vac site. The resident rolled to his right side and the nurse observed red drainage on a towel that the aide had placed under his dressing. She checked the tubing and pressed the edges of the dressing in an effort to check the seal. She claimed she saw red fluid in the tubing moving down towards the wound vac machine. The wound vac machine was on at that time. She checked the orders in the electronic medical record (EMR) and saw where thee dressing was to be changed on Monday. An email from LPN #245 sent 07/10/24 at 10:05 A.M. revealed on 07/08/24 around 9:00 A.M. to 9:30 A.M. she went into Resident #10's room to assist another nurse (LPN #120) with changing the resident's wound vac due to it getting changed every Monday, Wednesday, and Friday. When she entered the room to get the supplies ready, an aide showed her that it had been leaking for a while. LPN #120 entered the room and the two nurses assessed the wound. The wound was noted to be red/ pink, hot to touch, hard, and poured out with bloody drainage when touched or when they turned him. The nurses agreed it was not a good idea to put the wound vac back on and LPN #120 called the nurse practitioner (NP). The NP gave the orders to apply a wet to dry dressing, draw blood, and get a wound culture. Around 10:30 A.M., Physician #135 came in and examined the wound with LPN #120 present. The physician gave an order to send the resident to the hospital. An email from State tested Nursing Assistant (STNA) #200 sent 07/10/24 at 10:31 A.M. revealed Resident #10's wound vac on his side was coming off and leaking everywhere. She placed a folded sheet under his side as that was all she had on hand when she noticed it. She told the nurse about it (dressing) being almost completely off and leaking everywhere. She told the nurse right after her last rounds when she noticed it coming off. She thought it was probably around 6:00 A.M. The nurse replied to her that the dressing was scheduled to be fixed that day. Review of in-service records revealed the facility provided education to their nursing staff on 07/10/24. The education provided included a directive that, if a wound vac was off or not functioning properly, wound vac needed to be reinforced or changed no matter the time. When changing the wound vac, it was best practice to assess the wound bed and properly clean prior to placing a new wound vac. An in-service record dated 07/10/24 revealed education was provided to the transportation aide regarding the need to run the order listing daily. All orders needing appointments were to be called and made within the following business day. On 08/07/24 at 2:27 P.M., an interview with Wound Physician #100 revealed he had been managing Resident #10's wounds for months now. He confirmed he had seen the resident on 07/03/24 and ordered a CT scan to be done and wanted a re-consult with the surgeon due to an increase in drainage noted in the resident's wound vac. He was not aware that the CT scan had not been scheduled and the consult with the surgeon had not been made by the facility prior to the resident being sent out to the hospital on 07/08/24. He was told the consults were made but there was some issue getting them done around the holiday/ weekend. He did not order the CT scan to be done emergent, but he would have expected them to call to schedule the CT and make the appointment for the consult with the surgeon by at least Friday. He was not sure if the CT scan would have been able to be scheduled on the holiday and the ability to get him in for both would depend on staffing around the holiday and the schedules. He indicated the resident's wound had a small opening with a big tunnel under it between 06/19/24 and 07/08/24. He was not aware of there being any problem with the resident's wound vac leaking or it not being in place the evening of 07/07/24 going into 07/08/24. He stated it would have been his expectation for the facility's nurse to contact him if there was a problem with the resident's wound or his wound vac. The last time he saw the resident's wound on his left flank area was on 07/03/24, when he had increased drainage prompting him to order the CT scan and the consult with the surgeon. The resident's wound had looked like it always had the last time he saw it with the exception of the increase in drainage. He had not been told that the resident's wound vac had been left off for any length of time the early morning hours of 07/08/24. He indicated, even if the wound vac was just leaking and was not fully off as was indicated, there would not have been a proper seal and suction for it to be effective in removing the wound drainage. He was unaware of the foreign body that was removed from the resident's wound while he was in the hospital. He had not had the opportunity to see the surgeon's operative note or the consult that was done while the resident was in the hospital. He acknowledged that the foreign object ended up being a 14 cm x 1 cm piece of white foam that was used for his wound vac treatment. He indicated the white foam was less porous and, if it had been left in when they removed the wound vac when sending the resident to the hospital, it would have prevented the wound drainage from getting out of the tunneled area and increase the risk for infection. He also stated you could not leave the foam in a wound when the wound vac was not in place and functioning properly, as it would adhere to the wound bed rather quickly. He reported it would be speculation on his part to say if the problems he was having with the wound vac not being on and the dressing not being in place caused his infection he was found to have in the hospital. He stated the resident was known to have a history of getting infections quickly, so it was a possibility. On 08/07/24 at 5:05 P.M., an interview with LPN #222 revealed she had worked at the facility since February 2024. She denied having received any training on wound vacs prior to taking care of Resident #10 with his wound vac. She stated most of what she learned was on the job. It was not until after the incident on 07/08/24 that they received training on wound vacs. She was comfortable with checking the seal and reinforcing the wound vac dressing, but she did not feel comfortable changing the dressing. She had reinforced them in the past to get them to work properly without having to change it all. She was aware if the resident's wound vac was not working properly they could take it off and put a wet to dry dressing on it. She recalled the resident's wound vac dressing that was clear had red drainage under it. An aide came to her and told her about putting a towel under the resident because it was leaking. She claimed she checked it and the wound vac dressing was intact and sucking up drainage. It was sometime between 2:00 A.M. and 5:00 A.M. when she was made aware of the red drainage coming from the wound vac dressing. The machine was on when she checked it and the dressing was intact. She pressed around the edge of the dressing to verify it was intact. She denied she had to reinforce the dressing. The resident told her when she was in there the dressing was due to be changed that day. The aide had told her about the resident having drainage on his pad under him. She assumed the drainage was from his wound vac. There was a rolled up towel under his left side when she checked him. She reviewed the resident's EMR and saw something about drainage from the wound vac and the doctor already being aware. She recalled the order for the CT scan of his abdomen and the surgical consult so she thought it had been addressed. She did not feel the need to contact the physician since apparently the drainage he had was already known. She denied turning off the wound vac or removing his wound vac dressing. She assumed she would have notified the oncoming shift about an increase in the drainage in the canister, but could not recall specifically doing so. She denied going back into his room after that for any reason. She did not have to give him medications in the morning. She indicated she would contact Med One (an on-call physician service) if there was any problems with the resident's wound or wound vac. On 08/07/24 at 5:12 P.M., an interview with STNA #200 revealed she was the aide that worked on Resident #10's hall the night of 07/07/24 - 07/08/24, when he had the issues with his wound vac. She was told in report by the prior shift that the resident's wound vac had been leaking. She stated it was not that bad when she was in the resident's room earlier the time before she found him between 5:00 A.M. and 6:00 A.M. with a large amount of drainage leaking from his wound vac. The dressing to the wound vac was barely on at that time when she saw him. She informed the nurse about it, but could not recall the nurse's name that she worked with that night. She was not sure if the nurse had gone in and checked on the resident, after she reported that to her. She could not say for sure if the wound vac was on or not. She did not mess with that. She denied there was any drainage present in the tube when she was in there. The drainage she saw was leaking from under the dressing. She recalled, when she told the nurse about it, the nurse said she was not going to worry about it because day shift was due to change it. She changed the pad under the resident and put a folded sheet under him to catch the drainage prior to telling the nurse. She denied she showed the nurse what had leaked onto the pad, prior to disposing of it in the soiled utility room. On 08/08/24 at 8:55 A.M., an interview with Resident #10 confirmed he was having issues with the wound vac Sunday night (07/07/24) going into Monday (07/08/24). It had been leaking a little Sunday evening as was indicated by STNA #200. It was not until he woke up that morning that it was draining a lot and he had all that gunk from his wound drain out into his bed. He indicated the leaking from the wound was a lot heavier early in the morning. He could not recall if the nurse had been in to check him that night or not. He recalled the aide being in there and helping him change his bed. He has had problems with the wound vac in the past and that was the second one he was given. The first wound vac had stopped working during the night and just shut off. He was not sure if that was what may have happened this time as well. He did not recall anyone turning the wound vac off during the night and thinks it may have just done what the first one did and shut off on it's own. He thought the nursing staff had tried to patch it up the best they could. He denied that anyone had changed the wound vac dressing, after it was leaking, when it was ordered to be changed as needed (PRN) as well. He was not sure if the day shift nurses that came in found the wound vac off or not. They did find a lot of drainage in his bed though. He was aware of the order Wound Physician #100 gave on 07/03/24 for a CT scan of the abdomen and a referral to his surgeon. The wound physician told him he was going to order that when he was there Wednesday (07/03/24). He felt the facility staff dropped the ball with that as no one tried to schedule those for him before he ended up in the hospital on 07/08/24. He referred to the large wound he came back from the hospital with as his [NAME] bite. He referred to it as that because that was what it looked like. He indicated his wound looked like a [NAME] bit him on his side and just ripped the tissue away. Physician #139 told him when he saw him on 07/08/24 that he likely had a worse infection than his last. He was worried if he did not get him to the hospital that things were not going to end well for him. On 08/08/24 at 10:32 A.M., an interview with LPN #245 confirmed she worked day shift on 07/08/24, when Resident #10 was found to have problems with his wound vac and was sent to the hospital. She entered the resident's room with LPN #120 to change his dressing around 9:00 or 9:30 A.M. They both entered the room around the same time. She was not aware there had been any problems with the resident's wound or his wound vac treatment. When they went into the room, they noted his wound vac was leaking. The bandage around the wound vac was wet from the drainage and was not sticking to his skin. The area around the wound was red, hard, and warm to touch. The dressing was still intact but was peeling off where it had gotten wet. She denied she looked at the wound vac to see if it was on or looked at the tubing to see if anything was being sucked up through the tubing. She was on the opposite side of the bed and not in view of either. LPN #120 was on that side of the bed. She did not hear any beeping of the wound vac machine that would have indicated there was an active problem with the seal or it suctioning. They both decided it would be best not to put the wound vac back on. LPN #120 called the NP and got orders for a wet to dry dressing to be applied and to stop using the wound vac. She was not sure if the wet to dry dressing got put on, but knew LPN #120 went to get the supplies. She was told by LPN #120 that she did not need help with the dressing change since they were not putting on a wound vac dressing. She was not in there to see if LPN #120 removed any foam when switching it over to a new dressing. Physician #135 was in there 30-35 minutes later and gave the order for the resident to be sent to the hospital, as he was concerned about him filling with fluid again and would need an I&D. She was aware of the order for the CT scan of the abdomen and a surgical consult that was ordered by Wound Physician #100. She was not sure if it was ever set up. The transportation aide was the one that set up appointments. The nurses put the orders into the computer and the transportation aide checked them daily when she was there to see if anything needed scheduled. She did not know if the transportation aide worked Thursday (July 4th), but knew she was there the day after. Review of the facility's policy on Negative Pressure Wound Therapy, Dressing Change from Long Term Care Clinical Procedures by [NAME] Healthcare 2015 revealed the documentation guidelines included in that policy/ procedure was to notify the physician when a change in wound condition was noted. Notification was also needed when the current treatment did not appear to be effective or no improvement in wound status was noted. This deficiency represents non-compliance investigated under Complaint Number OH00155961.

Based on observation, record review, interview, and policy review, the facility failed to ensure fall interventions were implemented and failed to complete a comprehensive fall investigation after a fall resulting in serious injury. Actual Harm occurred on 01/15/23 when Resident #28, who was assessed to have moderate cognitive impairment, required extensive assistance of one staff member for toilet use and transfers and was identified as a fall risk, was instructed by staff (while in the bathroom with the resident) to transfer from the sink to the toilet without staff assistance and while wearing improper footwear, resulting in a fall. The resident sustained a fractured left femur (thigh bone) and possible nondisplaced fracture of the left wrist. This affected one resident (Resident #28) of two residents reviewed for falls. The census was 71. Findings include: Review of the Resident #28's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including severe protein-calorie malnutrition, chronic obstructive pulmonary disease, diabetes mellitus, anemia, cirrhosis of the liver, chronic kidney disease, and a history of transient ischemic attacks and cerebral infarction. Review of the fall risk assessment, dated 01/06/23, revealed Resident #28 was a moderate risk for falls. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 01/07/23, revealed the resident had moderate impaired cognition, required extensive, one-person physical assistance for bed mobility, transfers, dressing and toileting. The assessment indicated there was one fall with injury, and two or more falls without injury since admission or the prior assessment. Review of the Incident by Incident Type Report revealed Resident #28 sustained falls with injury on 09/06/22, 10/26/22, 01/15/23, and 05/05/23, and sustained falls without injury on 11/19/22, 12/15/22, and 04/01/23. This report was dated 05/18/23. Review of the plan of care revealed Resident #28 was at risk for further falls related to recent hospitalization after fall with fractures, which impeded her activities of daily living (ADL) ability, present condition, noted diagnoses, balance impairment, bowel and bladder incontinence with risk of the floor being wet, and taking medications which could cause dizziness. Interventions initiated on 04/09/21, included to assist with toileting and peri-care needs per request and as needed; to lock the bed, to have commonly used articles within easy reach implemented 04/09/21, grip strips to the bathroom floor implemented on 10/26/22 and revised on 11/18/22. The care plan was dated 02/08/23 however, interventions were dated prior to the plan of care initiated date. Review of a nursing progress note, dated 01/15/23 at 10:55 A.M., revealed State-tested Nursing Assistant (STNA) told Licensed Practical Nurse (LPN) #201 that the resident was on the floor in her bathroom. The STNA stated that she answered the resident's bathroom light and the resident was standing at the sink washing her hands. The resident's bed was soaked so she (the STNA) asked the resident to sit back down on the toilet. The resident turned and lost her footing. Before the STNA could reach her, the resident fell on to the floor, onto her left side. Upon assessment, a small abrasion was noted to the left knee. The resident stated that her left leg hurt really badly. She was unable to move her left leg. The knee abrasion was cleaned, and a dressing was applied. The resident screamed when her leg was touched. She was unable to roll off her left hip. The left leg appeared shorter than the other leg. The left leg was turned outwards. The resident was advised to stay lying on the floor and to try not to move. 911 was called. Two paramedics and two staff members lifted the resident onto the stretcher using a sheet. The resident yelled out in pain. The resident left with the paramedics in route to the hospital. The physician and resident's daughter were notified. Review of the Fall Investigation, dated 01/15/23, revealed the resident was attempting to toilet herself and was washing her hands. The cause of the fall was documented as being due to the resident wearing large slippers and losing her footing when trying to turn. The new intervention, added to the plan of care and the STNA assignment sheet to prevent further falls, was documented as removing the large slippers. The weekly review by the falls committee/administration on 01/17/23 revealed the cause of the fall was accurately identified and the intervention seemed appropriate to prevent further falls. Review of the Emergency Department Provider Notes, dated 01/16/23 at 3:02 A.M., revealed the resident stated that she was ambulating with the assistance of her walker to the restroom when she accidentally slipped and fell landing on her left hip and left knee region. The resident stated that she is unsure if she hit her head. The resident was given Morphine 2 milligrams (mg) intravenously (IV) for analgesia. The x-ray of the left femur revealed a subcapital fracture of the left femur and the x-ray of the left wrist revealed mild cortical buckling at the scaphoid waist on one projection only, a possible nondisplaced fracture, and severe osteopenia. Review of a nursing progress note, dated 01/17/23 at 9:45 A.M., revealed the interdisciplinary team (IDT) met and in agreement to have the oversized slippers removed from room and to encourage the resident to wear non-slip slippers upon return from the hospital. Review of the Hospital Discharge Summary, dated 01/18/23 at 3:33 P.M., revealed the resident presented to the emergency room after an accidental fall with left hip pain. X-ray revealed a subcapital fracture of the left femur and a suspected nondisplaced fracture of the left wrist. The resident underwent left hip hemiarthroplasty on 01/16/23 and a splint and brace were applied for the suspected nondisplaced fracture of the left wrist. The course was complicated by acute kidney injury and acute post-operative blood loss. Further review of Resident #28's medical record revealed a fall occurred on 05/05/23 without injury. Review of a nursing progress note, dated 05/05/23 at 5:15 P.M., revealed LPN #131 was alerted by Resident #28's roommate that the resident fell out of her bed and onto the floor. Upon entry, the resident was noted face down along the side of her bed with her head located at the head of the bed. The resident stated, I was reaching for that light thing. The resident was assessed for injuries, and she complained of pain in her right knee. The resident's knee was assessed further and range of motion was slightly limited with stiffness and bruising. LPN #131 and two others used a sheet to lift the resident onto the bed. The call light was placed within reach and usage encouraged. The resident had recently moved into a new room earlier in the shift. The resident was last seen sitting on the side of her bed during medication pass fifteen minutes prior. Management and the physician assistant were notified and family notification was attempted. Review of the Fall Investigation, dated 05/05/23 at 4:20 P.M., revealed the circumstance of the incident was a fall from the bed while the resident was reaching for the call light. The resident stated that she was reaching for the call light on the floor. The intervention implemented after the fall was to apply colored tape to the call light. Review of a nursing progress note, dated 05/06/23 at 11:33 A.M., revealed the x-ray results of the right knee were negative for fracture or dislocation. Review of a nursing progress note, dated 05/09/23, at 2:46 P.M., revealed the interdisciplinary team (IDT) met to review fall on 05/05/23 at 4:15 P.M., immediate intervention was to apply colored tape to the call light. IDT agreed with the intervention and the care plan was updated. New intervention in place at this time and will continue to monitor. During interview on 05/18/23 at 3:22 P.M., the Assistant Director of Nursing (ADON) verified Resident #28's fall investigation, dated 01/15/23, indicated the resident's slippers were too large and this was identified as the cause of the fall, and that the resident's slippers were removed from the room to prevent further falls. Observation on 05/17/23 at 9:04 A.M., revealed Resident #28 lying in bed with her eyes closed. The call light was not located within the resident's reach and was draped over the top and side of the bedside nightstand. The actual call light button was located on the side of the nightstand, facing way from the resident's bed. Observation and interview on 05/17/23 at 11:05 A.M., revealed Resident #28 was sitting in her wheelchair, in her room. The call light was draped over the top and side of the bedside nightstand, facing away from the resident's bed and not within reach of resident. The resident stated that she could not reach her call light. Interview with the resident at the time of the observation revealed she had experienced falls but was unable to recall details related to the fall with the femur fracture that resulted in surgical repair. During interview on 05/17/23 at 11:09 A.M., LPN #121 confirmed Resident #28's call light was draped over the top and side of her nightstand and was not within reach of the resident. LPN #121 stated the call light did not have a clip, but that she would get one, so that the call light could be clipped to the bed or within reach of the resident. Interview on 05/17/23 at 2:56 P.M. with STNA #202 revealed Resident #28 required extensive, one-person physical assistance for dressing and toilet use. Interview on 05/17/23 at 3:37 P.M. with Corporate Registered Nurse (CRN) #138 revealed the DON, LPN #201 and the involved STNA with the fall dated 01/15/23 were no longer employed in/with the facility (LPN #201 and the STNA were agency staff). CRN #138 verified the fall investigation lacked information such as staff interview/statements, the interventions that were in place at the time of the fall (non-skid strips to the bathroom floor). The CRN verified the investigation was not thorough and additional information should have been gathered, but the root cause analysis indicated the fall was related to the resident wearing too large of footwear. The CRN was unable to provide any information as to why the STNA did not assist the resident with sitting on the toilet as the resident required extensive assistance of one staff member with transfers and while wearing improper footwear, the resident fell and fractured her left femur. Review of the facility's policy titled, Fall Policy, revision date of 04/20/21, 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. An intervention will be put in place after a fall unless the IDT determines all appropriated interventions are in place. An intervention put in place after a fall will be reviewed by the IDT to determine if the intervention put in place is the most appropriate or if it should be changed.

Based on record review and interview the facility failed to provide adequate supervision and assistance to Resident #7 to prevent a fall with injury. Actual Harm occurred on 08/01/22 when Resident #7, who was cognitively impaired, required extensive assistance from two staff for toileting and transfers and was at high risk for falls was left unattended on a bedside commode. The resident fell off the bedside commode while unsupervised and sustained a deep cut above her eye requiring six stitches. This affected one resident (#7) of three residents reviewed for falls. Findings include: Review of the Resident #7's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], obstructive [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. Review of the fall risk assessment, dated 06/28/22 revealed Resident #7 was at high risk for falls. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 07/05/22 revealed the resident had impaired cognition, required extensive assistance from two or more staff members for bed mobility, transfers, dressing and toilet use and extensive assistance from one staff member for personal hygiene. Review of the plan of care, dated 07/07/22 revealed Resident #7 was at risk for falls due to present condition, noted diagnoses, legally [CONDITION(S)] and needing assistance with toileting, transfers and ambulation. The care plan revealed the resident was also at risk for falls related to incontinence with risk of floor being wet during transfers/etc, being on medications that could cause dizziness and diagnosis of seizures. Interventions included to ensure call light was in reach, encourage resident to use (call light) for assistance as needed, educate about safety reminders, wear appropriate footwear when ambulating or mobilizing in wheelchair and physical therapy to evaluate and treat as needed. The care plan also indicated for staff to remain with Resident #7 during toileting needs. Review of a nursing progress note, dated 08/01/2022 at 10:45 A.M. revealed the nurse aide called for this nurse to go to resident's room. Upon entering, resident was noted to be laying on her right side on the floor with a puddle of blood under the right side of her face. This nurse observed a deep cut above the resident's right eye. Resident #7 stated she was not having any discomfort or pain. The nurse applied pressure to right eye. When asked what happened she replied I was standing up. The resident was reminded to not get up by herself and ring her call light for help. At 10:50 A.M. Resident #7 was sent to the emergency room . On 08/01/22 at 11:30 A.M. a nursing progress note revealed the nurse aides were educated on not leaving Resident #7 on bedside the commode unattended. Further review revealed the resident returned to the facility (from the hospital) at 2:33 P. M with six stitches above the right eye. A physician order was noted to remove stitches in seven days (On 08/08/22). Review of two undated staff personal witness statements, from State tested Nursing Assistant (STNA) #134 and STNA #129 revealed both STNA's indicated they had assisted the resident to the bedside commode and then left the resident's room. Upon their return, the resident was found on the floor and had hit her head. Review of the fall investigation, dated 08/01/22 revealed Resident #7 was placed on the bedside commode and given the call light. Staff left the resident alone in her room on the bedside commode while they answered other residents' call lights. When staff returned to Resident #7's room, the resident was found on the floor and noted to have hit her head. On 08/12/22 at 11:22 P.M. interview with the Director of Nursing (DON) verified Resident #7 was left alone in her room on the bedside commode and sustained a fall with injury requiring a transfer to the hospital where she received stitches to a head laceration. This deficiency substantiates Complaint Number OH 658.

Based on observation, record review, facility policy and procedure review and interview the facility failed to prevent the development of an avoidable pressure ulcer and failed to develop and implement a comprehensive pressure ulcer prevention program to timely identify, assess and treat a new pressure ulcer to Resident #5's scrotum. Actual Harm occurred on 07/17/22 when Resident #5's family requested the resident be transferred to the hospital for an evaluation of a skin injury to his scrotum. The facility had no assessment or treatment to the area in place prior to the hospital transfer. Hospital records identified a scrotal ulcer, provided pressure ulcer treatment orders and orders for an antibiotic for scrotal infection and the resident returned to the facility the same day. On 07/18/22 the facility assessed the resident to have a suspected deep tissue injury to the scrotum measuring 4.8 centimeters (cm) long by 2.2 cm wide with eschar (dead tissue) present at the wound bed. The wound subsequently progressed to an unstageable pressure ulcer. A treatment was not initiated until 07/19/22. This affected one resident (#5) of three residents reviewed for pressure injuries. Finding include: Review of the medical record for Resident #5 revealed an admitted [DATE] and a re-admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care, dated 04/08/22 revealed Resident #5 was at risk for skin alterations related to history of biting/scratching self, being non-ambulatory, requiring extensive assistance from staff for bed mobility, total dependence on staff for toileting and bathing and being incontinent of bowel and bladder. Interventions included barrier cream after each incontinent episode as needed and skin to be inspected during routine daily care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/24/22 revealed Resident #5 had impaired cognition. The assessment revealed the resident required extensive assistance from two staff for bed mobility, dressing, and personal hygiene, was totally dependent on two staff for transfers and toilet use, was always incontinent of bowel and bladder and had no skin impairment. A general note, dated 07/16/22 at 2:28 P.M. revealed Resident #5 was placed in bed to relieve pressure on his scrotum. At 2:49 P.M. Resident #5 was yelling and tearful due to wanting to get out of bed. It was explained to the resident he needed to lay in bed to take pressure off buttocks and scrotum. Record review revealed no assessment or evaluation of the resident's scrotum at that time. A general note, dated 07/17/22 at 3:00 P.M. revealed Resident #5's family requested the resident be sent to the emergency department due to an area on his scrotum. An eInteract transfer form, at 3:20 P.M. revealed Resident #5 was transferred to the hospital due to a skin wound/ulcer. Review of the after-visit summary from hospital emergency department, dated 07/17/22 revealed Resident #5 was seen for testicle pain. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Instructions were given to elevate Resident #5's testicles to relieve pressure, [MEDICATION(S)] (antibiotic) 300 milligram (mg) twice a day for seven days, and [MEDICATION(S)] Border (foam dressing) to be applied every 12 hours as needed. The resident was referred to wound clinic and urologist for follow up care. Review of the discharge information from the hospital revealed it included a document titled, Preventing Pressure Sores: General Information. The document revealed pressure injuries could occur in places where the skin folds over on itself. Things that caused pressure injuries included sliding down in a bed or chair, forcing the skin to fold over itself (shear force). Skin could also be damaged by sweat, feces, or urine making pressure injuries more likely and harder to heal. A general note, dated 07/17/22 at 10:50 P.M. revealed Resident #5 returned from the hospital with orders for [MEDICATION(S)] 300 mg due to infection/scrotal ulcer twice a day for seven days and a [MEDICATION(S)] dressing to scrotum. Referrals were made to wound center and urology. Review of a Skin Grid Pressure form, dated 07/18/22 revealed a suspected deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration) to Resident #5's scrotum. The area measured 4.8 centimeters (cm) long and 2.2 cm wide with eschar (dead tissue) present at the wound bed. An order, dated 07/18/22 revealed Resident #5's scrotum was to be cleansed with sterile normal saline, patted dry, and proximal border to be applied every day shift. This order was discontinued on 07/19/22. Review of the treatment administration records (TAR) revealed no treatment was provided to the scrotal pressure ulcer on 07/17/22 or 07/18/22. On 07/19/22 Resident #5's scrotum was cleansed with sterile normal saline, patted dry, and proximal border was applied. Review of wound center notes, dated 07/20/22 revealed Resident #5's scrotum measured five cm long by 2.5 cm wide and 0.2 cm deep. There was a moderate amount of serous (clear, thin, and watery) drainage. Orders included Resident #5's scrotum was to be cleansed daily with soap and water. Zinc strips (two to three layers) were to be applied and covered with gauze with incontinence brief to hold dressing in place. The dressing was to be changed daily and as needed. Review of Skin Grid Pressure form, dated 07/21/22 revealed Resident #5 had an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to scrotum that measured four cm long and 1.8 cm wide with eschar present at the wound bed. An order dated 07/21/22 revealed Resident #5's scrotum to be cleansed with soap and water, zinc strips (two to three layers) applied, covered with gauze every day shift. Wound clinic documentation, dated 07/27/22 revealed the wound to Resident #5's scrotum measured 7.4 cm long, two cm wide and 0.1 cm deep. There was a moderate amount of sanguineous drainage. Attempts to observe wound care to the area on Resident #5's scrotum during the investigation were unsuccessful. On 07/26/22 at 8:27 A.M the resident was observed sitting in a wheelchair in the activity room. On 07/26/22 at 10:46 A.M. and 11:47 A.M. the resident sitting in a wheelchair and out of his room. On 07/26/22 at 2:44 P.M. the resident was observed in bed, however upon request to observe the resident's treatment, the resident would only yell out. On 07/27/22 at 10:33 A.M. the resident was out of bed sitting in a wheelchair and then out of the facility for an appointment. On 07/28/22 at 9:00 A.M. and 11:34 A.M. the resident was out of bed seated in a wheelchair. On 07/27/22 at 3:22 P.M. interview with Licensed Practical Nurse (LPN) #104 revealed the pressure ulcer to Resident #5's scrotum was first discovered by staff on 07/16/22. However, LPN #104 verified there was no documentation of the appearance, stage or size of the wound on that date. LPN #104 was unable to state why a comprehensive wound assessment was not completed on 07/16/22 when the wound was discovered. On 07/28/22 at 10:34 A.M. during a follow up interview with LPN #104, the LPN verified the only documentation of care provided for the pressure ulcer to Resident #5's scrotum on 07/16/22 was putting the resident in bed and she stated cream was applied. LPN #104 verified there was no assessment, measurements or description of the pressure ulcer until she observed the wound on 07/18/22 (after the resident was hospitalized due to the area on 07/17/22). LPN #104 verified orders were received from the emergency roiagnom on [DATE] but the treatment was not initiated (based on review of the TAR) until 07/19/22. On 08/03/22 at 4:40 P.M. interview with Resident #5's family revealed they requested the resident be sent to the hospital on 07/17/22 due to blood on mattress and blanket from various areas on the resident's body and the resident being in pain. The family member stated they asked to see the resident's bottom and noticed there was a hole in his scrotum. The resident's family revealed the resident had one kidney and the family member was afraid the wound could have an infection and the resident would go septic. Review of Wound Management Program policy, dated 11/2021 revealed a pressure ulcer referred to localized damage to the skin and/or underlying soft tissue. Staff participation and accountability included staff being involved in prevention and treatment and the expectation of all caregivers to observe resident skin integrity during the daily provision of the residents personal care. A comprehensive wound assessment included the location and staging of the wound. The length, width, and depth measurements, appearance of the wound base, appearance of wound edges, description of the peri-wound, and pain associated with the wound should also be documented. A written protocol was established for physician notification of pressure injury presence. This deficiency substantiates Complaint Number OH 271.

Based on observation, record review and interview the facility failed to prevent the development of pressure ulcers, failed to ensure pressure ulcer prevention interventions were in place prior to the development of pressure ulcers and/or failed to ensure pressure ulcer treatments were completed as ordered. Actual Harm occurred on 07/14/21 when Resident #1 was assessed to have an in house acquired avoidable deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration) to the left heel and unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcers to the bilateral buttocks. The resident, who had been admitted to the facility on [DATE] with no pressure ulcers was noted to have (on 07/09/21) a burst blister to the left heel and redness /shearing to the bilateral buttocks with no evidence of comprehensive or individualized pressure ulcer prevention measures or effective treatments being implemented. This affected two residents (#1 and #5) of three residents reviewed for pressure ulcers/wounds. Findings include: 1. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of admission packet documentation, dated 06/29/21 revealed a skin assessment was completed indicating Resident #1 had an incision to the groin and bruising to left antecubital. There was no evidence of any pressure ulcers noted at the time of admission. Review of Braden Scale for Predicting Pressure Ulcer Risk, dated 07/06/21 revealed Resident #1 was at risk for developing pressure ulcers. Review of the five day Minimum Data Set (MDS) 3.0 assessment, dated 07/06/21 revealed Resident #1 was cognitively intact, required extensive assistance of one staff for bed mobility, transfers, toilet use, and personal hygiene. The MDS 3.0 assessment revealed the resident had no pressure ulcers at the time of the assessment. Review of a progress note, dated 07/09/21 at 8:06 P.M. revealed Resident #1 had a burst blister to the left heel area and redness and shearing to bilateral buttocks. Record review revealed no evidence the physician was notified of the new pressure ulcer development, no evidence when the blister to the heel had first been identified, no evidence of any pressure ulcer interventions being in place or initiated at that time or evidence of treatment orders to promote the healing of these pressure ulcers. In addition, the nursing progress note failed to contain measurements or a comprehensive assessment of the areas identified on this date. There was no documentation on the treatment administration records of any interventions in place. Review of the plan of care, dated 07/11/21 revealed Resident #1 was at risk for impaired skin integrity due to recent hospitalization , need for assistance and occasional incontinence of bladder. The care plan documentation revealed there were no concerns at that time. The care plan also revealed house barrier cream was being used. Record review revealed no progress notes related to the resident's skin integrity were completed between 07/10/21 and 07/13/21. A progress note, dated 07/14/21 at 8:58 P.M. revealed Resident #1 had a deep tissue injury (DTI) to the left heel and unstageable pressure ulcers to the bilateral buttocks Review of a skin and wound evaluation, dated 07/14/21 revealed Resident #1 had an unstageable pressure ulcer to left buttock measuring 4.5 centimeters (cm) in length by 2.3 cm width with no depth noted and an unstageable pressure to right buttock measuring 1.6 cm length by 1.2 cm width with no depth noted. On 07/14/21 a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of plan of care dated 07/14/21 revealed Resident #1 had a pressure injury to left buttock, right buttock, and left heel. Interventions initiated at that time included to elevate heels off the mattress, a low-air-loss mattress, areas to be padded and protected as needed, and a ROHO (pressure relief) cushion to wheelchair. A skin and wound evaluation, dated 07/15/21 revealed Resident #1 had an unstageable pressure to left heel measuring 3.2 cm in length by four cm width with no depth noted. On 07/15/21 at physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The left heel was to be cleansed with sterile normal saline, pat dry, apply alginate (used on wounds that have a large amount of exudate) dressing and ABD and then wrap with Kerlix. On 07/15/21 (six days after staff had first identified concerns related to pressure ulcer development) a ROHO (pressure relieving) cushion was ordered to be placed in the resident's wheelchair and a low-air-loss mattress was to be placed on the resident's bed. Review of the treatment administration record, for July 2021 revealed Triad paste, a low-air-loss mattress and ROHO cushion were implemented on 07/15/21. The dressing to the left heel was not initiated until 07/16/21. On 07/21/21 at 12:09 P.M. Resident #1 was noted to be out of the facility and observations could not be made. On 07/22/21 at 7:52 A.M. Resident #1 was observed sitting in a wheelchair in his room. At the time of the observation, interview with Resident #1 revealed he believed the blister to his heel was caused from a brace he was wearing. The resident did not provide any information related to the pressure ulcers to his buttocks. On 07/21/21 at 4:07 P.M. interview with Wound Nurse #100 revealed she put a foam dressing on Resident #1's heel when the blister to the left heel was noted to burst and in-house barrier (protective) cream was applied to the resident's buttocks when the areas were found on 07/09/21. The wound nurse did not provide any information as to how the pressure ulcers had developed at that time. Wound Nurse #100 then verified physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Wound Nurse #100 verified the lack of evidence of any type of treatment being provided to Resident #1's pressure ulcers to the bilateral buttocks until 07/15/21 when Triad paste was started. In addition, there was no evidence of treatment to the resident's left heel being completed until 07/16/21. Wound Nurse #100 verified there was no evidence of pressure ulcer prevention interventions being initiated until the identification of the unstageable/deep tissue pressure ulcers to the resident's bilateral buttocks/left heel. Wound Nurse #100 did not provide any information related to a brace device the resident was wearing or had ordered associated with the pressure ulcer to the left heel. 2. Record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission packet documentation, dated 02/17/21 revealed Resident #5 had skin impairment to the coccyx and left heel. Review of the pressure ulcer risk assessment, dated 02/18/21 revealed Resident #5 was at high risk for the development of pressure ulcers. Review of the skin assessment weekly/return form dated 02/18/21 revealed Resident #5 had a Stage IV pressure ulcer to sacrum and unstageable pressure ulcer to the left heel. Review of the significant change in status MDS 3.0 assessment, dated 06/01/21 revealed Resident #5 had impaired cognition. The assessment revealed the resident was dependent on two staff for bed mobility, toilet use, personal hygiene and bathing. The resident was also dependent on one staff for eating. The resident had an indwelling catheter and was always incontinent of bowel. Resident #5 had a Stage IV pressure ulcer that was present on admission. The assessment also identified Resident #5 had seven unstageable pressure ulcers with two that were present on admission and two deep tissue injury pressure injuries that were not present on admission. Review of an unavoidable pressure injury form, dated 06/02/21 revealed Resident #5 had bowel incontinence, hemoglobin less than 12 milligrams per deciliter (mg/dL), poor skin turgor, muscle wasting, poor nutritional intake and was terminally ill. Interventions in place included low-air-loss mattress, a turning and repositioning program and nutritional supplements. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the treatment administration record (TAR) for July 2021 revealed the treatment to Resident #5's sacral wound, left medial heel, left lateral heel, right heel and right anterior toe were not completed on 07/09/21. The treatment to the left trochanter, left malleolus and left fifth toe were not completed on 07/09/21 or 07/15/21. On 07/22/21 at 11:47 A.M. interview with Wound Nurse #100 verified treatments were not completed as ordered on the dates noted above for Resident #5's sacral wound, left medial heel, left lateral heel, right heel, right anterior toe, left trochanter, left malleolus or left fifth toe. In addition, during the interview Wound Nurse #100 revealed the pressure ulcer to Resident #5's right fifth toe was marked as resolved on 07/07/21 by another nurse. Wound Nurse #100 verified the wound clinic had documentation on 07/08/21 of the right anterior/fifth toe not being healed and treatments not being completed as ordered. This deficiency substantiates Complaint Number OH 094. This deficiency is also an example of continued non-compliance from the survey dated 07/06/21 and 06/10/21.

Based on record review, staff interview and policy review, the facility failed to ensure weekly skin assessments were consistently completed by the nurses to identify any new pressure ulcers and weekly wound assessments for existing areas were accurately and/ or completely assessed. This affected three (Resident #29, #46, and #65) of three residents reviewed for pressure ulcers. The facility's census was 64. They identified six residents as having a stage II or higher pressure ulcer with three of those being present upon admission. Harm occurred for Resident #29 and Resident #46 when weekly skin assessments were not completed by the nurses as per the facility's Pressure Ulcer Prevention and Risk Identification policy and those residents were found to have developed facility acquired unstageable pressure ulcers. Findings include: 1. A review of Resident #29's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #29's admission packet revealed her skin was not intact upon her admission to the facility. She was identified as having a large pressure ulcer to her coccyx, deep tissue injuries (persistent non-blanchable deep red, purple or maroon areas of intact skin) to her right heel, and unstageable pressure ulcers to her left heel and fifth digit (pinky toe) of her right foot. A review of Resident #29's 5 day Minimum Data Set (MDS) assessment revealed the resident was usually able to make herself understood and was usually able to understand others. She had short and long term memory impairment and her cognitive skills for daily decision making was severely impaired. She was dependent on two for bed mobility. Transfers and ambulation did not occur. She was identified as being at risk for pressure ulcers and having unhealed pressure ulcers. The MDS was coded to reflect she had one stage IV pressure ulcer that was present upon admission and six unstageable pressure ulcers (known but not stageable due to coverage of wound bed by slough and/ or eschar) with only two of those being present upon admission. A review of Resident #29's care plans revealed she had a care plan in place for being at risk for further skin breakdown related to her present condition, diagnoses, being dependent on staff for bed mobility, and not getting out of bed. The care plan was initiated on 03/25/21 and revised on 05/13/21. The care plan indicated she had unstageable pressure ulcers to her bilateral heels, left lateral heel, left ankle, right fifth toe, left buttock and a stage IV pressure ulcer to her sacrum. The goal on the care plan was for her to be free of further skin breakdown. The interventions included the completion of skin assessments as ordered. Treatments were to be completed as ordered and they were to notify the doctor if the treatment was not effective or worsening of wounds. A review of Resident #29's weekly skin assessments revealed the resident's skin was assessed by a nurse for the presence of any new skin breakdown on 04/16/21 and 05/30/21. There was no documented evidence of a weekly skin assessment being completed by a nurse on 04/23/21, 04/30/21, 05/07/21, 05/14/21, 05/21/21, and 05/28/21. A review of Resident #29's skin and wound evaluations revealed the resident developed a new facility acquired unstageable pressure ulcer to her left buttock on 05/27/21. The area measured 1.3 centimeters (cm) x 1.4 cm. The assessment did not indicate an assessment of the resident's wound bed was completed to identify if the wound bed had epithelial, granulation (the part of the healing process in which lumpy, pink tissue containing new connective tissue and capillaries forms around the edges of a wound), slough (necrotic tissue that needs to be removed from the wound for healing to occur), or eschar (dead tissue found in a full thickness wound usually appearing as a tan, brown or black crust) present. A review of Resident #29's skin and wound evaluations for her stage IV pressure ulcer to her sacrum revealed her assessments completed on 05/10/21, 05/17/21, 05/24/21, 05/27/21 and 06/03/21 did not include an assessment of her wound bed, presence of any drainage, an assessment of the peri wound area or the wound healing progress compared to the previous week's evaluation. Findings were verified by the Director of Nursing (DON). 2. A review of Resident #46's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #46's quarterly MDS assessment dated [DATE] revealed the resident had unclear speech. She was rarely/ never understood and sometimes was able to understand others. She had both short and long term memory impairment and her cognitive skills for daily decision making were severely impaired. She was not known to display any behaviors during the assessment reference period (seven days) and was not known to reject any care during that time. She required extensive assist of two for bed mobility and transfers. Ambulation did not occur. She was identified as being at risk for pressure ulcers and having an unhealed pressure ulcer. The MDS was coded to reflect she had one stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough) that was not present upon admission. A review of Resident #46's care plans revealed she had a care plan in place for being at risk for impaired skin integrity related to impaired mobility, diabetes mellitus, [CONDITION(S)] and [CONDITION(S)]. The care plan was initiated on 02/12/19 and revised on 05/18/21. The goals included the resident's skin would be free of breakdown. The interventions included the completion of skin assessments as ordered. A review of Resident #46's weekly skin assessments revealed the resident's skin was assessed by a nurse for the presence of any new skin impairments on 04/20/21 and 05/18/21. The weekly skin assessment on 04/20/21 indicated the resident's skin was intact with no new areas noted. The weekly skin assessment dated [DATE] revealed the resident's skin was intact but indicated the resident was known to have a previously identified area that was a pressure ulcer. There was no documented evidence of a nurse completing a weekly skin assessment on 04/27/21, 05/04/21, or on 05/11/21. A review of Resident #46's skin and wound evaluations revealed a new facility acquired stage II pressure ulcer was noted to an unspecified location on 05/10/21. The area measured 0.5 cm x 0.4 cm but a depth could not be determined. The evaluation indicated the wound bed was covered with 100% slough, which would make it an unstageable pressure ulcer, not a stage II pressure ulcer as indicated by the nurse assessing the wound. The progress of wound healing was marked showing it was improving despite the pressure ulcer just being identified. A skin and wound evaluation for 05/17/21 identified the pressure ulcer as an unstageable pressure ulcer due to the presence of slough and/ or eschar. The location was indicated to be on Resident #46's right buttock. The exact date the wound was indicated to be present was on 05/15/21 despite it being first noted on 05/10/21. The wound measured 3.9 cm x 2.3 cm and the wound bed was filled with 60% granulation and 40% slough. A skin and wound evaluation for 05/24/21 revealed Resident #46's pressure ulcer to the right buttock remained an unstageable pressure ulcer. It decreased in size measuring only 0.8 cm x 0.4 cm but the wound bed went from having 60% granulation and 40% slough to being filled with 100% slough. The nurse completing the evaluation indicated the wound's progress was improving despite it then being covered with 100% slough. Findings were verified by the DON. 3. A review of Resident #65's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #65's admission packet dated 02/19/21 revealed the resident's skin was intact at the time she was admitted . There was no evidence of the resident having any pressure ulcers or any other skin impairments. A review of Resident #65's admission MDS assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was severely impaired. No behaviors were noted but the resident was known to reject care one to three days of the seven day assessment period. The resident required extensive assist of one for bed mobility and transfers and limited assist of one for ambulation in her room. The resident was assessed as being at risk for the development of pressure ulcers. She was not known to have any unhealed pressure ulcers at the time the assessment was completed. A review of Resident #65's care plans revealed she had a care plan in place for being at risk for impaired skin integrity. The care plan was initiated on 02/19/21 and revised on 05/25/21. She was at risk related to her condition, diagnoses, and needing assistance with bed mobility and transfers. The care plan indicated there were no areas of concern at the time it was initiated. The care plan was updated to reflect an open area was noted to her right inner buttock on 04/05/21. The resident's goals included her skin would be free of breakdown. The interventions included completing a skin assessment as ordered. A review of Resident #65's weekly skin assessments revealed there was no documented evidence of the resident's skin being assessed by a nurse for the development of any new areas of skin impairment between 03/09/21 and 03/30/21 or again between 04/05/21 and 04/24/21. Weekly skin assessments were missing for 03/16/21, 03/23/21, 04/12/21 and 04/19/21. A review of Resident #65's skin and wound evaluations revealed the resident developed a new facility acquired unstageable pressure ulcer to her right buttock on 04/05/21. The pressure ulcer was determined to be an unstageable pressure ulcer due to the presence of slough and/ or eschar. The wound measured 0.9 cm in length by 0.8 cm. in width. The depth was not applicable. The wound bed description was marked to reflect 100% of the wound was filled with granulation. There was no indication of any slough or eschar being present despite the nurse identifying it as being an unstageable pressure ulcer due to slough and/ or eschar earlier in the same assessment. A skin and wound evaluation dated 04/12/21 revealed Resident #65's pressure ulcer remained an unstageable pressure ulcer. The wound measurements were larger as it measured 1.8 cm x 1.4 cm and then had 30% of the wound filled with granulation and 70% of the wound filled with slough. The nurse assessing the wound indicated it was showing improvement despite the wound measurements being larger and the wound bed went from being filled with 100% granulation to 30% granulation and 70% slough. A skin and wound evaluation dated 04/19/21 revealed Resident #65's unstageable pressure ulcer to the right buttock measured 1.9 cm x 1.1 cm. The wound bed was assessed and the wound was filled with 100% slough. Despite the wound bed going from 30% granulation and 70% slough to 100% slough, the nurse who assessed the wound indicated it was improving. A skin and wound evaluation dated 05/03/21 revealed Resident #65's unstageable pressure ulcer to her right buttock measured 0.9 cm x 0.6 cm. The wound bed was assessed and the wound was filled with 90% granulation and 10% slough. The next skin and wound evaluation completed on 05/10/21 showed the unstageable pressure ulcer to the right buttock was larger at 0.9 cm x 1.2 cm and the wound was filled with 100% slough. Despite both the measurements being larger than the previous week and the wound bed going from 90% granulation with 10% slough to 100% slough, the nurse assessing the wound indicated it was improving. Findings were verified by the DON. On 06/10/21 at 11:10 A.M., an interview with the DON revealed weekly skin assessments were completed by the nurses at the time the residents received their showers. She reported the aides completed the shower sheets but the nurses signed off on them. She stated the nurses were present and checked the resident's skin for any new areas at the time the resident was showered. On 06/10/21 at 1:05 P.M., an interview with State tested Nursing Assistant (STNA) #16 revealed the aides filled out the residents' shower sheets when showers or bed baths were given. She denied the nurse was present when they checked the resident's skin during their bathing activity. She stated the aides checked the residents' skin and would alert the nurse if they noted any new areas of skin impairment. On 06/10/21 at 3:30 P.M., a follow up interview with the DON confirmed they could not find documented evidence of the nurses completing the weekly skin assessments for the missing dates of the residents identified above. She attempted to provide the shower sheets completed by the aides, as evidence they had been completed. She acknowledged STNA #16 reported the nurses were not present to assess the residents' skin when those shower sheets were completed unless they were alerted by the aide that a new area of skin impairment was noted. She then provided copies of the residents' skilled nurses' notes that documented their skin being intact. She acknowledged that did not provide evidence of the nurse completing the weekly skin assessment only the nurse indicating if it was known the resident's skin was intact or not. She also acknowledged the skin and wound evaluations were not completed in their entirety nor were some of the assessments accurate as they included conflicting information on the assessments. The facility's wound nurse Licensed Practical Nurse (LPN #12) was fairly new in that role and they were planning on providing her some additional training regarding wounds. A review of the facility's policy on Pressure Ulcer Prevention and Risk Identification undated revealed the facility would assess each resident for risk of pressure ulcer development in an effort to establish measures to prevent the development of pressure ulcers within the facility or to prevent further decline of already existing pressure ulcers. The procedure indicated a licensed nurse would perform a head to toe skin assessment upon admission and every seven days thereafter to identify any new skin areas. The licensed nurse would document the findings in the electronic health record. The licensed nurse would assess for any skin abnormalities to include, but not limited to redness, rashes, ecchymosis, shearing, and open areas. This deficiency substantiates Complaint Number OH 591.

Based on medical record review, observation, resident interview, staff interview, physician interview and review of facility's policy and procedure, the facility failed to timely identify, properly assess and/or [MEDICAL CONDITION] bruises. Actual Harm occurred when Resident #76's second degree burn (damage extends beyond the top layer of skin and causes the skin to blister and become red and sore) from a hot pack treatment to her left shoulder declined because staff failed to assess it, and failed to notify the physician timely for treatment. This affected three (Residents #39, #76 and #98) of four residents reviewed for skin conditions. Findings include: 1. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition was intact and required extensive assistance with two-persons' physical assistance by staff for dressing. Review of physician orders [REDACTED]. Review of the resident's plan of care (POC) revealed occupational therapy added hot packs as needed for both shoulders for pain and range of motion. Review of the resident's new skin progress note dated 07/28/17 at 11:50 A.M. revealed Licensed Practical Nurse (LPN) #136 indicated therapy notified her of a blister on the resident's left shoulder due to the hot pack from therapy. There was no documentation in the medical record with a description and measurements of the new blister, or that the physician was notified of the burn. Review of a physician telephone order, not signed by the physician, dated 07/28/17 revealed LPN #136 started a treatment to monitor and cleanse the left shoulder area with normal saline, pat dry and leave open to air every shift until resolved. On 07/28/17, the POC was revised and stated the resident had a blister on the left shoulder. The goal was for the blister to be healed and the intervention was to provide treatment as ordered to blister on the left shoulder and observe for signs and symptoms of infection until healed. Review of the physician's progress note dated 08/02/17 revealed the physician assessed the resident's burn on her left shoulder to be a second degree burn (damage extends beyond the top layer of skin and causes the skin to blister and become red and sore) and stated he was called into the facility to assess the burn. Observation and interview with Licensed Practical Nurse (LPN) #23 on 08/02/17 at 9:29 A.M. revealed the resident's burn area on the right shoulder appeared really red today and the LPN stated she might need to get the physician to change the treatment. The LPN noted a new intact blister beside the ruptured blister that had yellow and black eschar present and stated the new area wasn't there on 07/30/17. The LPN measured the wound including the red portion and new blistered area to measure 6.5 centimeters (cm) wide, 9.75 cm long and depth was unable to be determined. The black eschar measured 0.75 cm wide by 0.75 cm long. The resident stated it was painful to touch. The LPN confirmed the burn should have been measured with a description of it at the time it was discovered. On 08/02/17 at 7:35 A.M., an interview with Resident #76 stated she received hot pack therapy to her left shoulder on 07/24/17 and stated the hot pack therapy felt really good at the time of treatment and eliminated her pain to that area. She stated State tested Nurse Aide (STNA) #59 observed a blister on her left shoulder on 07/26/17 when he assisted with the resident getting dressed for the day. On 08/01/17 at 3:04 P.M., an interview with LPN #136 stated the resident was walking with therapy on 07/28/17 and noted a wet spot on her shirt in the area of the resident's left shoulder. The LPN stated she faxed the physician but could not recall if the physician responded to the fax and confirmed she initiated the treatment to the resident's left shoulder. On 08/02/17 at 9:51 A.M., an interview with Physician #193 revealed he was not aware of the resident's burn to her left shoulder until LPN #23 notified him that morning on 08/02/17 at 9:50 A.M. Physician #193 stated he would have to see the burn before stating what type of burn it was. The Physician stated he would have added to the treatment to the burn besides normal saline had he been notified at the time when the burn was identified. The Physician stated he would expect to be notified by nursing when the resident's burn was identified. 2. Review of Resident #98's medical record revealed he was admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #98's plan of care dated 02/23/17 for bruising called for observation of his skin for signs and symptoms of bleeding and bruising, observe for petechia, and to handle the resident gently. Review of Resident #98's shower sheets revealed on 05/18/17, 06/01/16, 06/08/17, 06/13/17, 06/22/17, 07/13/17, 07/25/17, 07/27/17, and 08/01/17 multiple bruising of the resident's skin was noted. Review of Nursing notes from 05/02/17 to 08/03/17 revealed the bruising was to be monitored. No assessment to determine the cause of the bruising was available for review and no interventions were put into place to try to prevent the bruising. Observation of Resident #98 on 08/01/17 at 8:43 A.M. revealed scattered bruising on both of the resident's arms. Interview of the Director of Nursing (DON) on 08/02/17 at 5:05 P.M. confirmed no evaluation to determine the cause of Resident #98's bruising and no additional interventions were implemented to prevent his bruising. 3. Review of Resident #39's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance of one staff member with bed mobility. transfers, dressing, toilet use and personal hygiene. On 07/31/17 at 12:11 P.M. Resident #39 was observed seated in her recliner chair wearing oxygen via nasal cannula. Bruising was noted on the resident's hands and forearms. Review of the Progress Note dated 08/01/17 at 12:12 P.M. revealed the resident's skin assessment was completed and no new skin alterations were noted. Review of the incident report dated 08/02/17 at 6:42 A.M. revealed bruising was noted to both hands and arms. The resident stated that she probably got the bruises when she went out with her family over the weekend. The resident's daughter confirmed she transferred her mother and grabbed her hands/arms to hold onto the resident. Review of the physician's orders [REDACTED]. If no resolution after 10 days, notify the physician for new orders. On 08/02/17 at 4:00 P.M. interview with the DON verified Resident #39's bruising was not discovered until 08/02/17 when the DON went to observe the resident's skin because of another skin alteration.

Based on observation, measurement of the hot water temperatures, observation of the facility ' s hot water supply tanks, staff interview, review of the facility ' s hot water temperature log, and review of information provided from the American Burn Association and Centers for Disease Control the facility failed to ensure hot water temperatures in the 100, 200, 300, 400, and 500 hallways were maintained at safe temperatures to prevent injury. This resulted in the potential for serious harm,burns, from the elevated temperatures. Immediate Jeopardy occurred when the facility failed to identify hot water temperatures between 124 and 133 degrees Fahrenheit (F). Of the 87 residents who resided in the facility, seven residents (Residents #22, #28, #53, #73, #87, #100 and #120), were assessed by the facility to have moderate to severe cognitive impairment, were independently mobile, and independently capable of using the sink in the bathroom. On 05/24/16 at 2:58 P.M. the Administrator was notified Immediate Jeopardy began on 05/16/16 at 10:30 A.M. when Maintenance Supervisor #300 ordered a new mixing valve (a mechanical device that mixes cold water with hot water to maintain a constant temperature) due to a staff member ' s comment regarding the hot water was too hot. The lack of corrective action at that time resulted in hot water temperatures obtained by the survey team on 05/23/16 ranging from 122 degrees to 130 degrees F in resident rooms which posed a significant safety risk for serious burns to the residents residing in the facility. The Immediate Jeopardy was removed on 05/23/16 when the facility implemented the following corrective actions: · On 05/23/16 at 3:55 P.M. Maintenance Supervisor #300 shut off the hot water supply to the facility. Staff and residents were notified verbally and by hanging multiple signs in the facility the hot water was no longer in use. Bottled water was available within the facility, hand sanitizer was available for hand hygiene, and personal cleansing wipes were available for resident care. · On 05/23/16 at 3:55 P.M. the boiler was turned off and the tanks were drained by Maintenance Supervisor #300. · On 05/23/16 at 4:30 P.M. the water was turned back on by Maintenance Supervisor #300 with temperatures maintained between 90 and 100 degrees F. The temperatures were evaluated by the Administrator or designated staff and residents were notified by facility departmental managers that bathing procedures would be adjusted; linens, wipes, sanitizer, and wash was available as needed. · On 05/23/16 the Administrator developed a new policy entitled Elevated Water Temperature to address actions required when the water temperatures were elevated. · On 05/23/16 at 4:00 P.M. Maintenance Supervisor #300 was educated by the Administrator on obtaining water temperatures, recognizing, reporting, and addressing water temperatures when they were not within normal limits. · On 05/23/16 at 4:30 P.M. the Administrator and Departmental Managers began an in-service to all 106 staff regarding the Elevated Water Temperature Policy dated 05/23/16 including water temperatures not to exceed 120 degrees F and to report elevated temperatures. This also included the redevelopment of water temperature log. By 05/26/16 all 106 of 106 facility staff had been educated. · On 05/24/16 at 1:00 P.M. Housekeeper #319 was educated by Corporate Officer #501 on the policy entitled Protocol for Taking Water Temperatures dated 05/24/16. Housekeeper #319 was also instructed by Corporate Officer #501 on communicating temperatures above 120 degrees F to the Administrator. · On 05/24/16 at 4:30 P.M. temperatures were obtained by the Administrator or designee every two hours utilizing the water temperature log. Logs were started on 05/24/16 at 4:30 P.M. with review through 05/26/16 at 9:15 A.M. The water temperatures will be monitored every two hours through 05/28/16 at 10:00 A.M. by the administrator or designee then twice daily by maintenance personnel. · On 05/25/16 at 9:00 A.M. Housekeeping #319 was educated by Corporate Officer #501 on the proper protocol for obtaining water temperatures. · On 05/24/16 at 2:30 P.M. interview with Registered Nurse (RN) #350, Licensed Practical Nurses (LPNs) #8 and #351 revealed they were knowledgeable of the facility ' s Elevated Water Temperature policy. · On 05/25/16 at 1:01 P.M. interview with Housekeeping #319 revealed she was knowledgeable of the facility ' s Elevated Water Temperature policy. · On 05/26/16 at 8:15 A.M. the mixing valve was replaced by Maintenance Supervisor #300 and Corporate Maintenance Director #500. · On 05/26/16 1:54 P.M. interview with State tested Nursing Assistants (STNAs) #352, #353 and #354, and RN #355 revealed they were knowledgeable of the facility ' s Elevated Water Temperature policy. Although the Immediate Jeopardy was removed on 05/23/16, the facility remained out of compliance at Severity Level 2 (potential for more than minimal harm that is not Immediate Jeopardy) as the facility was continuing with hot water audits. Findings Include: On 05/23/16 at 2:15 P.M. the hot water in Resident #53 ' s sink felt hot to the touch. The surveyor ' s hand became red prompting her to remove her hands from the water. At 2:30 P.M. the hot water temperature at the sink in Resident #53 ' s room was obtained using a bayonet thermometer. The hot water temperature was 130 degrees F. Resident #53 was later identified by the facility as being able to use the bathroom by herself and was confused. On 05/23/16 at 2:33 P.M. the hot water temperature in Resident #8 and #10 ' s bathroom sink measured 130 degrees F. At 2:40 P.M. the hot water temperature in Resident #37 and Resident #46 ' s bathroom sink measured 126 degrees F. At 2:44 P.M. the hot water temperature in Resident #73 and Resident #89 ' s bathroom sink measured 126 degrees F. On 05/23/16 at 3:20 P.M. interview with Maintenance Supervisor #300 revealed the facility ' s hot water system was a boiler that had two holding tanks. This system supplied the residents ' needs and the kitchen. Maintenance Supervisor #300 revealed he was aware the mixing valve had gone bad about three months ago as the temperatures were creeping up. No action was taken at that time to ensure hot water was maintained at safe levels. Maintenance Supervisor #300 verified the hot water temperature should be at or below 120 degrees F. On 05/23/16 at 3:21 P.M. temperatures were obtained with Maintenance Supervisor #300 and revealed the following: Resident #8 ' s and Resident #10 ' s sink hot water measured 126 degrees F. Resident #37 and Resident #46 ' s sink hot water measured 125 degrees F. Resident #73 and Resident #89 ' s sink hot water measured 124 degrees F. Resident #67 ' s and Resident #136 ' s sink hot water measured 125 degrees F. Resident #117 ' s sink hot water measured 127 degrees F. Resident #96 ' s sink hot water measured 126 degrees F. On 05/23/16 at 3:45 P.M. an additional interview with Maintenance Supervisor #300 revealed the 500 hall was closest to the boiler and the temperatures in that hallway were higher than the other halls. Maintenance Supervisor #300 stated he did not adjust the water in response to hot water temperatures greater than 120 degrees F. On 05/23/16 at 4:00 P.M. observation of the boiler system revealed two holding tanks. There were two thermometers on the lines for the holding tanks; one thermometer read 124 degrees F and the other thermometer read 130 degrees F. Maintenance Supervisor #300 stated that measured the temperature of the water going into the holding tank. On 05/24/16 at 2:02 P.M. interview with Maintenance Supervisor #300 revealed State tested Nurse Aide (STNA) #301 stopped him on 05/16/16 in the hallway and told him the Administrator stated the hot water seemed too hot when she was washing her hands. STNA #301 asked him if there was any way to adjust the hot water. Maintenance Supervisor #300 stated he told STNA #301 the water temperatures fluctuated so he did not do anything. Maintenance Supervisor #300 stated he did not worry much about it. On 05/24/16 at 2:09 P.M., interview with STNA #301 revealed the Administrator asked her if she recalled giving showers and the water being hot. STNA #301 stated she told the Administrator she worked the 200 hall a lot and knew how to adjust the water temperature. STNA #301 stated she did not have any issues with the water being too hot. STNA#301 stated she asked STNA #302 if she had any hot water issues because STNA #302 worked early and gave the majority of the resident ' s showers. STNA #301 stated STNA #302 replied no. STNA# 301 revealed there was no one in the facility who showered or bathed independently, the staff would be the ones adjusting the water temperature. On 05/24/16 at 2:16 P.M. interview with the Administrator revealed on or around 05/13/16 she washed her hands in an employee bathroom and she thought the water felt hot so she asked STNA #301 about the temperature of the water. STNA #301 told her it was not too hot and if anything residents said it could be hotter. The Administrator stated after her conversation with STNA #301 she did not think there was an issue with the hot water. The Administrator stated Maintenance Supervisor #300 had not come to her with any high water temperature concerns. The Administrator stated she had not checked the Monthly Water Temperature log. The Administrator stated she did not know what prompted Maintenance Supervisor #300 to order a part for the boiler. The Administrator stated the first time she knew the temperatures were too hot was when she was informed during the State survey process. On 05/24/16 at 2:42 P.M. interview with Maintenance Supervisor #300 revealed he thought STNA #301 and Housekeeper #319 came to him and wanted to know if there were controls to adjust the hot water temperature. He stated he told them the adjustment for the hot water was in the boiler room, but he did not know how to adjust the temperature. Maintenance Supervisor #300 stated he ordered the mixing valve on 05/16/16 the same day STNA #301 and Housekeeper #319 had asked about the water being too hot. Maintenance Supervisor #300 stated he told his boss (Corporate Maintenance Director #500) on 05/16/16 when he called him to inform him the water temperature had been running high on the logs. On 05/25/16 at 1:01 P.M. interview with Housekeeper #319 revealed she had been taking the water temperatures in the building for several years. Housekeeper #319 revealed she was told by Maintenance Supervisor #300 the hot water temperatures should be maintained between 115 and 120 degrees F. Housekeeper #319 stated she told Maintenance Supervisor #300 when the water temperatures were too hot. She stated if Maintenance Supervisor #300 was not in the facility she would lay the log on his desk and tell him the next day. Housekeeper #319 stated the temperatures had been going up slowly for a while . Housekeeper #319 stated it was sometime last year the hot water temperatures went over 120 degrees F. Housekeeper #319 stated she told Maintenance Supervisor #300 the monthly temperatures were above 120 degrees and he said he would look into it . On 05/26/16 at 11:12 A.M. additional interview with Maintenance Supervisor #300 revealed when STNA #301 questioned him about the hot water temperatures he decided to go ahead and order the mixing valve. Maintenance Supervisor #300 revealed in February, 2016 the hot water temperatures were 122 degrees F. He tried to turn down the hot water temperature and the hot water remained hot. Maintenance Supervisor #300 stated he called Corporate Maintenance Director #500 and told him the water remained hot after he had turned the temperature down and that Maintenance Supervisor #300 did not know anything about the facility ' s hot water system. Corporate Maintenance Director #500 told him it sounded like it was the mixing valve and he would come to the facility and help him figure out what was wrong. Corporate Maintenance Director #500 never came to the facility. On 05/23/2016 between 4:51 P.M. and 4:53 P.M. observations of Residents #28, #73 and #22 revealed they were moving about the facility independently. These residents were identified by the facility as being independently mobile and confused. On 05/24/16 at 9:05 A.M. observation of Resident #100 revealed the resident walked independently and appeared confused. STNA #410 confirmed the resident ambulated independently and was cognitively impaired. On 05/24/16 at 10:49 A.M. observation of Resident #53 revealed she was in the bathroom in her room by herself. On 05/24/16 at 10:51 A.M. interview with Registered Nurse (RN) #323 revealed Resident #53 took herself to the bathroom independently using her walker. She confirmed Resident #53 was confused. On 05/26/16 at 8:42 A.M. interview with STNA #309 revealed Resident #87 was confused and independently walked to the bathroom. According to the American Burn Association, the severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. The most common regulatory standard for the maximum temperature of water delivered by residential water heaters to the tap is 120 degrees F. At this temperature, the skin of adults requires an average of five minutes of exposure for a full thickness burn to occur. When the temperature of a hot liquid is increased to 140 degrees F, it takes five seconds or less for a serious burn to occur. Since immediate removal of the hot liquid from the skin may lessen severity, splash and spill burns may not be as deep as burns suffered in a bathtub. According to the Center for Disease Control (MMWR Weekly, 09/18/09), adults over age 65 have a worse prognosis than younger patients after scald burns because of age-related factors and comorbid medical conditions, and are subject to more extensive medical treatment. Compared with younger adults, older adults with scald-related burns are more frequently admitted to hospitals, experience longer intensive-care unit and hospital stays, and have increased hospital mortality.

Based on record review and staff interview the facility failed to ensure appropriate nutrition interventions were implemented to prevent weight loss. This affected one (Resident #95) of four residents reviewed for nutrition. The facility identified 17 residents with unplanned significant weight loss or gain. The census was 88. Harm occurred when the facility failed to ensure Resident #95 received appropriate nutritional interventions to prevent a significant weight loss of 13% in less than five months with a declining pressure ulcer. Findings include: Review of Resident #95's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Further review revealed 2 cal (a nutritional supplement) 90 milliliters four times a day for weight loss. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact and required set up help only with meals. The resident was frequently incontinent of urine and occasionally incontinent of bowel. Review of the skin alteration record revealed the resident had a deep tissue injury to the left buttock with an onset date of 09/30/14. The documentation revealed the area to be nine cm in length and seven cm in width with a depth of less than 0.1 cm. On 10/06/14 the area was still staged as a Deep Tissue injury. On 01/28/15 the area was assessed by the facility as unstageable and has remained unstageable. The resident is being followed by the wound clinic. On 10/06/14 a physician's orders [REDACTED]. On 10/07/14 a physician's orders [REDACTED]. On 11/14/14 a physician's orders [REDACTED]. On 12/08/14 a physician's orders [REDACTED]. On 01/09/15 a physician's orders [REDACTED]. On 02/20/15 a physician's orders [REDACTED]. On 12/24/14 a [MEDICATION NAME] level (used to assess nutritional status) revealed the level to be 15.7 mg/dL normal range 17.6-36.0 Review of the nutritional assessment dated [DATE] and completed by registered dietary tech #150 revealed the resident was a high nutritional risk. Review of the Nutritional plan of care dated 10/06/14 revealed the resident was a nutritional risk secondary to [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the resident's record revealed the following weights: 10/01/14 84.1 pounds, 10/16/14 86 pounds, 10/22/14 78 pounds, 10/23/14 77 pounds, 10/24/14 76 pounds, 10/25/14 76 pounds, 10/26/14 76 pounds, 10/28/14 76 pounds, 11/6/14 77 pounds, 12/4/14 75 pounds, 12/11/14 76 pounds, 1/4/14 78 pounds, 2/5/15 77 pounds, 2/12/15 75 pounds and 02/19/15 73.4 pounds. Review of the wound clinic notes revealed a recommendation on 01/30/14 to offer smaller more frequent meals. Review of the nutrition progress notes revealed the following: - on 10/06/14 there was to be no salt packet and ground meat with soft veggies. Recommend 60 cc of 2 cal four times a day -Her body is visibly emaciated and gradual weight gain is desirable. Recommend a high protein high calorie diet to provide approximately 2500 kilocalories at meals and 2 cal will provide approximately 480 kcal per day. IBW based on original 66 inches is 117-143 pound. - the current intakes were adequate for present estimated needs of 1009-1509 kcal per day. -10/23/14 experienced significant weight loss in one week 83 pounds to 77.3 pounds down 5.7 pounds or 6.8% added daily weight for 5 days to verify the weight -10/30/14 experienced significant weight loss in one month from 84.1 pounds to 76.3 pounds a 7.8 pound or 9.2% loss. Will continue to monitor -11/12/14 significant weight loss noted for one month however last 3 weights have been stable. Intakes vary from one to 10 points per meal. High calorie, high protein diet in place to aid in weight/gain control and wound healing. Suggest to add Prostat one ounce three times a day for 30 days to boost protein intake and improve wound healing. -11/13/14 up 0.5 pound in a week intakes 50-75% of meals. Continues below normal range with weight gain desirable. No recommendations at this time. Current intakes adequate to meet estimated needs. -11/20/14 supplement 2 cal 60 ml four times a day snack cart offered three times a day and prostat 30 ml three times a day for 30 days BMI 16.8 with a weight of 75.2 pounds. No recommendations at this time. -12/18/14 weight 75.8 with BMI 16.9 weight remains below normal. Current intakes adequate for present estimated needs. No recommendations at this time. -01/8/14 weight down 3.4 pounds in a week or 4.3% recommended an increase in supplement to 90 ml four times a day -02/5/15 intakes 75-100% at meals with snack cart offered three times a day. Weight 77 pounds BMI 17.2 weight down 4 pounds or 4.9 % in one week. The resident refuses an increase in dietary supplement. No recommendations at this time. -02/12/15 weight 75.1 BMI 16.9 will trial helping hands dining group for increased assist and encouragement to greater intakes. No recommendations -02/18/15 resident with low BMI and wound center care. Overall weights have been stable. Suggest multivitamin as a preventative measure. On 02/20/15 at 12:57 P.M. interview with registered dietary tech #150 revealed the regular diet in the facility averaged 86.89 grams of protein per day and a high protein diet is 1.5 times the entree protein size to increase the protein content to 125 grams per day. The resident receives 27 grams protein with ordered 2 cal four times a day and 720 calories. The resident has a Blood urea nitrogen (BUN) (a test for kidney function) of 31 so her kidneys are compromised so I don't want to add a lot of protein to her diet and blow her kidneys out. On 02/18/15 the dietician recommended a multivitamin as a preventative. We have tried assisted feeding but she is resistant to let staff help her. I did not have knowledge of the wound clinics recommendation of the increased protein and the smaller meals on 01/30/15 however the snacks offered are equivalent to smaller meals. The resident did have a significant weight loss and she was unsure what the resident's usual body weight was and her BMI was under 19. The resident's BMI is 16.4 and a weight of 73.4 which indicated a significant weight loss. Further interview revealed the dietary technician would like to see the resident's BMI at 19. On 02/20/15 at 3:10 P.M. interview with Registered Dietician (RD) #910 verified the Pre-[MEDICATION NAME] was 15.7 on 12/24/14 and she was unaware of the abnormal laboratory value. Further interview revealed she did not feel the resident's admission weight was accurate but the resident did not re-weigh the resident to confirm the weight. The RD felt the resident's weight had stabilized from 02/05/15 until this week. The RD shared she would probably recommend a magic cup since the resident likes the magic cup. On 02/20/15 at 3:23 P.M. interview with Registered Nurse (RN) #44 verified the medical record did not contain documentation of all ordered supplements during January 2015.

Based on observation, medical record review, skin care management policy review, physician notification policy review, review of skin product information sheets, review of the facility's pressure ulcer report, and staff interview, the facility failed to ensure pressure sores were accurately assessed, failed to notify the physician of a deterioration of a pressure sore and failed to provide appropriate care and services to prevent the development of avoidable pressure sores resulting in harm to Resident #170. The facility also failed to accurately assess Resident #171's pressure ulcer. This affected two of three residents reviewed for pressure sores (Resident #170 and #171). The facility identified three residents with pressure sores; however Resident #170 was not one of the residents identified by the facility as having a pressure sore. Harm resulted to Resident #170 when the resident's coccyx pressure sore was not comprehensively assessed at admission on 06/04/11 until 06/14/11 and the pressure sore deteriorated from a Stage II pressure sore (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without non-viable yellow, tan, gray, green or brown tissue. This may also present as an intact or open/ruptured blister) to an unstageable pressure sore (wound covered with non-viable yellow, tan, gray, green or brown tissue and unable to assess the depth of the tissue layers involved). Resident #170 also developed an avoidable, unstageable pressure sore on the lateral coccyx and an avoidable Stage II pressure sore on the left buttock. Findings include: 1. Medical record review revealed Resident #170 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the initial skin inspection dated 06/04/11 revealed Resident #170 had an open area to the coccyx that measured 0.2 centimeters (cm) in diameter and the area was not staged. Review of the resident status assessment dated [DATE] revealed Resident #170 had no pressure sores and was at moderate risk for the development of pressure sores. Review of the physician orders [REDACTED]. Review of the treatment administration record (TAR) dated June 2011 revealed weekly skin inspections were completed on 06/08/11 and 06/15/11. Review of the medical record revealed no documented evidence of what skin alterations were discovered. Review of the product information sheet for Sensi-care revealed no documented evidence or indication of use for a Stage II pressure sore. Review of the medical record revealed no documented evidence Resident #170's Stage II pressure sore was assessed between 06/04/11 and 06/14/11. Review of the nurse progress notes dated 06/04/11 through 06/10/11 revealed the resident's skin was documented as being warm, dry, thin and fragile. Review of the nurse progress note dated 06/10/11 at 2:57 A.M., revealed Resident #170's coccyx was red. Review of the medical record revealed no documented evidence Resident #170's unstaged, coccyx pressure sore was comprehensively assessed between 06/04/11 through 06/14/11. Review of the nurse progress note dated 06/14/11 at 11:45 P.M., revealed a 1.3 cm length (l) by 0.2 cm width (w) coccyx pressure ulcer that was cleansed with normal saline and dermalevin (a foam, [MEDICATION NAME] dressing) applied. The note did not indicate the stage of the ulcer. Review of the medical record revealed no physician or family notification of the change in condition of Resident #170's pressure sore and no documented physician order [REDACTED]. Review of the interim care plan dated 06/04/11 revealed no documented evidence Resident #170 had a pressure sore. Review of the facility's skin care management system policy (undated) revealed residents with pressure sores were to be identified, assessed and provided appropriate treatment to encourage healing. Residents admitted with skin impairments were to have appropriate interventions implemented to promote healing, a physician's orders [REDACTED]. An interim care plan was to be developed upon admission that identified the contributing risks for breakdown, including the actual impairment and the interventions implemented. Pressure ulcers were to be measured and staged weekly. Review of the facility's physician notification policy (dated 2005) revealed a resident's physician was to be notified with the development or worsening of a pressure sore and when there was a need to significantly alter a resident's treatment. On 06/15/11 at 9:05 A.M., interview with Licensed Practical Nurse (LPN) #65 verified the medical record revealed no documented evidence Resident #170's coccyx pressure sore was comprehensively assessed until 06/14/11 and Sensi-Care protective barrier was not an appropriate treatment for [REDACTED]. On 06/15/11 at 2:40 P.M., interview with LPN #65 verified there was no documented evidence of a physician order [REDACTED]. On 06/15/11 at 2:45 P.M., interview with LPN #65 verified the medical record revealed no physician or family notification of the deterioration of the coccyx pressure ulcer or change in treatment. On 06/15/11 at 4:32 P.M., observation of Resident #170's coccyx with LPN #65 revealed no dressing or treatment. The resident's coccyx was observed to be dark-red with three unstageable areas to the coccyx. The medial, unstageable coccyx pressure sore measured 1.2 cm (l) by 0.4 cm (w). Depth (d) was unable to be assessed due to the wound bed was covered with yellow slough. The lateral, unstageable coccyx pressure sore measured 0.3 cm (l) by 0.3 cm (w). Depth was unable to be assessed due to the wound bed was covered with yellow slough. The left buttock, Stage II pressure sore measured 0.5 cm (l) by 0.5 cm (w) by <0.1 cm (d) with red, granulation tissue. On 06/16/11 at 8:30 A.M., interview with LPN #65 verified Resident #170's pressure sore assessment that was completed on 06/15/11 was not documented in the medical record. On 06/16/11 at 2:38 P.M., interview with LPN #65 verified no documented evidence in the medical record of Resident #170's pressure sores between 06/04/11 and 06/14/11. LPN #65 also verified the physician was not notified of the lateral, unstageable coccyx pressure sore or the left buttock Stage II pressure sore. On 06/16/11 at 2:45 P.M., review of the pressure ulcer report dated 06/08/11 indicated Resident #170 had a Stage II coccyx pressure ulcer and LPN #65 stated Resident #170's pressure ulcer was reviewed with the Director of Nursing (DON) and the Dietary Technician (DT) #12 on 06/08/11. On 06/16/11 at 3:20 P.M., interview with DT #12 stated the pressure ulcer report included all residents with pressure sores and a copy was provided to the DON, LPN #65 and DT #12. Review of DT #12's pressure ulcer report dated 06/08/11 revealed no documented evidence Resident #170 had a pressure ulcer. 2. Medical record review revealed Resident #171 was admitted to the facility on [DATE] with an open area to the coccyx that measured 3.0 cm (l) by 3.0 cm (w). The area was not staged. On 06/16/11 at 8:05 A.M., Resident #171 was observed lying in bed on his back with the head of the bed at a 45 degree angle. Review of the TAR dated June 2011 revealed a weekly skin inspection was completed on 06/12/11. Review of the medical record revealed no documented evidence of what skin alteration was discovered. Review of the skin alteration record revealed no documented evidence of Resident #171's coccyx pressure sore. On 06/16/11 at 8:35 A.M., LPN #65 verified Resident #171 had no documented skin alteration record until 06/16/11 and Resident #171's pressure ulcer had not been staged. On 06/16/11 at 9:51 A.M., observation of Resident #171's coccyx revealed a Stage II pressure sore that measured 1.0 cm (l) by 1.4 cm (w) by <0.1 cm (d). Review of the facility's skin care management system policy (undated) revealed residents with pressure ulcers were to be identified, assessed and provided appropriate treatment to encourage healing. Pressure ulcers were to be measured and staged weekly.