Every finding on record at Country Club Center I

Based on closed record review, policy review and interviews the facility failed to ensure residents were appropriately prepared for discharge when Resident #47 was discharged home without access to prescribed medications. This affected one (Resident #47) of four residents reviewed for discharge.Findings include: Closed record review revealed resident #47 admitted to the facility on [DATE] and discharged home on [DATE] with diagnoses including chronic obstructive pulmonary disease, heart failure, end stage renal disease, type two diabetes, pain, cerebrovascular disease, schizoaffective disorder, myocardial infarction (heart attack), major depressive disorder, and hypertension.Review of the Quarterly Minimum Data Set Assessment (MDS) MDS completed 03/31/26 the resident had intact cognition and received hypoglycemic medication (medication to help control blood sugar levels).Review of Resident #47's orders revealed an order dated 06/12/26 for pregabalin (Lyrica) (used to treat nerve pain) 75 milligram (mg) by mouth (PO) three times a day (TID) and hydralazine HCL tablet 25 mg by mouth TID related to hypertension.Further review of Resident #47's orders revealed an order dated 06/19/26 for Dexcom G7 15 day sensor. Apply 1 unit trans dermally under the skin one time a day every 15 days for blood glucose monitoring.Further review of the medical record revealed the resident was to continue medications at home but there was no evidence the resident received partially used medication packs to take home with her upon discharge. This included pregabalin, hydralazine and the Dexcom sensors.Interview on 07/15/26 at 10:40 A.M. with Resident #47's home-use pharmacy, Pharmacist #444, revealed the pharmacy had been working with Resident #47's husband for a few weeks (since 06/23/26) regarding some of Resident #47's medications that needed filled due to the resident not having access to them. The pharmacy was having issues filling the resident's hydralazine, pregabalin, and Dexcom due to it not being time to fill yet; the refills were denied by the resident's insurance due to it being too early to fill them. On several occasions from 6/23/26 until 07/15/26 the pharmacy attempted to fill the residents' prescriptions with the pregabalin and hydralazine being approved on 06/29/26 and the residents Dexcom sensor being approved on 07/15/26.Interview on 07/15/26 at 12:58 P.M. with facility Pharmacist #555 confirmed the pharmacy did not receive Resident #47's remaining Dexcom sensor for return, so the resident could not be credited by Medicaid for this item. Pharmacist #555 revealed Medicaid will re-imburse/credit unopened packages of medications but not partial packages. For example, Resident #47 had three packs of pregabalin 75 mg filled, but the resident only received capsules out of one package- that package is technically the resident's property since it is partially used, unable to be credited, and the resident's insurance had paid for it. Then, the two unopened packs of pregabalin should have been sent back to the pharmacy in order for the pharmacy to credit Medicaid for not using those medications. Pharmacist #555 revealed that without giving the resident the partial package, they would not have had access to those medications.Review of the facility-controlled substance patient medication disposition record revealed Resident #47's pregabalin 75 mg, totaling 84 capsules, was destroyed by Facility Director of Nursing (DON) and Assistant Director of Nursing on 07/13/26. This was 28 day's worth of the medication.Interview on 07/15/26 at 1:17 P.M. with facility DON and corporate Registered Nurse #999 verified Resident #47 was not sent home upon discharge with their hydralazine, pregabalin, or Dexcom sensor. Facility DON confirmed the resident's pregabalin was destroyed, corporate Registered Nurse #999 confirmed the resident's pregabalin should have been sent home with them upon discharge. Corporate Registered Nurse #999 confirmed the resident's unused Dexcom sensor was not sent back to the pharmacy for re-imbursement/credit, and was not sent home with the resident upon discharge however, the Dexcom sensor was left in a medication cart. The Corporate Nurse verified this resulted in the resident not having access to their prescribed medications after discharge from the facility.Review of the facility policy titled Transfer and Discharge Policy dated 03/30/2020 revealed the facility will strive to meet each residents individual discharge needs. The facility will develop and implement a discharge plan that focuses on the residents discharge goals, the preparation of resident to be active partners and effectively transition them to post discharge care and the reduction of factors leading to preventable readmissions.This deficiency represents non-compliance investigated under Complaint Number 3067332

Based on medical record review, review of hospital records, review of medical education provided by The University of Pittsburgh Medical Center, facility policy review, and interview, the facility failed to timely and accurately assess Resident #24 and failed to respond to an acute change in condition. This resulted in Immediate Jeopardy and Actual Harm beginning on [DATE] at 7:30 A.M. when Resident #24 was noted to have an oxygen saturation (SpO2) of 83% (normal SpO2 95-100%), a heart rate of 138 ((tachycardic) normal heart rate 60-100), was febrile (elevated body temperature) with a temperature of 102.1 degrees Fahrenheit (normal temperature 97.5 to 98.9 degree Fahrenheit) and rhonchus lung sounds bilaterally (abnormal lung sounds in both lungs occurring when air moves through partially obstructed or narrowed airways due to fluid, mucus, or thick secretions). There was no evidence of further evaluation or monitoring of the resident until [DATE] at approximately 6:30 P.M. when Resident #24 was transferred to the hospital. At the time of transfer, Resident #24 was hypotensive (low blood pressure) with a BP of 55/31 millimeters of mercury (mm/Hg) (normal blood pressure 120/80 mm Hg), and she was febrile (elevated body temperature) at 102 degrees Fahrenheit. At this time the resident had irregular respirations and was lethargic with difficulty breathing. The resident was admitted to the hospital where she required continuous bi level positive airway pressure (BiPAP) ventilation, intravenous (IV) antibiotics, continuous intravenous life sustaining blood pressure medication requiring internal jugular central venous catheter placement, and admission to the intensive care unit due to acute hypoxic respiratory failure and severe septic shock secondary to pneumonia and urinary tract infection. The resident remained hospitalized until [DATE] at which time she was re-admitted to the facility with additional days of IV antibiotic therapy required. On [DATE] at 2:23 P.M. [NAME] President of Operations #957, Corporate Clinical Director #751, Administrator #750 were notified Immediate Jeopardy began on [DATE] at 7:30 A.M. when Resident #24 was noted to have abnormal vital signs and a significant decline in condition with subsequent transfer to the hospital and admission to the intensive care unit for necessary medical intervention. Prior to the hospitalization, the facility failed to ensure Resident #24 was comprehensively assessed and provided timely, necessary and effective intervention to prevent the decline in her condition. This affected one resident (#24) of one resident reviewed for change in condition. The facility census was 52.The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: - On [DATE] at 6:30 P.M. Resident #24 was transferred to the hospital. The resident returned to the facility on [DATE]. - On [DATE] Resident #24 was seen by the Psychiatric Nurse Practitioner (NP) and Primary NP with orders in place for on-going care/medical treatment. -Between [DATE] and [DATE] facility staff were educated on monitoring and reporting resident changes of condition.-On [DATE] a facility Quality Assessment and Performance Improvement meeting was held which included the Administrator and facility management team. During the meeting the education that was provided between [DATE] and [DATE] was discussed. - On [DATE] the facility Resident Condition Changes policy was reviewed by Corporate Clinical Director #956 and [NAME] President of Operations (VPO) #957. - On [DATE] an interdisciplinary team (IDT) meeting was held to complete a root cause analysis (RCA) of what had happened with Resident #24. The meeting included Corporate Clinical Directors #956 and #751, VPO #957, Corporate Minimum Data Set (MDS) Director #3 , Director of Dietary Services #4, Interim Director of Nursing (DON) #390, Assistant Director of Nursing (ADON) #140, and Administrator #725. The analysis included record review of nurse's notes, vital signs (VS), provider notes, medication administration record (MAR), and treatment administration record (TAR). The facility concluded nursing staff failed to follow the order obtained on [DATE] at 730 A.M. for every four (4) hour vital sign monitoring, therefore the resident's decreasing blood pressure (BP) and declining condition wasn't noted until [DATE] at 6:18 P.M. resulting in resident (#24) being sent to the hospital [DATE] at 6:30 P.M.- On [DATE] all residents (52 total) were assessed by ADON #140 which included obtaining vital signs, respiratory status, signs/symptoms of infection (fever, respiratory distress, hypotension). All results were sent to Medical Director #1122 for review on [DATE].- On [DATE] 24 the DON/designee initiated hour audits. This included resident observations, staff interviews (at least one certified nurse aide (CNA), licensed practical nurse (LPN) or registered nurse (RN) assigned to resident care during assessment period to question if they observed a change in resident's condition.- On [DATE] all licensed nurses (three RNs and seven LPNs), one respiratory therapist (RT), 27 Certified Nursing Assistants (CNAs), seven medication technicians, one MDS LPN, and one wellness director were re-educated either in-person or via phone by ADON #140 and Interim DON #390. Agency nurses were educated via clipboard (email confirmation included). Education topics included Change in Condition policy and procedure, recognition of change in condition, sepsis indicators (fever, tachycardia, hypotension, decreased O2 saturation), physician notification requirements, frequency of monitoring per orders (e.g., every four (q4) hour vitals). Education also included documentation expectations of information to be documented in the resident medical record (objective observations, medications administered, treatments or services performed, changes in the resident's condition, events, incidents or accidents involving the resident, and progress toward or changes in the care plan goals and objectives).-On [DATE] all other staff were educated by Administrator #725 either in-person or via phone on reporting of change in condition and included five activity staff, two general administrative staff, two ADONs, 13 dietary staff, one driver, seven housekeeping staff, two laundry staff, two maintenance staff, one marketing director, one social service designee (SSD). -On [DATE] Director of Rehab (DOR) #753 was educated by Administrator #725. In turn, DOR #753 educated therapy staff to include two occupational therapists (OT), five physical therapy assistants (PTA), and four occupational therapy assistants (OTA). One speech language pathologist (SLP) who is PRN would be educated before returning to work. New hires would be educated upon hire. -On [DATE] the Change in Condition Protocol was reinforced by Corporate Clinical Director #956 to include nurses reporting to provider immediate any significant change triggers, immediate nurse assessment, Physician/NP notification, and documentation in progress notes. The expectation was no delay in escalation. A change in condition was identified as a new, worsening, or unexpected change in resident status including but not limited to: new onset or uncontrolled pain, falls or injuries, skin issues - new or worsening, change in mobility or ADL's, weight loss/gain, poor intake, abnormal VS, new or worsening confusion, delirium, or altered level of consciousness, new or worsening behaviors, sudden mood changes, new diagnosis or infection, change in respirator status, medication reactions or ineffectiveness, and hospitalization or ER visit.- On [DATE] an Infection/Sepsis Early Recognition Process was implemented facility-wide to include sepsis screening triggers with a Point Click Care assessment to trigger. Sepsis screen triggers occur as follows: Upon admission: every shift for three days; Suspected sepsis: every shift until resolution of symptoms and/or resolution of known infection: 1. Temperature above 100.4 2. Heart Rate above 90 3. Pulse Ox < 90 or increasing oxygen demands 4. SBP below 100 5. WBC > 12,000 or WBC < 4,000 (new onset) 6. Respiratory rate above 20 BPM; Upon diagnosis of infection: every shift until completion of antibiotic therapy and resolution of infection. Escalation protocol for abnormal findings includes Does the resident have an infection and meet two or more of the SIRS criteria: -1. Temperature above 100.4 2. Heart Rate above 90 3. Pulse Ox < 90 or increasing oxygen demands 4. SBP below 100 5. WBC > 12,000 or WBC < 4,000 (new onset) 6. Respiratory rate above 20 BPM or have an infection and meet 1 or more of the SIRS criteria with elevated blood glucose for a non-diabetic (if yes suspect sepsis) and contact provider. The Infection Preventionist (DON #390) is to oversee sepsis screening triggers to ensure ongoing compliance.- On [DATE] an Ad Hoc Quality Assessment and Performance Improvement (QAPI) meeting was completed with the interdisciplinary team (IDT) team in person (included Maintenance Director #170, Office Manager #240, Marketing Director #635, MDS LPN #632, ADON #230, DON #390, DOR #1122 , Activity Director #110, Transportation #535, SSD #275, Dietary Manager #315, and Clinical Director of Operations #751 to include the Medical Director #1122 (participated via phone). Trends tracked include delayed physician notification, missed monitoring, and documentation gaps. Corrective actions would be implemented as needed. An audit tool would be utilized to ensure the completion of all of the above.-On [DATE] Clinical leaders including DON #390, ADON #140, MDS LPN #632, and LPN #230 were educated by Corporate Director of Clinical Services #956.-On [DATE] at 1:26 PM, VPO #957 and Corporate Clinical Director #956 spoke with Medical Director #750 regarding the concern with Resident #24. - On [DATE] Corporate Clinical Director #956 and DON #390 implemented shift-to-shift clinical review of high-risk residents. Nurse shift to shift report sheets utilized with added areas to include the following mandatory review: new orders, abnormal vital signs, residents on antibiotics. Daily clinical standup meeting was reinforced. Daily clinical stand-down meeting was reinforced to include follow-up items that were identified in the stand-up meeting to include abnormal vitals / change in condition. Clinical Leaders to attend standup and stand-down include DON #390, ADON #140, MDS LPN #632 and nonclinical leaders to attend clinical standup and stand-down include Administrator #750 and SSD #275.-Beginning on [DATE] a company clinical morning meeting and follow up tool was provided to be utilized daily starting [DATE] for 14 days then on [DATE] change to every business day (Monday to review weekend data, day returning from holiday to review holiday data). This would be completed by DON #390 and/or ADON #230. To ensure compliance this would be overseen by Corporate Clinical #751 or #956.-Beginning on [DATE] a change in condition compliance audited by utilizing Company clinical morning meeting and follow up tool provided daily starting [DATE] for 14 days then on [DATE] change to every business day (Monday to review weekend data, day returning from holiday to review holiday data). This would be completed by the DON #390 and/or ADON #230. To ensure compliance this would be overseen by Corporate Clinical Director #751 or #956.-Beginning on [DATE] vital sign monitoring compliance would be audited by DON #390 by utilizing Company clinical morning meeting and follow up tool provided to be utilized daily starting [DATE] for 14 days then on [DATE] change to every business day (Monday to review weekend data, day returning from holiday to review holiday data). All orders for increased monitoring (e.g., q4 vitals) must be completed as ordered and audited daily by DON/designee. Any missed documentation would result in immediate corrective action including contacting nurses that missed the documentation immediately with disciplinary action as necessary. Immediate assessment of the resident to include missing VS and immediately contacting overseeing medical provider. -Beginning on [DATE] compliance would be audited by DON#390 by utilizing company clinical morning meeting and follow up tool provided to be utilized daily starting [DATE] for 14 days then on [DATE] change to every business day (Monday to review weekend data, day returning from holiday to review holiday data). Nurses must document assessment findings, physician communication, and resident responses to interventions.-Beginning on [DATE] the facility implemented a monitoring system to ensure ongoing compliance including daily monitoring (for the first 14 Days to start [DATE]). Company clinical morning meeting and follow up tool provided to be utilized daily starting [DATE] for 14 days then on [DATE] change to every business day (Monday to review weekend data, day returning from holiday to review holiday data). The DON/designee audits would include 100% of residents with change in condition, antibiotic use, and abnormal vitals. The audits include timeliness of assessment, physician notification, and documentation completeness. -Beginning on [DATE] weekly monitoring will include company clinical morning meeting and follow-up tool provided to be utilized. The random audit of would include 10-20 residents per week to be completed by DON/designee. The focus areas would include change in condition response, monitoring compliance, and documentation. Although the Immediate Jeopardy was removed on [DATE] the facility remains out of compliance at severity Level 2 (no actual harm with potential for more than minimal harm that is not immediate jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance.Findings Include: Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease (GERD), hyperlipidemia, hypothyroidism, chronic gout, fatty liver, intellectual disabilities, obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), fibromyalgia, insomnia, anxiety, diabetes mellitus, and panic disorder. Review of Resident #24's care plan initiated [DATE] revealed the resident had a potential for alteration in respiratory function related to diagnoses of COPD, OSA, preferring to have head of bed (HOB) elevated or to be in a recliner. Goals included the resident will have no signs or symptoms of respiratory distress, the resident will have adequate oxygen exchange as evidenced by no increase in confusion, and the resident would be free from infection. Interventions included auscultation of lung sounds, elevate head of bed as needed, encourage fluids, encourage the resident to cough and deep breathe, obtain pulse oximetry as needed, obtain vital signs as ordered and as needed.Review of Resident #24's record revealed a paper order signed and dated by Nurse Practitioner (NP) #20 on [DATE] for Mucinex 600 mg twice a day (BID) for seven days then as needed (PRN). Also, percussive ventilation per respiratory therapy. There was no evidence of a corresponding nursing progress note or NP note to indicate why the orders were given and/or evidence of a comprehensive resident assessment being completed at this time. Review of Resident #24's record revealed a paper order signed and dated by NP #20 on [DATE] for Diflucan 150 mg orally for one dose, and nystatin powder to groin, cleanse and apply daily. Signed and dated by RN #30 on [DATE]. There was no evidence of a corresponding nursing progress note or NP note to indicate why the orders were given and/or evidence of a comprehensive resident assessment being completed at this time. Review of paper order signed and dated by NP #20 on [DATE] revealed two view chest x-ray, Doxycycline 100 mg BID for seven days, COVID-19 test, and monitor vital signs BID for three days and update the provider if temperature is above 100 degrees Fahrenheit, systolic blood pressure below 100, diastolic blood pressure below 50, pulse is above 120, respiratory rate is above 24, or SpO2 below 91%. Complete blood count (CBC) and basic metabolic panel (BMP), and DuoNeb inhalation 3 milliliter (ml) BID for three days. Signed and dated by RN #30 on [DATE]. There was no evidence of a corresponding nursing progress note or NP note to indicate why the orders were given and/or evidence of a comprehensive resident assessment being completed at this time. Review of Resident #24's chest x-ray (CXR) completed on [DATE] resulting at 4:13 P.M. revealed the resident had diffuse opacity seen in the bilateral lower lungs. This could be due to pulmonary edema, atelectasis and/or pneumonia. Record review revealed there was no evidence Resident #24's medical provider was notified of the abnormal chest x-ray results.Review of Resident #24's COVID-19 test results resulted [DATE] revealed the resident tested negative for COVID. Review of an untimed progress note dated [DATE] authored by NP #20 revealed Resident #24 was seen in assisted living or long-term care for respiratory congestion, increased temperature, and decreased oxygen saturation. Resident #24 had been experiencing respiratory congestion, increased temperature, and decreased oxygen saturation. Staff reports fever of 101-102 degrees Fahrenheit and a pulse of 113 beats per minute (bpm). Vital signs taken on [DATE] at 11:36 A.M. were heart rate of 113, respiratory rate of 20, and SpO2 of 91%, lung sounds revealed rhonchi throughout. Ordered a chest x-ray, complete blood count (CBC), and basic metabolic panel (BMP) for the next available lab services on [DATE]. Prescribed Doxycycline 100 Milligram (mg) twice daily due to increased temperature in the setting of respiratory congestion. Ordered a COVID nasal swab. Changed DuoNeb inhalations from as needed (PRN) to scheduled twice daily for three days. Encourage oral hydration, deep breathing, and sitting up in chairs and in bed. Ordered a green Acapella device (a handheld, drug-free airway clearance system that uses a combination of Positive Expiratory Pressure (PEP) and vibrations to mobilize mucus, making it easier to cough up) to be used three times a day for 10 repetitions each. Please encourage hydration, deep breathing, and upright positioning, monitor vital signs and alert the provider if any changes are noted, contact the provider for any changes in pain, appetite, constipation, sleep, recent falls, or memory disturbances in the resident. Review of Resident #24's nursing progress note dated [DATE] at 7:30 A.M authored by Respiratory Therapist (RT) #958 revealed Resident #24 was febrile with a temperature of 102.1 degrees Fahrenheit, heart rate (HR) of 138 (tachycardic), respiratory rate (RR) of 24, oxygen saturation (SpO2) of 83% on room air (RA), with rhonchi auscultated bilaterally. Resident #24 was placed on oxygen (O2) via nasal cannula (NC) at 3 liters per minute (LPM). The note included nursing is aware.Review of Resident #24's progress note dated [DATE] at 7:30 A.M. authored by RN #30 revealed Resident #24 was febrile with a temperature of 102.1 degrees Fahrenheit, BP 96/73, HR 138, RR 24, SpO2 83% on RA. Respiratory Therapist placed resident on oxygen at 3 LPM via NC. Order received from Clinical Nurse Practitioner (CNP) for (antibiotic) Augmentin 875 mg twice a day (BID) for seven days along with the Doxycycline prescribed [DATE]. Also received order for Tylenol 325 mg, two tabs every six hours for 24 hours. Order for complete blood count (CBC), Basic Metabolic panel (BMP), and C-type natriuretic peptide (CNP) and to continue to monitor vitals every four hours for 24 hours. There was no rationale for the addition of the Augmentin antibiotic or evidence of a medical diagnosis to warrant the recommended treatment orders at this time. In addition, there was no evidence the resident's abnormal vital signs were addressed other than the order for Tylenol (which is frequently ordered for fever). Review of Resident #24's medical record revealed no corresponding documentation on [DATE] as to why NP #20 placed new orders (from the original orders placed by NP's first note on [DATE]) and changed treatments for the resident. In addition, there was no documentation regarding the reason NP #20 was notified the second time on [DATE] regarding Resident #24 status or what specifically was communicated with NP #20 that resulted in the second set of orders on this date.Review of Resident #24 progress note dated [DATE] at 8:12 A.M authored by RT #958 revealed Resident #24 was given a nebulizer treatment (Tx), post treatment vital signs SpO2 91%, HR 121 (tachycardic), RR 24, and lung sound rhonchi bilaterally. The note included resident remains on oxygen via NC at 3 LPM.Review of Resident #24's medical record revealed no documentation of vital signs including blood pressure, heart rate, SpO2, or temperature being monitored every four as directed by NP #20. In addition, review of Resident #24's record revealed no documentation of increased monitoring, encouragement of fluids, deep breathing, or sitting up- right.Review of Resident #24's progress note dated [DATE] at 6:30 P.M. (over 10 hours later) authored by LPN #40 revealed Resident #24's condition gradually declined throughout the day according to report given by the off going nurse. At this time, assessment of Resident #24's blood pressure revealed a BP of 55/31 mm Hg (hypotensive), mean arterial pressure (MAP) of 39. The resident's temperature was 102.3 degrees Fahrenheit, heart rate 94 (tachycardic), SpO2 90% on 3 LPM NC, RR 15 with respirations that peaked then dropped irregularly. Resident #24 was visibly lethargic with increased difficulty breathing. 911 was called with Resident #24 subsequently being transferred to the hospital and admitted to the hospital in the Intensive Care Unit (ICU). Review of Resident #24's hospital records revealed Resident #24 was admitted to the hospital on [DATE] with diagnoses of severe septic shock, acute cystitis, pneumonia, urinary tract infection, and acute kidney injury with a white blood cell (WBC) count of 17.46 k/uL (normal range 3.7-11 k/uL), blood urea nitrogen (BUN) of 46 (normal range 7-21) and creatinine of 2.42 (normal 0.58-0.96 mg/dl), PH of 7.30 (7.35-7.45). Hospital record review revealed Resident #24 had a central venous catheter inserted via internal jugular vein (a long catheter placed into the superior vena cava of the heart through a large vein of the neck) on [DATE] at 1:02 A.M. due Resident #24's BP being unresponsive to fluid boluses. The resident was started on a continuous norepinephrine drip (a life sustaining vasoconstrictive medication used to raise blood pressure in those with severe hypotension and shock, including septic shock). Resident #24 was admitted to the intensive care unit, started on bi level positive airway pressure (BIPAP) and an indwelling urinary catheter was inserted due to urinary retention. The resident was identified with cardiovascular impairment, severe metabolic abnormality and shock (hypercapnic respiratory failure and septic shock), which the resident had and/or has high probability of suddenly developing. Resident #24 was started on several intravenous (IV) antibiotics including Vancomycin, Zosyn, and Meropenem The resident remained in the hospital for intensive care and required hospital treatment until [DATE]. Hospital record review revealed a discharge summary by Physician #22 revealing Resident #24 was admitted to the hospital due to septic shock and acute hypoxic respiratory failure. The resident was treated for pneumonia and transferred to the ICU due to the requirement of vasopressor and Levophed (norepinephrine) support. Resident #24 also required BiPAP ventilatory support. Resident #24 was found to have positive blood cultures for E. coli and urine culture and sensitivity revealed E. coli, which was multidrug resistant and sensitive to carbapenems, therefore the resident was treated with IV Ertapenem (antibiotic). Resident #24 completed a 5-day course of IV Ertapenem and discharged back to the facility with two additional days of IV Ertapenem. Review of Resident #24's record revealed a progress note dated [DATE] at 10:44 P.M. stating the resident had an IV site to the right had for Ertapenem sodium injection solution reconstituted one gram. Use one gram IV one time a day for sepsis until [DATE] at 11:59 P.M. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment completed on [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had no cognitive impairments. The resident had no exhibited behaviors. The assessment revealed the resident required mobility assistance with a walker and a wheelchair. The resident required maximal assistance for toileting, showering, lower body dressing including footwear, and personal hygiene. The resident required supervision/ touching assistance for toileting and tub / shower transfer. The resident was at risk for developing pressure ulcer/ injuries. The resident did not require oxygen therapy. On [DATE] at 9:18 P.M. interview with Resident #24 revealed in [DATE] she had a urinary tract infection (UTI) for approximately two weeks. Resident #24 stated she went septic and they almost called her (death). Resident #24 stated the day she went to the hospital she was incoherent, she recalls the emergency room Physician telling her it was almost too late, she would have expired. Resident #24 stated it was very traumatic; she was scared now. Resident #24 became tearful while telling the story of her hospitalization - near death experience in September of 2025. Resident #24 stated for several days prior to going to the hospital she did not feel well, she was complaining of issues such as being unable to void (urinate) and other symptoms, but no one would listen. Resident #24 stated she expressed concerns to staff members for four to five days that something was wrong, eventually she was sent to the hospital, but she remembered nothing from that day, just little pieces and things others had told her. Resident #24 stated she was out of it and incoherent for that time period. Interview on [DATE] at 11:52 A.M. with ADON #390 revealed any e-triage notes would be in the electronic health record. For Resident #24 any notification to the provider whether e-triage or not should be in the resident's record either progress notes or miscellaneous. ADON #390 confirmed it was the expectation that any communication was documented including reason for communication and outcome (orders/ recommendations provided by the provider).Interview on [DATE] at 7:31 A.M. with Certified Nurse Assistant (CNA) #60 revealed for a few days leading up to Resident#24 discharge to the hospital (in [DATE]) the resident was complaining of itching, burning, and having the urge to urinate frequently. Resident #24 had mentioned she was not cleaned well or changed enough. CNA #60 stated Resident #24 was very routine, she gets up every morning around the same time, 8:00 A.M. the day she went out (to the hospital) she wouldn't get out of bed, she laid there the entire day until emergency medical services (EMS) came to take her to the hospital. To CNA #60's knowledge no one did anything for Resident #24 or looked into her having a UTI prior to the resident going to the hospital even though the resident had voiced concerns.Interview on [DATE] at 7:51 A.M. with RT #958 revealed he could recall Resident #24 going out to the hospital in September of 2025. RT #958 reported having a good rapport with Resident #24 revealing she would joke around with hm, and he knew something was off because she wasn't doing that, she wasn't herself, her heart rate was outside of her normal - cannot recall specifics but remembers it was high, she was always below 100. RT #958 stated Resident #24 was not a person who complained of sickness but the morning of the day she was sent to the hospital she mentioned she didn't feel good, she did not feel right.Interview on [DATE] at 10:44 A.M. with RN #30 revealed concerns with the facility staffing stating staffing was bad, there was nothing but agency. Staff nurses were expected to do so much, it could affect residents and their care. When nurses asked management for help, they would tell staff they were not there to hold their, they would gloat about firing people, and there was no communication. Things would change [orders, procedures, etc.] for residents and staff would have no idea. Management kept adding more tasks to floor staff. RN #30 revealed Resident #24 in September of 2025 was sent to the hospital. Resident #24's vital signs were not great, the resident was on antibiotics, so they were told by NP #20 that day [[DATE]] to let the antibiotics work, keep an eye on the resident, and breathing treatments were ordered. Through the day Resident #24 became out of sorts. Resident #24 had antibiotics ordered so the NP wanted to give them [the antibiotics] time to work. RN #30 stated she recalls the situation being scary but stated it was difficult to remember specifics from that long ago.Interview on [DATE] at 11:08 A.M. with CNA #50 revealed the CNA recalled taking care of Resident #24 the day she was sent out (to the hospital), and the days leading up to it in [DATE]. CNA #50 stated Resident #24 was not doing well. Resident #24 wouldn't eat, which was out of her norm. Resident #24 was sick for a few days before she was sent out. CNA #50 stated she and other people reported to the nurses [cannot recall which ones] something was wrong with Resident #24; she was acting strange- she wasn't herself. The nurse told staff they would give her [Resident #24] some medications and keep an eye on her. Resident #24 wouldn't get out of bed, she was someone who got up every single day, and would walk to the bathroom in the mornings, but those days she was very under the weather. Resident #24 was complaining of generally not feeling good during the days leading to her hospitalization.Interview on [DATE] at 12:22 P.M. with Transportation/Medical Record #535 confirmed all information regarding Resident #24's paper chart including physician notifications, orders, and documentation were provided to the surveyor for review. Interview on [DATE] at 1:32 P.M. with Corporate Clinical Director #751 revealed it was the expectation that any resident with a change in condition (vital signs, behavior, activity of daily living (ADL) assistance, or refusals) have documentation in the medical record. Corporate Clinical Director #751 stated if a resident had these changes, a provider should be notified, and a representative if applicable, and the resident should have continued frequent monitoring. Corporate Clinical Director #751 stated for changes in vital signs, cognition, or behavior they would expect to see orders for the residents from the providers and the orders and interventions to be implemented with continued monitoring, and/or the resident being sent out (to the hospital) if necessary. Interview on [DATE] at 2:40 P.M. with LPN #40 revealed she worked on the evening of [DATE] and could recall the incident with Resident #24. LPN #40 revealed upon starting her shift she began walking rounds, during report with the off going nurse, the off going nurse reported Resident #24 was sick but fine. When walking by Resident #24's room she [LPN #40] immediately stopped shift report and began assessing the resident and contacted EMS because her [Resident #24] eyes were rolled back, she was unresponsive, and she did not look good. This was not Resident #24's norm or even close to it. Resident #24 was someone who could talk with you - she was ornery. The LPN revealed Resident #24 would occasionally walk to the bathroom on her own, she would utilize her call light when needed- it was on often, and the resident did not require oxygen. Resident #24 was oriented and could voice her needs. LPN #40 stated she believed Resident #24 would have been dead soon if she was not sent out immediately upon finding her. Interview on [DATE] at 12:55 P.M. Medical Director (Physician) #50 revealed with the clinical presentation of Resident #24, on [DATE] the low blood pressure, high heart rate, other symptoms she was having sounded septic, and the resident was obviously going into respiratory failure. Medical Director #50 reveale[TRUNCATED]

Based on observation, record review, interview, and policy review the facility failed to ensure residents were free from physical abuse.Actual harm occurred on 03/20/26 when the facility failed to implement appropriate interventions to prevent a resident-to-resident physical altercation despite staff knowledge of Resident #52's known history of aggression and verbal threats to kill his roommate, Resident #15. Resident #15 sustained bruising and psychosocial harm of fear and self-isolation because of the altercation. This affected two residents (Resident #15 and #52) of two residents reviewed for abuse. The facility census was 52. Findings include: 1.Review of Resident #15's medical record revealed an admission date of 10/22/21 with diagnoses including hypertension, hemiplegia (left side) and hemiparesis following cerebral infarction, major depressive disorder, muscle weakness, chronic pain syndrome, and insomnia. Review of Resident #15's care plan dated 11/01/21 revealed the resident needs assistance from staff to meet activity of daily living (ADL) needs related to decreased mobility, hip fracture, and hemiparesis due to an old cerebrovascular accident. Interventions include assisting the resident with transfers and mobility as needed. Review of Resident #15's quarterly minimum data set (MDS) completed on 01/30/26 revealed Resident #15 was moderately cognitively impaired. The resident did not exhibit behaviors or indicators of psychosis during the assessment period. The resident had upper and lower extremity impairment on one side and required a wheelchair for mobility (left sided hemiparesis, required maximum assistance (from staff) for showering, toileting hygiene, lower body dressing including footwear, and personal hygiene and required moderate assistance from staff for mobility and transfers. Resident #15 received antiplatelet medication. Review of Resident #15's care plan dated 02/02/26 revealed the resident had potential for bleeding related to anemia and aspirin therapy. Goals included the resident would be free from bruising, or injury. Interventions included observe for bruising. Review of Resident #15's progress notes revealed a late entry, dated 03/24/26 at 9:05 A.M., for 03/21/26 at 1:00 A.M. The progress note was authored by the Director of Nursing (DON), who was not in the facility at the time of the incident, that documented Resident #15's roommate was upset about the TV volume. Resident #15 wanted the TV volume to stay increased. Resident #52 was upset, and no harm came to Resident #15. Review of the grievance form dated 03/23/26 for Resident #15, completed through interview by Social Services Designee (SSD) #275, revealed Resident #15 said he was lying in bed, dozing on and off, when his roommate, Resident #52, came through the closed curtain and punched him in the left shoulder. Resident #15 stated he did not know why Resident #52 hit him. During an interview on 04/08/26 at 9:01 A.M., SSD #275 stated she was called by Certified Nursing Assistant (CNA) #22 on 03/10/26 related to a verbal altercation between Resident #15 and his roommate, Resident #52. CNA #22 reported there was a verbal altercation and Resident #52 had threatened to shoot Resident #15. SSD #275 stated she was not in the facility at the time of the incident and she was unsure if Resident #52 and/or Resident #15 needed to be sent out for evaluation so she called the Director of Nursing (DON) and the DON said to move Resident #52 out of the room. Resident #52 was moved to a private room at that time. The DON informed SSD #275 to instruct staff (CNA #22 and an agency nurse) not to document the incident in the progress notes. SSD #275 stated she did not instruct the CNA/nurse not to document the incident and the agency nurse did make an entry in the medical record regarding the incident in Resident #52's record. The following day on 03/11/26, SSD #275 spoke with Resident #52 and he stated he didn't remember threatening Resident #15 but he remembered the TV was loud. Resident #52 stated he would apologize to his roommate, Resident #15. SSD #275 stated she checked with the DON and shared what Resident #52 said and the DON advised the CNAs Resident #52 could return to the room he shared with Resident #15. SSD #275 verified there was no room change documentation but when Resident #15 was informed Resident #52 would be returning as his roommate, Resident #15 stated whatever. SSD #275 stated there were no interventions or increased monitoring after the verbal altercation and no updates to either resident's care plan. SSD #275 stated the was not discussed afterwards, it was never mentioned in the morning stand-up meetings and the DON acted like it didn't happen. SSD #275 shared there was a physical altercation between Resident #52 and Resident #15 which occurred on 03/20/26, when SSD #275 was not in the building. SSD #275 found out about the physical altercation on Monday 03/23/26 when she returned to work after the weekend. She was informed that late in the evening on Friday, 03/20/26 Resident #52 hit Resident #15. SSD #275 confirmed there was a nurse progress note entered by the DON regarding the incident but the DON was not working when the incident occurred. SSD #275 stated she was not made aware of the incident until 03/23/26 and she observed Resident #52 in a different room and the DON told her it was a long story but she was provided with no additional information. SSD #275 stated the CNAs (cannot recall who) informed her the residents had a physical altercation with Resident #52 striking Resident #15. SSD #275 stated she interviewed each resident. Resident #15 stated he was lying in bed, dozing on and off with the TV on and his roommate, Resident #52, came through the privacy curtain and hit him in the shoulder. Resident #15 then demonstrated what happened and lifted his right arm with his hand in a fist and swung towards his left shoulder. Resident #15 was unable to move his left arm due to a previous stroke and when he lay in bed, his left side would be toward Resident #52's bed. SSD #275 stated she asked Resident #15 if he was hurt and the resident stated he had a knot on his shoulder but she did not confirm this. SSD #275 she reported the information to the Administrator, but the administrator denied knowledge of a physical altercation, as she (the Administrator) was originally told by the DON the altercation was verbal and nothing physical happened. SSD #275 stated she followed up with Resident #52 on 03/24/26, the next day. Resident #52 reported Resident #15 said the F' word and Resident #52 was tired of hearing it so he slapped him. Resident #52 stated he hit Resident #15 in the head or the shoulder. SSD #275 stated she shared this information with Corporate Staff #21 and then called the [NAME] President of Operations (VPO) #957 who advised her to write up the concerns for each resident (Resident #15 and #52) and send them to VPO #957. SSD #275 completed grievance forms and emailed both forms to VPO #957 on 03/24/26. Following the email, Corporate Registered Nurse (RN) #751 called the SSD and they did a rundown of the situation. Corporate RN #751 wanted to know who worked the night of 03/20/26 and SSD #275 provided the information which included the name of Agency Nurse #23. SSD #275 said she was unsure where it went from there so she asked VPO #957 and was informed to provide the grievance forms to the Administrator because the Administrator was to investigate the incident. SSD #275 stated she emailed the grievance forms to the Administrator around 03/27/26. SSD #275 believed the grievance was given to the DON to investigate but she was unsure if the DON investigated the incident as she never got an update. During an interview on 03/31/26 at 9:26 A.M., Resident #15 stated his previous roommate, Resident #52, moved rooms about a week ago. Resident #15 stated he was attacked by Resident #52 when the resident ran up to him and hit him in the shoulder. At the time, the hit was painful. Resident #15 stated he reported what happened to him to the nurse but he couldn't remember which nurse he told. Resident #15 shared, as of this time, no one followed up with him regarding the incident or asked him for a statement. Resident #15 stated there was no investigation done that he was aware of. During an interview on 04/08/26 at 11:20 A.M., the Administrator stated she was told Resident #52 and Resident #15 had a disagreement about the TV sometime in March 2026 but she could not recall the exact dates. The Administrator stated the DON informed her that Resident #52 had requested to return to the room with Resident #15 however there was no documentation of Resident #52's request or that Resident #15 was notified. There was no evidence Resident #15 said he felt safe and that he agreed with Resident #52 returning. On 03/20/26, the DON called her twice and ADON #390 called her once but was sleeping and didn't see the calls until about an hour and a half later. The Administrator stated she called the ADON back but the DON answered since they were together. The DON informed the Administrator Resident #15 and Resident #52 had a verbal altercation but there was no physical contact made. The DON stated she was going to separate the residents because it was an ongoing issue between the two residents bickering about the TV. The Administrator stated she didn't feel the incident needed reported to the State Agency as she thought it was a verbal altercation and not physical. The following Friday, 03/27/26, the Administrator received the concern/grievance form from SSD #275, and Resident #15 was saying he was hit by Resident #52. The Administrator stated she spoke with Resident #52 about the altercation and he didn't want to talk about it, he said he was happy in his private room. The Administrator stated SSD #275 did interviews with the residents following the altercation. The Administrator confirmed, until notification on 03/27/26 from SSD #275, she was told by the DON that the altercation was verbal, not physical. During an interview on 04/08/26 at 12:31 P.M. ADON #390 stated she was unaware of Resident #52 threatening to shoot Resident #15 until after the altercation on 03/20/26 as no one reported this to her. ADON #390 stated it was not appropriate to move Resident #15 and Resident #52 back into the same room and she was unsure who made the decision to do so but this placed Resident #15 at risk of being hurt. On 03/20/26 ADON #390 was called by Agency Nurse #23 around 9:00 P.M. to 10:00 P.M. ADON #390 confirmed she was not in the building at the time and there was no documentation of either party's family being notified, or a physician being notified of Resident #15 being hit by Resident #52. ADON #390 confirmed Resident #52 was the aggressor. ADON #390 stated when asking Resident #15 about the incident he did not want to talk about it but didn't state why. During an interview on 04/08/26 at 1:39 P.M., CNA #22 stated that around 03/10/26, she came into work, and Resident #52 was in front of the building, which was unusual. CNA #22 approached Resident #52 and asked him what wrong as Resident #52's face was beet red. Resident #52 responded I need you to move me to another room because I'm going to (explicit word) kill my roommate (Resident #15). CNA #22 reported this to SSD #275, and they (CNAs on shift) moved Resident #52 to a separate room. The next day the DON told the CNAs to move Resident #52 and Resident #15 back into the same room. Several staff members voiced concerns it wasn't safe because Resident #52 has a temper, he has physically assaulted staff and even had one CNA pinned against the wall with his cane. It was pretty evident where Resident #15 would not be able to fend for himself as Resident #15 is very dependent on staff. He is either in his bed or wheelchair. Despite staff concerns of the residents moving back into the same room, the DON told them they had to do what she said. On 03/20/26 CNA #22 heard Agency Nurse #23 yell for help. The nurse stated Resident #52 was punching Resident #15. CNA #22 asked Resident #15 if he was okay, he stated he could not talk about it, when asked why Resident #15 said I don't want him [Resident #52] to get me again. CNA #22 stated Resident #15 looked scared and terrified. CNA #22 stated they were not asked to make a statement on 03/20/26 or the days following. During an interview on 04/08/26 at 2:50 P.M., Resident #15 recalled what happened the night of 03/20//26 and stated he was scared for while after the incident because he was afraid Resident #52 would find him again. Resident #15 stated he was unable to use his left arm after a stroke and depended on the staff for mobility and transfers as well as dressing and other activities. During an observation on 04/09/26 at 12:12 P.M., Resident #15 had a yellow green bruise on the left bicep approximately 1.5 inch in length, and a quarter sized bruise, in various stages of healing, to the left shoulder. Resident #15 stated at the time of the observation those bruises were from the altercation with his roommate. This observation was verified by CNA #115. 2.Review of Resident #52's medical record revealed an admission date of 01/02/25 with diagnoses including anxiety, hypertension, heart failure, and pulmonary embolism. Review of Residents #52's care plan dated 03/14/25 revealed the resident had inappropriate behaviors at times related to being verbally/ physically aggressive towards staff, had delusions of seeing communists, and seeing stars. Goals included no injury to self or others. Interventions included documenting behaviors and speak to the resident about inappropriate behavior and redirect as possible. Review of Resident #52's annual MDS completed on 01/09/26 revealed he was moderately cognitively impaired. Resident #52 was independent/ required supervision from staff for mobility and transfers and received anti-anxiety and anti-depressant medications. Review of Resident #52 progress notes on 03/11/26 at 1:41 A.M. at approximately 6:30 P.M. this nurse was notified by staff that Resident #52 stated he was going to shoot Resident #15 due to his TV being too loud. The on-call person for nursing was notified and Resident #52 was removed from the room and placed in private room until morning. Notified on call physician who gave orders for trazadone 25 milligram, hourly checks for six hours, urinalysis, culture and sensitivity, complete blood count, and basic metabolic panel. Review of a late entry progress note dated 03/21/26 at 12:50 P.M., entered on 03/24/26 at 8:53 A.M., and authored by the DON documented Resident #52 was yelling and being verbally aggressive towards staff, mad about TV volume while trying to sleep, told roommate (Resident #15) to turn the volume down. Review of a grievance form completed on 03/24/26 via interview by SSD #275 revealed Resident #52 stated Resident #15 said expletive and he (Resident #52) had heard that word enough so he went over and slapped him with an open hand on the head. (The grievance form was used by the SSD to document the interview/incident as reported by Resident #52). During an interview on 03/31/26 at 9:33 A.M., Resident #52 stated he had problems with his previous roommate, Resident #15. Resident #52 stated Resident #15 was a grouchy old man, and about a week ago before they moved his room, Resident #15 dropped the F bomb so he hit him. Resident #52 stated he hit Resident #15 in either the head or the shoulder. During an interview on 04/02/26 at 10:08 A.M., CNA #685 stated prior to the evening of the physical altercation between Residents #15 and #52, Resident #52 was threatening to kill Resident #15, and Resident #15 was moved out of the room to a different room. At some point they moved the two residents back into the same room. On the evening of 03/20/26, less than a week after Resident #52 threatened to shoot Resident #15, Resident #15 was physically assaulted by Resident #52. CNA #685 stated Resident #15 would not be able to defend himself as he was dependent on staff for most activities of daily living (ADL) and was weak, and Resident #52 was pretty independent. CNA #685 stated several staff members were concerned why the two residents were moved back into the same room as the two residents had ongoing issues between the two of them, CNA #685 was working at the time of the incident but did not witness the incident but came to help staff. During an interview on 04/02/26 at 2:30 P.M., CNA #480, who came in at 5:00 A.M. the morning after the incident and received report of the occurrence, stated Resident #52 threatened to shoot and kill Resident #15 about two to three days prior to their physical altercation. Resident #52 was moved to a separate room away from Resident #15 after threatening him. Then at some point Residents #15 and #52 were moved back into the same room, leading up to Resident #52 physically assaulting Resident #15. CNA #480 stated Resident #15 was upset for a few days after the altercation, he would not talk to anyone, he was withdrawn, he seemed terrified. CNA #480 stated Resident #15 has started talking to people again. The day after the physical altercation Resident #15 was complaining of his body being sore and hurting. CNA #480 stated they were unsure who physically moved the residents back together before the incident occurred. During an interview on 04/02/26 at 3:18 P.M., CNA #485, who came in to work the night of the incident at 10:00 P.M., heard of the incident through report. She stated the DON had the residents moved back in together. On the evening of 03/19/26, or 3/20/26, (could not recall exact date) Resident #15 and Resident #52 got into it. Resident #52 attacked Resident #15. Prior to this incident Resident #52 would threaten Resident #15 that he would choke, shoot or kill him. The facility moved Resident #52 to a different room, then they placed him back into the same room with Resident #15, but Resident #52 became hostile again leading to the attack. During an interview of 04/06/26 at 10:55 A.M., CNA #195 stated Resident #52 had an episode and beat up Resident #15. The two have been split up before due to arguing and threats. Staff advocated the residents needed split up. Management moved Resident #52 to a different room once, and then he and Resident #15 ended up in the same room again. After being moved back into the same room Residents #15 was physically assaulted by Resident #52. Review of facility policy titled Abuse, revised on 01/30/20 revealed it is the facility policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property including injuries of unknown origin in accordance with the policy. Residents have the right to be free from abuse, neglect, exploitation and misappropriation. Individuals who report such incidents and allegations are free from retaliation or reprisal for reporting the incident. Staff should report allegations to the administrator and to the Ohio department of health (ODH). If a staff member is disciplined for failing to report an incident/ allegation timely in accordance with this policy, any disciplinary action taken as a result of that failure shall not constitute retaliation or reprisal. abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. it includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Mistreatment is inappropriate treatment or exploitation of a resident. Neglect is the failure of the facility, its employees, or facility service providers to provide good and services to a resident necessary to avoid physical ham, pain, mental anguish, or emotional distress. Willful means the individual must have acted deliberately. Initial response is to protect the resident. If a resident is accused or suspected of abuse, mistreatment, exploitation, or misappropriate, the facility will ensure other residents are protected as determined by the circumstances, which may include but are not limited to, increased supervision, of the victim, perpetrator, and/or other residents, room or staffing changes, and immediate transfer or discharge if indicated. The resident's representative and the attending physician should be notified. Notification to social services so that it may take appropriate interventions to care for the psychosocial needs of any involved resident. Documentation in the nurses notes should include the results of the resident's assessment, notification of the physician and the resident representative, and any treatment provided. Appropriate quality assurance documentation should be completed as well. For the initial report, incidents and allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property an all injuries of unknown source must be reported in a timely manner to the administrator or designee per regulations. ODH will be notified of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation, and injuries of unknown source must be reported as soon as possible, but in no event later than 24 hours from the time of the incident/allegation was made to the staff member. If the allegation involves an allegation of abuse or serious bodily injury it should be reported to ODH no later than 2 hours after the allegation is made. the investigation must be completed within five working days. Interview the resident, the accused, and all witnesses including 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 employees and/ or alleged victim the day of the incident. if there are no direct witnesses then the interviews may be expanded. Obtain a statement from the resident, if possible, the accused, and each witness, obtain all medical reports and statements, review the resident record. evidence of the investigation should be documented. Ensure involved residents plan of care is reviewed and revised and complete staff training. in the case of resident to resident abuse, mistreatment, the facility will refer the matter to the facility interdisciplinary team to determine appropriate interventions. This deficiency represent noncompliance investigated under Master Complaint Number 2964189.

Based on observation, record review, interview, national library of medicine review, drug manufacturer review, and policy review, the facility failed to ensure effective pain management interventions were implemented to adequately control resident pain. This affected three (Residents #1, #10 and #30) of three residents reviewed for pain.Actual Harm occurred to Resident #10 on 03/28/26 at 9:30 A.M. when the facility failed to administer the ordered dosage of Lyrica (an anticonvulsant medication and gabapentin used to treat neuropathic pain, fibromyalgia, and partial-onset seizures) and failed to provide any pharmacological or non-pharmacological interventions. This resulted in Resident #10 suffering excruciating pain and extreme nausea. Resident #10 was crying and restless, lying in bed while grabbing her legs due to complaints of severe leg pain. Findings include: 1. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, end stage renal failure, diabetes mellitus with neuropathy and dependence on renal dialysis. Review of the care plan titled Potential for Alteration in Comfort related to generalized pain, Neuropathy initiated 01/28/26 revealed interventions including administering medication as ordered and per resident preference/request. Assist with repositioning as needed, consult physician as needed, encourage resident to report pain early prior to becoming severe, observe for signs and symptoms of pain including non-verbal symptoms i.e. facial grimacing and restlessness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/26, revealed Resident #10 was cognitively intact for daily decision-making, received scheduled pain medications, non-pharmacological interventions and denied pain at the time of the assessment. Review of the facility document titled N Adv – Vitals and Pain Only Evaluation dated 02/09/26 revealed the resident had no complaints of pain. Review of the Chronic Care Visit Progress Note written by Nurse Practitioner (NP) #650 dated 03/27/26 revealed Resident #10 was seen for follow-up including management of diabetes mellitus type-2 with neuropathy. A dose reduction was requested due to side effects of sedation. The resident was agreeable and will start reduction in two days. The resident denied neuropathic pain at the time of the assessment, was on high doses of Lyrica and reports sedation from Lyrica. The resident did complain of mild, aching right wrist pain rated a two on a scale of zero to 10. The resident was to wean off Lyrica as prescribed and stated if neuropathy was stable, may wean completely off the Lyrica. Review of the electronic Physician Orders (ePOS) dated March 2026 revealed Resident #10 received pregabalin (Lyrica) 75 milligrams (mg) three times a day for pain and had an order to receive PRN (as needed) Tylenol 1000 (mg) every six hours for pain. There was an order to decrease Lyrica starting on 03/26/26 as follows: Lyrica 75 mg twice a day for two days, then decrease to 50 mg twice a day for two days then decrease to 25 mg twice a day for two days. Review of the Medication Administration Record (MAR) revealed the resident received the first four doses of the Lyrica taper between 03/27/26 and 03/28/26 (ordered 75 mg twice a day for two days); however, the next ordered dose of 50 mg (the next step in the plan to wean the resident off of the medication) was not available to be administered starting the evening of 03/28/26 due to the pharmacy had not received a prescription for the medication. There was no evidence that the physician, nurse practitioner or electronic physician on-call was notified of the need for the prescription until 03/30/26 at 12:08 A.M. and at 9:45 A.M. the NP notified the pharmacy, and the resident received Lyrica 50 mg on 03/30/26 at 12:45 P.M. from the Ebox that was available at the facility. (The resident did not receive the Lyrica 50 mg from 03/28/26 morning dose until 03/30/26 at 12:45 P.M.) During an observation on 03/30/26 at 10:57 A.M., Resident #10 was in bed crying. The resident's husband was in the room standing next to the resident's bed trying to comfort her. When asked why she was crying, the resident stated she receives peritoneal dialysis every day and the facility had been trying to wean her off the Lyrica but she needed it due to her nerve pain. Resident #10 stated she did not get any Lyrica yesterday or this morning. Resident #10 was crying, grasping her legs and moving restlessly in the bed. Resident #10 described her pain as sharp, stabbing and rated her pain a 10 on a zero to ten scale. Resident #10 stated the facility had not done anything, pharmacological or non-pharmacological, to help decrease the pain. Resident #10 stated she had told the nurses but was told the dosage of Lyrica that had been ordered had not arrived from the pharmacy. On 03/30/26 at 11:03 A.M., Registered Nurse (RN) #955 was informed of Resident #10's complaints of severe pain. RN #955 went to Resident #10's room and informed her they were still working on trying to get the ordered dose of Lyrica. Resident #10's spouse asked RN #955 why she couldn't just give her one of the 75 (mg) capsules, and RN #955 explained the resident no longer had an order for that dosage. RN #955 asked Resident #10 to rate her pain and Resident #10 stated she was having severe leg pain rated a 10 on a scale of zero to 10. The resident told RN #955 that she felt like throwing up because the pain was so bad. Resident #10 was intermittently sobbing and moving restlessly in the bed. RN #955 informed the resident and her spouse that she would follow-up again with the Director of Nursing (DON). RN #955 verified the resident had been experiencing severe pain; however, the resident was on a taper to decrease her Lyrica by the physician. The resident previously received Lyrica 75 (mg) three times a day and the physician was titrating her off the Lyrica. The resident was supposed to receive 50 (mg) twice a day for the last two days; however, the facility did not have 50 (mg) from the pharmacy yet. RN #955 was going to address it with the pharmacy, but the DON stated she would handle it. RN #955 verified the resident was crying and had been complaining of severe pain, but the physician had not ordered anything else for pain. RN #955 stated the resident had no other pain control options, pharmacological or non-pharmacological, at this time. There was no evidence that the resident's medical provider had been notified that Resident #30's tapering of the Lyrica was not working until brought to their attention by the survey team on 03/30/26. During an observation on 03/31/26 at 8:29 A.M., Resident #10 was lying on her right side in bed, moving her legs intermittently back and forth. Resident #10 stated she was still having pain and rated her leg pain an eight on a scale of zero to 10. Resident #10 stated she did receive two Lyrica yesterday, but her neuropathy pain was not much better. Resident #10 stated she had not received any PRN Tylenol for the pain. During an interview on 03/31/26 at 11:35 A.M., the DON verified Resident #10 had missed three doses of Lyrica and had not been offered or administered PRN Tylenol to help alleviate her pain. The DON stated she would have to review the information regarding why the resident's Lyrica was not available to administer. No additional information was provided regarding Resident #10's Lyrica by the DON during the survey. Review of the Nurse Progress Note dated 03/31/26 at 6:05 P.M. revealed Resident #10 had consistent complaints of pain due to changes in Lyrica. The NP was notified. The resident and her husband were notified and were agreeable with the orders to restart Lyrica 75 mg three times a day for pain. On 04/01/26 at 1:30 P.M., Resident #10 was observed lying in bed grabbing her legs and moving her legs around in bed. The resident complained of bilateral leg pain and rated her pain a nine on a scale of zero to 10. Review of the Pain Level Summary dated 04/06/26 at 9:51 A.M. revealed Resident #10 complained of pain rated a nine on a scale of zero to 10. During an interview on 04/09/26 at 7:20 A.M. and 12:30 P.M., RN #390 verified Resident #10 did not receive Lyrica as ordered between 03/28/26 and 03/31/26. RN #390 verified the pharmacy had not received the order to fill the Lyrica 50 (mg) prescription that was due on 03/28/26 until 03/30/26. The resident's Lyrica was then pulled from the available emergency facility stock and administered on 03/30/26 at approximately 12:30 P.M. per RN #390. RN #390 verified the resident also missed a dose of Lyrica on 04/05/26. Review of the Emergency Medication Supply List, revised 07/10/25, revealed medications available at the facility for residents on an emergency basis included eight capsules of pregabalin (brand name Lyrica) (nerve pain) 50 (mg) and pregabalin 75 (mg) capsules. Review of the drug manufacturer guidelines for Lyrica (dated 2025) revealed Lyrica was to be taken as prescribed, and not to be stopped without talking to your healthcare provider. If you stop suddenly taking the medication, you may have headaches, nausea, diarrhea, trouble sleeping, increased sweating, or you may feel anxious. 2. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic pain, encephalopathy, acute respiratory failure with hypoxia, pneumonia, diabetes mellitus, severe protein-calorie malnutrition, malignant neoplasm of right lower bronchus or lung, generalized anxiety disorder and a deep tissue injury to the sacrum and right outer ankle. Review of the hospital discharge orders dated 02/13/26 revealed orders to address the resident's pain including gabapentin (nerve pain) 600 milligrams three times a day and Hydrocodone-Acetaminophen (Norco) 5 milligrams/325 milligrams (5/325 mg) one tablet by mouth four times daily. The last dose of Norco was administered on 02/11/26 at 8:09 P.M. Review of the electronic Physician Orders dated February 2026 revealed an order on 02/13/26 to administer Norco 5/325 (mg) one tablet by mouth three times a day for pain for three days. Gabapentin 600 (mg) three times a day was not transcribed onto the physician orders and was identified to be ordered for the resident according to the resident's hospital discharge orders. Review of the Progress Notes dated 02/14/26 at 12:59 A.M. revealed Resident #1's face sheet and hospital Discharge Summary was faxed to NP #600. The note indicated a prescription was needed for the Norco to be faxed to the pharmacy. NP #600 reviewed and approved the medications and indicated to administer the Norco 5/325 (mg) three times a day for three days to allow the primary care physician to evaluate and ensure the resident did not run out of scheduled or PRN (as needed) medications. Review of the Pain Assessment/Evaluation dated 02/16/26 revealed the resident diagnoses and origin of pain was diabetes mellitus with diabetic neuropathy, lung cancer of right lower lobe, pressure ulcer and bilateral primary osteoarthritis of hip. The resident verbalized pain as aching and stabbing that was chronic and frequently present. Pain was described as worse in the morning, afternoon and night. Pain was rated at seven out of 10 that was relieved by medication, frequent position changes and heat. The resident's acceptable pain level was rated as three out of 10. The resident was to be receiving scheduled pain medications of Norco 5/325 (mg) three times a day which was effective within one hour and she was not receiving PRN pain medication. Review of the care plan titled Potential for Alteration in Comfort related to arthritis and neuropathy, initiated 02/16/26, revealed interventions to administer medications as ordered. Administer medication as ordered and per resident preference/request; Assist resident with repositioning as needed; Attempt alternate relief measures relaxation, reposition, exercise, music, prior to PRN medications; Consult physician as needed; Encourage resident to discuss feelings of pain management; Encourage resident to report pain early prior to becoming severe; Observe resident for any signs/symptoms of pain; Observe resident for nonverbal signs of pain, i.e facial grimacing, restlessness, grabbing effected area. Review of the eMAR dated February 2026 revealed Resident #1's gabapentin 600 (mg) three times a day was not transcribed or ordered upon admission. Resident #1 also did not receive ordered Norco 5/325 (mg) three times a day until 02/20/26. Review of the modified admission MDS assessment dated [DATE] revealed Resident #1 was cognitively intact for daily decision-making, did not receive scheduled pain medication within the last five days, no PRN pain medications and was not receiving non-pharmacological interventions for pain. The resident complained of frequent pain over the last five days that made it occasionally hard to sleep at night and day-to-day activities. Resident #1 rated worst pain as a seven out of 10 over the past five days and was receiving an opioid with indication of use since admission. Review of NP #650's Progress Note dated 02/19/26 revealed the resident was seen on 02/18/26 for follow-up and management of her chronic pain, obstructive sleep apnea and excoriation of buttocks. The resident reported to NP #650 she had chronic pain rated a nine out of 10 in severity. The pain was in her lower back and right ankle. She states this is a chronic issue and that the pain is exacerbated by movement. She has been taking Norco for this pain for approximately three years and takes it three times a day and she has not had it at this facility yet. Chronic pain was unstable at this point due to the lack of a Norco regimen. Plan was to ensure the resident's Norco regimen is continued and administered as scheduled three times daily to manage her severe chronic pain (ordered today). Monitor for efficacy, instructed to report increased pain. Opioid dependence was chronic and the resident admits to being on Norco for three years now, longer than initially intended. Resident #1 admitted to craving next dose and feeling nervous & jumpy without doses. She did not want to trial non-opioid pain medication at this time. Plan was to continue Norco three times a day due to history of chronic pain, the need for medication management as her Norco was discontinued when she was admitted to this facility. Her primary issue was severe chronic pain in her lower back and right ankle which she rated a nine out of 10. Review of the eMAR monitoring of Pain from 02/14/26 through 02/16/26 did not rate pain using numerical or non-verbal scale. On 02/17/26 the morning pain was rated a nine out of 10. There was no evidence of non-pharmacological pain interventions implemented. Pain was documented on the eMAR between 02/17/26 and 02/19/26 as a zero. During an interview on 03/30/26 at 1:25 P.M., Resident #1 stated she had pain in her right ankle and back. She has an ordered cream that helped but they could not find it this morning and rated her pain as an eight on a scale of zero to 10. During an interview on 04/02/26 at 7:58 A.M., Resident #1 stated she was not currently having any pain; however, she did not get her pain medications upon admission which caused her to have a lot of pain upward to a 10 on a scale of zero to 10. During an interview on 04/02/26 at 1:25 P.M., RN #751 verified there was no evidence of pain management between 02/13/26 through 02/20/26 as ordered in the hospital Discharge Summary, including gabapentin 600 (mg) three times a day. During an interview on 04/06/26 at 12:40 P.M., RN #390 verified the first dose of scheduled Norco 5/325 (mg) was not administered until 02/20/26 at 8:00 A.M. and there were additional doses of scheduled Norco 5/325 (mg) not administered as ordered on 03/03/26 (no dose administered between 6:00 A.M. and 10:00 A.M.), on 03/17/26 (no dose administered between 6:00 P.M. and 10:00 P.M.), on 03/22/26 (no dose administered between 11:00 A.M. and 2:00 P.M.), and there were no doses administered on 03/23/26, 03/24/26, 03/25/26 or 03/26/26 until a dose on 03/26/26 at 9:08 P.M RN #390 verified there was no documentation as to why the medications were not administered, and no documentation if the pharmacy or physician were notified. RN #390 also verified gabapentin 600 (mg) was not ordered as written. During an interview on 04/06/26 at 2:50 P.M., RN #751 verified the eMAR for March 2026 and April 2026 did not accurately reflect the dates of Norco administration. During an interview on 04/08/26 at 8:53 A.M., Pharmacist #800 stated controlled drug prescriptions received by facilities were processed the same day they were received. Depending on the time received, the controlled drugs would be sent to the facility with the next delivery. Regarding Resident #1, the first Norco 5/325 (mg) prescription for a 90-day supply was received on 02/18/26 by NP #650. The pharmacy sent a card of 30-tablets on 02/19/26 for the resident. A resupply was sent on 02/28/26 with a card of 30-tablets. The third resupply (for the 90-day prescription) was sent the same day as received on 03/10/26. Pharmacist #800 stated there was no evidence of a prescription sent to reorder Resident #1's Norco 5/325 (mg) until 03/26/26 by Physician #901. Physician #901 wrote the prescription to dispense 42 tablets and a card of 30 tablets were sent and received at the facility on 03/26/26 at 10:00 P.M During an interview on 04/08/26 at 10:47 A.M., RNs #390 and #751 verified NP #600 ordered Resident #1 to be administered Norco 5/325 scheduled three times a day upon admission for three days until the primary care physician could assess to ensure no break in pain management. Both verified no scheduled Norco or PRN pain medication were administered between 02/13/26 and 02/20/26. During an interview on 04/14/26 at 12:52 P.M., Medical Director #750 stated it would be his expectation for the facility nurse to follow up with the pharmacy and/or the NP regarding the scheduled Norco 5/325 (mg) not being available to be administered. 3. Record review revealed Resident #30 was admitted on [DATE] with diagnoses including unspecified dementia with other behavioral disturbance, generalized anxiety disorder, psycho-physiologic insomnia, unspecified mood disorder, weakness, history of falling, dysphagia oropharyngeal phase, hyperlipidemia, age-related osteoporosis, unspecified osteoarthritis, essential hypertension, major depressive disorder, vitamin D deficiency, muscle weakness and difficulty walking. The resident had a physician order dated 03/03/21 to monitor the resident for signs and symptoms of verbal and nonverbal pain every shift for comfort and record the level of pain on a zero to ten scale. Review of orders for Resident #30 revealed an order dated 10/04/22 for regular strength Tylenol 325 milligrams (mg) two tablets every four hours as needed for pain. Review of Resident #30's MDS assessment, dated 03/13/26, revealed Resident #30 was severely cognitively impaired, required a wheelchair for ambulation and was dependent for all activities of daily living (ADLs). Review of a progress note for Resident #30 marked as a late entry, revealed on 03/18/26 at 6:30 P.M. and authored by Licensed Practical Nurse (LPN) #150, documented the nurse was alerted the resident was lowered to the floor during a mechanical lift due to lift pad needing adjustment. At the time of the incident, the nurse asked the resident if she was having any pain, the resident replied no. There were no signs of injury. Review of the medical record revealed a telephone telehealth triage note dated 03/19/26 at 6:03 A.M. The unknown caller revealed Resident #30 had a fall the prior evening and was complaining of pain to the right inner thigh. As a result of the call, Nurse Practitioner (NP) #616 gave orders for Tylenol ES (extra strength) two tablets by mouth NOW, cold compresses to the area, and a STAT (immediate) X-ray to the right hip. The eCare Triage note was completed by NP #616 on 03/19/26 at 6:57 A.M. Review of the medical record for Resident #30 revealed no evidence the order dated 03/19/26 for the Tylenol extra strength or the cold compress were transcribed to the medical record. There was no evidence Resident #30 received any Tylenol extra strength or a cold compress. There was no evidence of any documentation of the resident's pain or assessment of Resident #30 on 03/19/26 despite the report of the resident's pain to the telehealth medical provider. Review of the resident's Annual Wellness visit completed on 03/20/26 by the nurse practitioner revealed in the past seven days Resident #30 had some pain. During an interview on 04/14/26 at 12:14 P.M. Medical Director (MD)/Physician #750 stated he had never personally seen Resident #30; he just provided oversight to the facility. He confirmed the complaint of pain the resident had on 03/19/26 would be in-line with an injury from a fall (as reported on 03/18/26). MD #750 confirmed the resident should have received the Tylenol ES she had been ordered to receive as well as the cold compresses. MD #750 confirmed he could not see in the medical record where this had occurred. MD #750 explained the fact the resident did not receive the ordered Tylenol ES and cold compresses to manage her acute pain from her injury concerned him. Review of the policy titled Pain Management Program, revised 08/01/17, revealed the goal of the program was to minimize/decrease the level of pain, whether acute or chronic, the resident may have, and to implement individualized comfort measures through the advice of the interdisciplinary team, family, and attending physician and to utilize non-pharmacological interventions prior to administrating medication for pain. All residents were to be reviewed upon admission, on a quarterly basis and prn for acute, chronic or no pain. A baseline tolerance of pain will be established within 24 hours of admission upon completion of the admission nursing assessment. Residents on the pain management program will be reviewed at least weekly and PRN for four weeks in the weekly QA program meeting. The consultant pharmacist will review all residents who use PRN pain medications at least monthly and PRN. Residents on the pain program will have individualized interventions. Review of the Pain Management Master Interventions used to assist in managing pain included assess for pain, consult physician and administer medications per physician order.

Based on observation, interview, review of the facility assessment, and review of facility grievances the facility failed to timely to resident concerns regarding dietary, housekeeping, and staffing services. This affected all 52 residents residing in the facility. The facility census was 52.Findings include:Review of grievances filed in December 2025, January 2026, and February 2026 revealed grievance resolutions stated the grievances were resolved by education in all staff meeting. However, during the course of the annual recertification survey, the surveyors requested to review the training and education that was provided to staff in relation to the grievances and resolutions and the facility was unable to provide the surveyors the requested training and education. Review of Grievance filed by Resident #54's family on 02/19/26 revealed a concern the food is cold and the resident asked for fruit, and doesn't receive it, even if it is circled on the menu. Action taken revealed education was provided to Certified Nurses Assistants on getting fruits from the cooler. Review of the grievance revealed no action taken regarding the concern for cold food. Review of the facility assessment updated 02/20/26 revealed the facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure residents safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility resident population in accordance with the facility assessment.Observation of a Resident Council Meeting on 04/01/26 at 2:02 P.M until 3:27 P.M revealed Resident Council President (Resident #3) asked Activities Supervisor #110 where the Director of Nursing (DON) and Administrator were, as he had asked and invited them to the meeting. Activities Supervisor #110 stated they were told by the DON that she (the DON) does not attend resident council meetings when state surveyors are present.Resident #3 stated that was a bad excuse as management should be looking forward to resident council to know what the resident concerns are. Resident #3 stated that things have gotten 'much worse around here [the facility] since the DON came and she is setting them up for failure, she is not pulling her weight. Resident #3 stated they [Resident #3 and facility residents] feel that no one is listening to them, they [Resident #3 and other facility residents] are tying to advocate for themselves, and no once cares, no one addresses the issues.During the meeting, Resident #53 stated they are sad and concerned. Resident #53 stated it is a shame the way things are going here [at the facility].Resident #3 agreed with Resident #53's statement along with other residents who voiced their agreement.Resident #3 stated management has no communication with the residents, and when floor staff try to do the right thing, and advocate, they are fired. Resident #3 stated they [the residents] are tired, and fed up, things need to start going the right way. Residents still are not getting cleaned properly, residents are not getting care due to inadequate staff; the nurses, aides, and residents deserve better. Resident #3 stated he wants to see things improve in the facility, for residents, and for staff; they need more positivity not negativity.Resident #53 thanked Resident #3 for his courage and for speaking for the residents and doing it in a composed manner, other residents at the meeting voiced their agreement and gave thanks to the resident council president. Resident #37 stated it took a lot of courage for the Resident #3 to stick up for them [the residents].Interview of 04/02/26 at 2:06 P.M. with Resident #3 revealed he feels staff does not listen to the residents concerns, or listens to what they [the residents] have to say in resident council. Resident #3 stated management knows in advance when meeting are and they don't come, they're always invited but they do not come. Resident #3 stated the facility is negative in every area. Resident #3 stated when residents, including himself, voice issues or concerns it just gets swept under the rug. Resident #3 revealed the DON is bringing the facility down. Resident #3 stated the DON and ADON #390 are not helpful, the residents do not feel safe with them, they are not approachable and don't want to hear concerns. If you bring up concerns to them they argue with you, they don't listen, they're not actively listening and understanding. They are making it worse. When Resident #3 heard a new DON was coming he was very optimistic, but then it went bad fast, they brought a black cloud with them. Resident #3 stated management [the DON] will watch residents get hurt and do nothing about it, just cover it up, residents beating on other residents and staff; they [DON] does not care. The DON does not care, she shows no empathy towards the residents. Resident #3 stated he knows nothing will be done, but he felt good voicing his concerns and advocating for the residents.Interview on 04/06/26 at 2:12 P.M. with certified nurse aide (CNA) #22 revealed the DON was in her office alone, and Resident #3 requested to talk with her. Resident #3 was treated horrible by the DON. The DON asked staff to tell him she left the building because she didn't want to hear from him. Review of facility policy titled Resident Dignity and Respect dated 04/17/17 revealed it is the policy of the facility that all resident be treated with kindness, dignity and respect in recognition that they are provided a homelike environment. Staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as a human being. Schedules of daily actives will allow maximum flexibility for residents to exercise choice about what they will do a d when they will do it. Resident individual preferences regarding such things as menus, clothing, religious activities, are elicited and respected by the facility.

Based on observation, resident interview, staff interview, resident council minute review, grievance review, review of call light audits, record review, facility assessment review and facility policy review the facility failed to maintain sufficient levels of staff to meet the total care needs of all residents. This had the potential to affect all residents residing in the facility. The census was 52.Findings include: 1.On 03/30/26 at 5:55 A.M. the survey team entered the facility to conduct the annual recertification survey and complaint investigation. There were four licensed nurses and five certified nurse aides (CNA) on duty to provide care for 52 residents currently residing in the facility.Review of the Facility assessment dated [DATE] revealed the total number needed or average or range Daily Staffing Numbers included the following Nursing Positions: 4 licensed nurses providing direct care, 13 nurse aides, 3 other nursing personnel.The General Staffing Plan to ensure sufficient staff to meet the needs of residents at any given time included: 1 DON RN full time days, ADON to equal one FTE, MDS RN full time Days, RN/LPN Charge Nurse : 2 for each shift, Direct Care Staff: 1:12 ratio days (total licensed or certified), 1:12 ratio evenings, 1:20 ratio nights.Individual Staff Assignment stated: The IDT will meet to discuss staffing levels or particular staff needed to care for current census meet in QOC, QAPI and daily Nurse Manager Meeting.Review of facility policy titled Resident Dignity and Respect dated 04/17/17 revealed it is the policy of the facility that all residents be treated with kindness, dignity and respect in recognition that they are provided with a homelike environment. Staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as a human being. Schedules of daily activities will allow maximum flexibility for residents to exercise choice about what they will do and when they will do it. Resident individual preferences regarding such things as menus, clothing, religious activities, are elicited and respected by the facility.2. The following resident concerns were lodged during the survey related to facility staffing: a. On 03/30/26 at 8:29 A.M until approximately 8:43 A.M., interview with Resident #3 (also the resident council president) revealed the call light responses are an issue and residents have waited a long time for assistance because staffing is short. Resident #3 stated he requires mechanical lift assistance for transfers; he has a nice new electric wheelchair, but he cannot get into it due to there isn't enough staff to help him. Resident #3 stated he is in his chair maybe once a week, he would really enjoy being in it at least two to three days if possible. Resident #3 stated he is the resident council president, and he has missed resident council meetings due to inadequate staff to get him into his chair. b. On 03/30/26 at 10:36 A.M. interview with Resident #50 revealed the facility is seriously understaffed and call lights are not responded to for 45 minutes to two hours. c. On 03/30/26 at 1:25 P.M. interview with Resident #1 revealed there were not enough staff. It has taken up to two hours for staff to answer the call light because there are not enough nurses or aides. Call lights are not answered timely. Resident #1 stated he is in the facility for therapy due to weakness and needs assistance with daily activities.d. On 03/31/26 at 8:33 A.M., interview with Resident #10 revealed the residents do not have enough staff especially certified nurse aides (CNA)'s on nightshift. Resident #10 has had to wait up to 30 minutes for someone to answer their call light, especially nightshift. Resident #10 stated she has had to pull the bedpan out from under herself due to sitting on it for so long waiting on staff to come and assist her. Resident #10 stated the bedpan is painful to be on for too long.e. On 03/31/26 at 9:23 A.M. interview with Resident #24 revealed staffing is short. Resident #24 stated she has to wait a long time for assistance. Sometimes staff run in and give an excuse and a list of what they need to do, it makes her feel less important. Some of the things that get put off include going to the bathroom, if she doesn't get help soon enough [the resident requires assistance with transferring and walking to the bathroom] she becomes incontinent, it makes her feel less than. The incontinence is causing her legs and vaginal area to become raw and painful. The staffing issue is with nurses and aides, basically all the time but, at night is the worst, Resident #24 stated she does not get the care she is supposed to receive.3. The following staff concerns were lodged during the survey related to facility staffing: a.On 04/02/26 at 9:41 P.M. interview with CNA #685 revealed it was the expectation of an aide to do eight resident showers per shift. CNA #685 stated the aides would do as many as they could, however it was almost impossible to get all of the resident showers done with all of the other responsibilities and resident needs they had to meet throughout a shift. Per CNA #685 there were usually only three aides on day shift, and it was the only place she had ever worked where you were told not to shower someone who required a mechanical lift, even though they had a lift chair which was new in the shower room. She had heard Resident #30 tell CNA #115 she wanted a shower, but the other aide told the resident she did not have time, and she just washed her hair. b. On 04/02/26 at 12:40 P.M., interview with CNA #700 revealed she never felt they had enough staff to meet resident needs. CNA #700 stated, in fact two extra people were added to the schedule at 2:00 P.M. today because surveyors are here. c. On 04/06/26 at 1:22 P.M., interview with Registered Nurse (RN) #390 stated it was her expectation call light response should be five minutes or less. If it was greater than 10 minutes she should follow up to see why (examples would be staff on their phones, assisting other residents, if nurses were helping, etc.). RN #390 verified there were 16 residents that required the use of a mechanical lift and that takes two staff at a minimum. d. On 04/06/26 at 2:20 P.M., interview with CNA #340 revealed she did not believe the facility had enough staff. She was concerned because the residents were not getting the care they needed. Residents were not even able to get showers, and she felt the residents deserved better than that.e. On 04/06/26 at 2:03 P.M. an interview by phone with Anonymous Staff Member #2222 revealed resident care is not timely or quality, when it gets done. One night the DON came in due to short staffing of nurses, and slept in her office, she told staff State requires a certain number of Registered Nurses to be in the building.f. On 04/09/26 at 10:44 A.M. with RN #30 revealed staffing was bad. You [the staff nurse] were expected to do so much, it could affect the residents and their care. Management kept adding more and more tasks to the floor staff. RN #30 stated the facility would have residents on ventilators with no respiratory therapy, there were so many residents with wounds, it was dangerous. The residents needed more staff, a better system, and better management.4. During the onsite survey, concerns were identified residents were not provided with routine showers/baths and ADL care. This concern was correlated to a lack of staff as noted per the interviews above. a. Review of medical record for Resident #65 revealed he was admitted to the facility on [DATE] with diagnoses that included acute osteomyelitis of the left ankle and foot, type two diabetes mellitus with foot ulcer, repeated falls, pain in left and right hip and major depressive disorder.Review of the Minimum Data Set (MDS) assessment version 3.0 dated 02/13/26 revealed a Brief Interview for Mental Status (BIMS) score of 12 on a 0-15 scale. A score of 12 would indicate the resident had moderate problems with thinking and memory. The MDS further revealed the resident needed partial/moderate assistance with bathing, lower body dressing, and toileting. Review of the care plan indicated the resident needed assistance from staff to meet ADL needs and was initiated 01/14/26. The goal was for the resident to participate in self-care to his/her maximum capacity. Interventions included assisting the resident with bathing as needed, per resident's preferences. It also indicated the resident had inappropriate behaviors such as being non-compliant, and staff was to provide support and encouragement while allowing resident to make choices with daily care when possible. The resident had impaired cognition with occasional forgetfulness, and staff were to assist with ADLs, and explain all treatments and procedures to the resident.Review of paper shower sheets for the month of March 2026 revealed Resident #65 refused showers on 03/03/26, 03/07/26, 03/17/26, 03/24/26, 03/27/26,and 03/28/26. There was no documentation that indicated interventions to encourage or explain need for ADL assistance to the resident.Review of the electronic bath task documentation from 01/14/26 through 03/30/26 revealed Resident #65 had shower assistance on only two occasions, 01/27/26 and 02/02/26. On 04/07/26 at 2:30 P.M., an interview with Resident #65 revealed he wanted to get showered, however he had to have the wounds covered on both of his legs. He had a device he had been given by the wound clinic for his right leg but needed the staff to cover his left lower leg as well. He reported every time he asked for the staff to cover both, he would be told they did not have time, so he just told them, Never mind. He would just wipe off if he needed to.On 04/07/26 at 2:37 P.M., an interview with Assistant Director of Nursing (ADON) #140 revealed Resident #65 always refused shower assistance. She reported she had tried numerous times. She was not sure why no one would apply the shower devices for him because they knew he needed them. b. Medical record review revealed Resident #1 was admitted on [DATE] with diagnoses including diabetes mellitus, malignant neoplasm of right lower bronchus or lung, generalized anxiety disorder, obstructive sleep apnea, asthma, chronic obstructive pulmonary disease, weakness and a urinary tract infection. Review of the modified admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact for daily decision-making, required maximum assistance with bathing/showering and required moderate assistance with personal hygiene. Review of the care plan: Needs Assistance from Staff to meet ADL needs related to decreased mobility, diagnoses and impaired cognition dated 02/18/26 revealed interventions including to assist Resident #1 with bathing as needed per resident's preference. Review of the medical record for Resident #1 revealed a Nurse Practitioner (NP) progress note dated 02/27/26 that identified Resident #1 had acute urinary incontinence due to being too weak to get up to bathroom at this time. The resident has been experiencing incontinence of urine due to waiting for staff to assist her to the bathroom. The NP encouraged the resident to avoid late night drinking, keep Depends clean, dry. The resident was encouraged to notify staff when (incontinence) brief is wet and do not wait for staff to check. Clotrimazole 1% ointment (antifungal medication) was ordered to be applied twice a day.Review of the undated Shower Schedule Book revealed Resident #1 was scheduled for a dayshift shower on Monday, Wednesday and Friday. Review of the paper Shower/Bath Sheets and electronic Bath Task documentation dated 02/13/26 through 04/06/26 revealed Resident #1 was not provided a shower/bed bath as scheduled on 03/02/26, 03/11/26, 03/16/26, 03/18/26 or 03/20/26. On 03/30/26 at 1:25 P.M., interview with Resident #1 stated she does not always receive showers as scheduled and had only received one shower last week. Resident #1 stated she was to receive her showers on Monday, Wednesday and Fridays and needed staff to complete as she could not do it by herself. At the time of the interview, observation revealed Resident #1 was sitting up in her room and was covered with a light blanket. The resident's hair appeared greasy, uncombed and a body odor was noted. On 04/07/26 at 11:18 A.M., interview with Registered Nurse #751 verified Resident #1 bathing/showers were not provided as scheduled during March 2026. c. Review of the medical record for Resident #18 revealed an admission date of 04/28/25. Diagnoses included sepsis, dysphagia, pneumonitis due to inhalation of food and vomit, unspecified asthma with exacerbation, acute respiratory failure, dyspnea, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified right bundle-branch block, obesity, unspecified protein-calorie malnutrition, major depressive disorder, insomnia, generalized anxiety disorder, repeated falls, and personal history of transient ischemic attack and cerebral infarction without residual deficits.Review of a Minimum Data Set (MDS) version 3.0 for Resident #18 dated 03/12/26, revealed the resident had a Brief interview Mental Status (BIMS) score of 15 on a 0-15 scale. A score of 15 indicated the resident was cognitively intact. The MDS further indicated that the resident required partial assistance from another person to complete any activities. She used both a manual wheelchair and walker for ambulation and required partial to moderate assistance with bathing/showering and dressing. Review of a care plan for Resident #18 dated 03/23/26 revealed a focus of care for assistance from staff to meet ADL (activities of daily living) needs. The goal was for resident to remain clean, dry and odor free. Interventions included assisting with hair care, oral care, dressing, and bathing using resident choice, as needed.Review of electronic bathing and showering tasks in medical record for Resident #18 revealed from 03/07/26 through 04/07/26, the resident was assisted with a shower on 03/15/26, 03/31/26, and 04/01/26. Shower sheets for the resident were only available for 03/04/26 and indicated the resident was assisted with shower set up.On 03/30/26 at 10:26 A.M., an interview with Resident #18's spouse revealed he was there all of the time and assisted the resident with all of her care. He did not feel the staff did enough to assist his wife with her ADLs.On 04/07/26 at 7:57 A.M., an interview with the Administrator confirmed shower sheets and tasks for Resident #18. 5. During the onsite survey, review of the facility Call Light Audit reports revealed the following concerns.a. During the time period of 03/06/26 and 03/13/26, residents had activated their call lights with responses exceeding 30 minutes, 19 times. For those 19 times the call lights were activated, the shortest response time was 37 minutes, and the longest response time was 144 minutes. This deficiency represents non-compliance investigated under Complaint Number 2809745.

Based on observation, interview, and sampled test tray the facility failed to ensure food was served at appropriate and palatable temperatures and was appetizing. This affected three residents (Resident #3, #11 and #39) of three residents. The facility census was 52. Findings include: Interview on 03/30/26 at 8:47 A.M. with Resident #03 revealed the kitchen runs out of food sometimes. By the time your meal is delivered it is cold, it took a long time for trays to come out and be delivered.Observation on 04/07/26 at 11:03 A.M. of temperatures for lunch items from the steam table revealed mashed potatoes were 131 degrees Fahrenheit and ready for meal service. This was confirmed by Dietary [NAME] #440.Observation on 04/07/26 at 11:57 A.M. revealed Resident #39 was served lunch in her room, and had selected pizza. Resident #39's pizza was 132 degrees Fahrenheit, checked with a facility food thermometer by Certified Nursing Assistant(CNA) #485. Resident #39 stated the food was always cold by the time it was delivered to her room. CNA #485 confirmed the cold food served to residents at times. Observation on 04/07/26 at 12:02 P.M. revealed Resident #11's lunch tray was delivered to their room. The serving temperature was taken of the vegetable medley by CNA #485 and the thermometer read 110 degrees Fahrenheit. After taking a bite of the vegetable medley, Resident #11 stated the veggie medley was cold and did not taste good. Interview on 04/07/26 at 12:16 P.M. with CNA #485 revealed a lot of the residents complain of the food being cold. For residents who choose to eat in their rooms, the aides can only take four trays out at a time, and its sporadic across the building (not one hall at a time), so they have to run to different halls and deliver four trays, go back to the kitchen get four more and so on. CNA #485 stated this was the way the Director of Nursing (DON) told them to do meal times and delivery, but it takes so long. The CNA verified the meal trays were delivered late because the four meal trays at a time, is very disorganized.On 04/07/26 at 12:20 P.M. in the dining room, a test lunch meal tray was delivered to the surveyor. The bottom of the dinner roll was wet from the juice of the vegetable medley, making the roll soggy and with an unappetizing presentation. Upon tasting the vegetable medley, some vegetables were mushy and other vegetables were still frozen in the center. The medley had no flavor. CNA #485 verified the findings.On 04/07/26 at 1:07 P.M. interview with Dietary Supervisor #315 revealed dietary averaged 30 room trays during each meal time and the DON told them to put any four trays on a beverage cart for delivery, at a time, and after those four trays were delivered, the CNAs would return to the dining room, obtain four more trays and continue until all meal trays for those dining in their rooms, were delivered. The Dietary Supervisor said the dietary department tried to sort the trays the first few days (send out four trays on the same unit at a time to prevent the aides having to go back and forth, through the building with other residents' trays on the cart) but the DON told them to stop sorting the trays as that was not the way the facility was to deliver meal trays. The Dietary Supervisor stated the meal trays have been served this way for about a month and described it as chaotic and hard on the residents, CNAs and dietary staff. The supervisor continued and said the meal tray delivery process was more efficient and food stayed warmer when they had the larger warming shelf carts but those carts were removed from the facility. When asked why the warming shelf carts were removed from the facility, the Corporate Dietary Director said it wasn't the [NAME] way.Review of facility policy titled Menu and preferences revised 12/17/24 revealed food and drink items will be served attractive, palatable, and at safe and appetizing temperatures. Review of facility policy titled food preparation revealed dietary staff will ensure that all foods are held at appropriate temperatures greater than 135 degrees for holding hot foods.This deficiency represents noncompliance investigated under Complaint Number 2961570.

Based on observation, interview, and policy review the facility failed to store food in a manner to prevent contamination and spoilage. The facility also failed to ensure staff wore appropriate hair restraints while in the kitchen. This had the potential to affect all residents in the facility. The census was 52.Findings include: Observation on 03/30/26 at 6:00 A.M. revealed a dietary aide with no hair restraint in place, standing at the kitchen steam table. Dietary Assistant Manager #430 verified the dietary aide was not wearing a hair restraint and stated they did not have any in the kitchen for the surveyor and would have to get some from supply. Observation on 03/30/26 at 6:10 A.M. revealed an opened package of sliced pepperoni, not sealed or dated, located in a silver stand up refrigerator, and hard boiled eggs, not sealed or dated. Observation of the walk in cooler revealed five bags of un-opened carrots with an expiration date on 03/05/26. Observation of the freezer revealed an opened package of hash browns, not sealed or dated.On 03/30/26 at 6:20 A.M. interview with Assistant Dietary Manager #430 confirmed the items identified in the fridge, cooler and freezer were either expired, or not dated and properly sealed to prevent spoilage and/or contamination.Review of facility policy titled use of hair nets revised 07/31/14 revealed all personnel will wear hair nets and/or hats in the kitchen and/or serving area for sanitary purposes.

Based on observation, medical record review, policy review and interview, the facility failed to maintain the privacy of residents. This affected four residents (#27, #49, #45, and #65) of 52 residents reviewed for privacy. The facility census was 52 residents. Findings include: 1.An observation on 04/01/26 at 12:19 P.M. revealed Resident #27, #45, and #49 were sitting in the dining area near the nurse's station of the facility. Also present in the dining area were several dietary staff and multiple other residents who were lingering in the dining area following lunch. Nurse Practitioner (NP) #758 was observed talking with Resident #27, #49, and #45. She used her stethoscope over their clothing on their chests. This was confirmed by Assistant Director of Nursing (ADON) #140 at the time of the observation. On 04/01/26 at 12:24 P.M., an interview with ADON #140 confirmed NP #758 was assessing residents in a public area. She agreed this did not protect the privacy of Residents #27, #45, and #49 and assessments should take place in a private area. On 04/01/26 at 12:25 P.M., an interview with NP #758 confirmed she had completed her initial assessment of the residents in the dining area. She did not feel anyone could overhear her conversation with each resident, but acknowledge there were others in the general area of the residents she was assessing. Review of a facility policy titled Dignity and Respect, updated 04/17/17, revealed the facility would treat all residents in full recognition of their right to dignity and respect. The policy indicated residents should be examined and treated in a manner to maintain the privacy of their bodies. A closed door or drawn curtain would shield the resident. 2. Medical record review revealed Resident #65 was admitted on [DATE] with diagnoses including diabetes mellitus and osteomyelitis of the left foot and ankle. Review of the electronic Physician Orders dated March 2026 revealed Resident #65 was ordered blood glucose monitoring prior to meals and administer Humalog (insulin) 5 units sq with meals and per sliding scale. Review of the electronic MAR revealed Resident #65 was administered 5 units of scheduled Humalog insulin and 4 units of sliding scale humalog insulin during the lunch meal on 03/30/26 for a blood glucose of 216. On 03/30/26 at 11:33 A.M., observation revealed Resident #65 was seated at a table in the main dining room with other residents eating his lunch. Staff were observed delivering meal trays, assisting residents with feeding and bringing residents out to the dining room. Registered Nurse (RN) #955 was observed walking towards the Resident #65's table and told him she needed to check his blood glucose. RN #955 used a lancet (needle) to expel a blood sample for the glucose monitoring machine as the resident was observed eating bread stuffing covered with gravy and a glass of milk. On 03/30/26 at 11:49 A.M., RN #955 was observed administering an insulin pen injection to Resident #65's right arm while at the dining room table. RN #955 was not observed asking the resident to go to a private area for glucose testing or administration of insulin. On 03/30/26 at 1:42 P.M., interview with RN #955 verified she completed a blood glucose test and administered insulin to Resident #65 during the lunch meal at the table in the main dining room. RN #955 verified she administers medications including injections in the dining room and the resident seemed to be okay with it. On 03/30/26 at approximately 3:30 P.M. interview with RN #751 verified glucose monitoring and insulin administration should be completed in a private area. RN #751 verified Resident #65''s privacy was not maintained. 3. On 04/02/26 at 8:01 A.M., observation of a medication cart positioned across the hallway from the Director of Nursing office revealed the electronic Medication Administration Record was open and residents due to be administered medications were observed including their pictures, names and room numbers. At the time of the observation, the director of nursing (DON) was informed of the medication cart and came out of her office to close the screen and turn the nurses' report sheet over to protect resident information. The DON verified the screen was to be closed or covered when not in the nurses direct view. On 04/02/26 at 8:05 A.M., interview with RN #385 verified she left the electronic medication administration screen open exposing resident information. Review of the policy: IIB1: Administration Procedures for All Medications dated 07/01/21 revealed privacy was to be provided for residents during administration of medications and secure (cover) records that contained protected health information including Medication Administration Records and Treatment Administration Records.

Based on observation, interview, and policy review, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly and comfortable interior which was neat and well kept. This affected six residents (#4, #7, #44, #54, #55, and #57) of 52 residents reviewed for a safe, clean, comfortable homelike environment. The facility census was 52.Findings include: On 03/30/26 at 10:57 A.M., an observation of Resident #54 and #55's room, revealed blue carpeting which had multiple white stains, a brownish-red stain, and tears/snags at the entryway to the room and scattered throughout the room. The stained and snagged areas could be viewed from the hallway. On 03/30/26 at 10:59 A.M., an interview with certified nurse aide (CNA) #115 revealed the facility had several rooms with stained, torn/snagged and dirty carpets which were not well kept (including the room of Resident #54, #55). She reported someone had tried to bleach them to clean them, and that was what had caused the stains. She reported it was mostly the rooms which still had blue carpet, because most of the other rooms had wooden floors.On 03/30/26 at 12:50 P.M., observations of the rooms for Resident #44, #57, #54, #55, #4, #7 revealed blue carpeting which was stained, torn/snagged and not well kept. All of these could be viewed from the hallway. At the time of the observation, the condition of the carpeting was confirmed by Regional Maintenance Director (RMD) #1500. During the observation, RMD #1500 confirmed the carpeting of these rooms all needed replaced, and he believed it was in the facility capital plan for 2026. He thought one of the stains on the floor appeared to be feces and not an actual stain, and the carpet of the room needed cleaned as soon as possible.Review of a facility policy titled 5 Step Resident Room Cleaning Procedure, dated 10/2019, revealed a policy to ensure resident rooms were cleaned and disinfected. The policy failed to reveal a process to clean and maintain the carpeting of resident rooms.This deficiency represents noncompliance investigated under Complaint Number 2961570.

Based on record review, observation, policy review and interview, the facility failed to provide activities of daily living (ADLs) for residents who needed assistance. This affected seven residents (#65, #55, #30, #7, #18, #51 and #1) of seven residents reviewed for ADLs. The facility census was 52.Findings include: 1. Review of medical record for Resident #65 revealed he was admitted to the facility on [DATE] with diagnoses that included acute osteomyelitis of the left ankle and foot, type two diabetes mellitus with foot ulcer, repeated falls, pain in left and right hip and major depressive disorder. Review of the Minimum Data Set (MDS) assessment version 3.0 dated 02/13/26 revealed a Brief Interview for Mental Status (BIMS) score of 12 on a 0-15 scale. A score of 12 would indicate the resident had moderate problems with thinking and memory. The MDS further revealed the resident needed partial/moderate assistance with bathing, lower body dressing, and toileting. Review of the care plan indicated the resident needed assistance from staff to meet ADL needs and was initiated 01/14/26. The goal was for the resident to participate in self care to his/her maximum capacity. Interventions included assisting the resident with bathing as needed, per resident's preferences. It also indicated the resident had inappropriate behaviors such as being non-compliant, and staff was to provide support and encouragement while allowing resident to make choices with daily care when possible. The resident had impaired cognition with occasional forgetfulness, and staff was to assist with ADLs, and explain all treatments and procedures to the resident. Review of paper shower sheets for the month of March 2026 revealed Resident #65 refused showers on 03/03/26, 03/07/26, 03/17/26, 03/24/26, 03/27/26,and 03/28/26. There was no documentation that indicated interventions to encourage or explain need for ADL assistance to the resident. Review of the electronic bath task documentation from 01/14/26 through 03/30/26 revealed Resident #65 had shower assistance on only two occasions, 01/27/26 and 02/02/26. On 04/07/26 at 2:30 P.M., an interview with Resident #65 revealed he wanted to get showered, however he had to have the wounds covered on both of his legs. He had a device he had been given by the wound clinic for his right leg, but needed the staff to cover his left lower leg as well. He reported every time he asked for the staff to cover both, he would be told they did not have time, so he just told them never mind. He would just wipe off if he needed to. On 04/07/26 at 2:37 P.M., an interview with Assistant Director of Nursing (ADON) #140 revealed Resident #65 always refused shower assistance. She reported she had tried numerous times. She was not sure why no one would apply the shower devices for him because they knew he needed them. 2. Review of the medical record for Resident #55 revealed an admission date of 04/30/25. Diagnoses included Parkinson's disease without dyskinesia, fall on same level, muscle weakness, chronic pain, major depressive disorder, and dementia. Review of a MDS dated [DATE] for Resident #55 revealed he used a wheelchair for ambulation and was dependent for all ADLs. Review of a care plan for Resident #55, last reviewed 02/04/26, revealed the resident needed assistance from staff to meet ADL needs and would participate in self-care to his/her maximum capability. Staff would assist the resident with bathing as needed, per resident's preference. Review of the undated Shower Preference book revealed the resident had a preference for showers during the day time three times per week on Monday, Wednesday and Friday. Review of paper shower sheets and electronic bathing task for the month of March 2026 for Resident #55 revealed he was bathed on his preferred day on 03/04/26, 03/20/26, and 03/23/26. He was showered on 03/04/26, and 03/24/26. On 03/30/26 at 10:57 A.M., an observation revealed Resident #55 was up in wheelchair, hair was disheveled and dirty appearing. His clothing was soiled. The condition of the resident was confirmed by Certified Nurse Aide (CNA) #715 at the time of observation. 3. Review of the medical record for Resident #30 revealed an admission date of 03/31/21. Diagnoses included unspecified dementia with other behavioral disturbance, generalized anxiety disorder, psycho-physiologic insomnia, unspecified mood disorder, weakness, history of falling, dysphagia oropharyngeal phase, hyperlipidemia; age-related osteoporosis, unspecified osteoarthritis, essential hypertension, major depressive disorder, vitamin D deficiency, muscle weakness and difficulty walking. Review of the Minimum Data Set (MDS) version 3.0, dated 03/13/26, for Resident #30 revealed a Brief Interview for Mental Status (BIMS) score of 7 on a 0-15 scale. A score of 7 would indicate severe problems with thinking and memory. Per the MDS, the resident required a wheelchair for ambulation, and was dependent for all activities of daily living (ADLs). Review of a care plan dated 03/23/26 revealed Resident #30 required assistance from staff to meet activities of daily living (ADL) needs related to decreased mobility, depression, arthritis, history of left tibia and femur fracture, and osteoporosis. The goal was for the resident to participate in her maximum capacity. Interventions included mealtime assistance, hair care, incontinent care, oral care, assisting with toileting as needed, assist with transfers using a mechanical lift for all transfers, assist with clothing, and bathing as needed per resident preference. Review of Resident #30's preferences listed on the demographics page of the electronic medical record indicated the resident preferred an early morning shower versus a bed bath, three times weekly. Review of the undated Shower Preference book documented Resident #30 preferred showers Sunday, Tuesday and Thursday. Review paper shower sheets for the month of March 2026 for Resident #30 revealed the resident was given a bed bath on 03/01/26, 03/03/26, 03/15/26, and 03/29/26. Documentation did not specify if the resident received a bed bath or a shower on 03/05/26, 03/08/26, 03/10/26, 03/12/26, 03/17/26, 03/22/26, and 03/26/26. 4. Review of medical record for Resident #7 revealed an admission date of 09/29/25. Diagnoses included osteomyelitis of vertebra, lumbar, epistaxis, venous insufficiency, morbid obesity due to excess calories, moderate protein-calorie malnutrition, chronic respiratory failure with hypoxia, generalized anxiety disorder, delirium due to known physiological condition, depression, Alzheimer's disease with early onset, essential hypertension, paroxysmal atrial fibrillation, dermatophytosis, superficial mycosis, insomnia, muscle weakness, retention of urine, nausea, constipation, and pain. Review of a Minimum Data Sheet (MDS) version 3.0 for Resident #7, dated 12/31/25, revealed a Brief Interview for Mental Status (BIMS) score of 12 on a 0-15 scale. A BIMS score of 12 indicated moderate problems with thinking and memory. The MDS also indicated the resident required a walker or wheelchair for mobility. He required partial to moderate assistance with showering, and supervision for dressing. Review of a care plan for Resident #7 revealed a focus of care for activities of daily living (ADLs). The goal was for the resident to remain clean, dry and odor free. Interventions were to include assistance with hair care, oral care, toileting, clothing, shaving and bathing as needed. On 03/30/26 at 9:00 A.M., an interview, and observation, with Resident #7 revealed he could not shower in his room because the floor gets too slippery. The resident stated he does not always get to shower when he would like to. The resident was hoping someone was coming shortly to get him to the shower room. The resident appeared disheveled and his shirt was dirty. 5. Review of the medical record for Resident #18 revealed an admission date of 04/28/25. Diagnoses included sepsis, dysphagia, pneumonitis due to inhalation of food and vomit, unspecified asthma with exacerbation, acute respiratory failure, dyspnea, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified right bundle-branch block, obesity, unspecified protein-calorie malnutrition, major depressive disorder, insomnia, generalized anxiety disorder, repeated falls, and personal history of transient ischemic attack and cerebral infarction without residual deficits. Review of a Minimum Data Set (MDS) version 3.0 for Resident #18 dated 03/12/26, revealed the resident had a Brief interview Mental Status (BIMS) score of 15 on a 0-15 scale. A score of 15 indicated the resident was cognitively intact. The MDS further indicated the resident required partial assistance from another person to complete any activities. She used both a manual wheelchair and walker for ambulation, and required partial to moderate assistance with bathing/showering and dressing. Review of a care plan for Resident #18 dated 03/23/26 revealed a focus of care for need of assistance from staff to meet ADL (activities of daily living) needs. The goal was for resident to remain clean, dry and odor free. Interventions included assisting with hair care, oral care, dressing, and bathing using resident choice, as needed. Review of electronic bathing and showering tasks in medical record for Resident #18 revealed from 03/07/26 through 04/07/26, the resident was assisted with a shower on 03/15/26, 03/31/26, and 04/01/26. Shower sheets for the resident were only available for 03/04/26 and indicated the resident was assisted with shower set up. On 03/30/26 at 10:26 A.M., an interview with Resident #18's spouse revealed he was there all of the time and assisted the resident with all of her care. He did not feel the staff did enough to assist his wife with her ADLs. On 04/07/26 at 7:57 A.M., an interview with the Administrator confirmed shower sheets and tasks for Resident #18. The Administrator indicated she thought the Assistant Director of Nursing (ADON) #140 was working on the issue to document reasons for refusals. 6. Review of the medical record for Resident #51 revealed an admission date of 11/01/25. Diagnoses included acute systolic congestive heart failure, chronic obstructive pulmonary disease, type two diabetes mellitus with diabetic polyneuropathy, low back pain, muscle weakness, fall on same level, fatigue, hypertension, obesity, peripheral vascular disease, and longstanding persistent atrial fibrillation. Review of a Minimum Data Set (MDS) version 3.0 dated 03/04/26 for Resident #51 revealed the resident required a wheelchair for mobility, and partial to moderate assistance for bathing/showering. Review of a care plan for Resident #51 revealed a focus of care of need for assistance to meet activities of daily living (ADL) needs, with a goal to remain clean, dry and odor free and participate in self care to his maximum capacity. Interventions included assisting with meal time, ambulation, hair care, oral care, toileting, transfers, bed mobility, clothing, shaving, bathing and care of glasses as needed. Review of the undated Shower Preference book documented Resident #30 preferred day shift showers on Sunday, Monday and Thursday. Review of paper shower sheets revealed the resident refused a shower on 03/05/26 and opted for a bed bath because the shower was offered too close to Bingo. A shower was documented on 03/12/26, and a bed bath on 03/19/26. There were no other documented baths/showers for this resident on the paper shower sheets. Review of the electronic bath/shower tasks for the month of March 2026 for Resident #51 revealed the resident received a bed bath on 03/05/26 and 03/19/26. He last received a shower on 03/12/26. The last documented bath or shower for Resident #51 for the month of March was 03/19/26. On 03/30/26 at 10:26 A.M., during observations and interview, Resident #51 reported it had been four weeks since he had been in the actual shower. He would love nothing more than to get in the shower. He reported all staff did was wash up his groin area and thought that was ok. He felt like he was not getting clean and that made him uncomfortable. The resident appeared disheveled and his shirt was soiled with what appeared to be dried food stains. An interview with CNA #685 on 04/02/26 at 9:41 A.M. revealed it was the expectation an aid do eight showers per shift. They would do as many as they could, however it was almost impossible to get all of those done with all of the other responsibilities and resident needs they had to meet throughout a shift. There were usually only three aides on day shift, and it was the only place she had ever worked where you were told not to shower someone who required a mechanical lift, even though they had a lift chair which was new in the shower room. She had heard Resident #30 tell CNA #115 she wanted a shower, but the other aide told the resident she did not have time, and she just washed her hair. She could not recall when this occurred. An interview with CNA #700 on 04/02/26 at 12:40 P.M. revealed she never felt they had enough staff to meet resident needs. CNA #700 stated, in fact two extra people were added to the schedule at 2:00 P.M. today because surveyors are here. An interview with CNA #340 on 04/06/26 at 2:20 P.M. revealed she did not believe the facility had enough staff. She was concerned because she felt the residents were not getting the care they needed. Residents who were asking were not even able to get showers, and she felt the residents deserved better than that. On 04/13/26 at 9:32 A.M., an interview with Registered Nurse (RN) #956 confirmed residents of the facility were not getting showered or bathed per their preference, and it appeared from what she could see that activities of daily living (ADLs) were not being completed as ordered or needed to keep residents clean, dry and odor free as noted in their care plans. 7. Medical record review revealed Resident #1 was admitted on [DATE] with diagnoses including diabetes mellitus, malignant neoplasm of right lower bronchus or lung, generalized anxiety disorder, obstructive sleep apnea, asthma, chronic obstructive pulmonary disease, weakness and a urinary tract infection. Review of the modified admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #1 was cognitively intact for daily decision-making, required maximum assistance with bathing/showering and required moderate assistance with personal hygiene. Review of the care plan: Needs Assistance from Staff to meet ADL needs related to decreased mobility, diagnoses and impaired cognition dated 02/18/26 revealed interventions including to assist Resident #1 with bathing as needed per resident's preference. Review of the undated Shower Schedule Book revealed Resident #1 was scheduled a dayshift shower on Monday, Wednesday and Friday. Review of the paper Shower/Bath Sheets and electronic Bath Task documentation dated 02/13/26 through 04/06/26 revealed Resident #1 was not provided a shower/bed bath as scheduled on 03/02/26, 03/11/26, 03/16/26, 03/18/26 or 03/20/26. On 03/30/26 at 1:25 P.M., interview with Resident #1 stated she does not always receive showers as scheduled and had only received one shower last week. Resident #1 stated she was to receive her showers on Monday, Wednesday and Fridays and needed staff to complete as she could not do it by herself. At the time of the interview, observation revealed Resident #1 was sitting up in her room and was covered with a light blanket. The resident's hair appeared greasy, uncombed and a body odor was noted. On 04/07/26 at 11:18 A.M., interview with Registered Nurse #751 verified Resident #1 bathing/showers were not provided as scheduled during March 2026. Review of the policy: ADL's revised 03/04/26 revealed support was to be provided to meet care deficits related to ADL needs including the ability to bathe. A resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal hygiene and oral hygiene. The facility was to maintain individual objectives of the care plan and periodic review and evaluation. This deficiency represents non-compliance investigated under Complaint Number 2809223, 2809745 and 2961570.

Based on record review and interview, the facility failed to ensure physician ordered parameters were followed related to medication administration. This affected five residents (Resident #9, Resident #42, Resident #55, Resident #7, and Resident #5) of six reviewed for unnecessary medications. The facility census was 52. Findings include:1.Review of medical record revealed Resident #9 was admitted on [DATE]. Diagnoses included secondary Parkinsonism, anxiety disorder, type two diabetes without complications, essential hypertension, bipolar disorder, chronic pain, schizoaffective disorder, history of falling, vascular dementia and muscle weakness. Review of the care plan for Resident #9 revealed the resident had cardiac impairment related to hypertension, hyperlipidemia, and hypotension, initiated 08/21/24. The goal was for the resident to have cardiac conditions treated per nursing staff and physician interventions. Interventions included obtaining vital signs as ordered and as needed and reporting any medication side effects to the physician. Review of the Minimum Data Set (MDS) version 3.0, dated 01/21/26 revealed a Brief Interview for Mental Status (BIMS) score of 14 on a 0-15 scale. A score of 14 indicated the resident had intact cognitive functioning. The MDS indicated the resident took antipsychotics, antidepressants, diuretics, hypoglycemics, and anticonvulsants. Review of an orders for Resident #9 revealed an order for Midodrine 5mg (milligrams) Give 10 mg by mouth three times daily for hypotension. Monitor blood pressure (bp) daily, hold Midodrine for systolic blood pressure (SBP) greater than 120. Review of Midodrine administration record for the month of March 2026 revealed the morning dose of Midodrine was administered when the SBP was greater than 120 on 03/22/26 in the morning, on 03/07/26, 03/10/26, and 03/15/26 in the afternoon, and 03/28/26 in the evening. The dose was held when the SBP was less than 120 on 03/09/26 and 03/23/26 in the morning, on 03/05/26, 03/08/26, and 03/22/26 in the afternoon, and 03/08/26, 03/15/26, and 03/27/26 in the evening. 2. Review of the medical record for Resident #42 revealed an admission date of 01/27/26. Diagnoses included cerebrovascular disease, epilepsy, multiple sclerosis, sepsis and pneumonia. Review of an orders for Resident #42, dated 01/27/26, revealed an order for Midodrine which read Midodrine HCL tablet 5mg Give one tablet by mouth three times a day for hypotension. Hold if SBP greater than 110. Reveal of the Medication Administration Record for March 2026 revealed Resident #42 was administered Midodrine on 03/10/26, 03/16/26, 03/24/26, and 03/28/26 in the morning, on 03/02/26, 03/16/26, and 03/24/26 in the afternoon, and on 03/16/26, 03/08/26, 03/11/26, 03/23/26, 03/27/26, 03/28/26, 03/29/26, and 03/30/26 when the SBP was greater than 110. The medication was held on 03/02/26 in the morning, on 03/02/26, 03/03/26, 03/08/26, and 03/26/26 in the afternoon, and on 03/02/26 in the evening when the SBP was lower than 110. 3. Review of medical record for Resident #55 revealed an admission date of 04/30/26. Diagnoses included Parkinson's disease without dyskinesia, fall on same level, muscle weakness, essential hypertension, spinal stenosis, major depressive disorder, generalized anxiety, auditory hallucinations, and dementia in other diseases classified elsewhere, moderate with other behavioral disturbance. Review of a care plan for Resident #55 revealed a cardiac impairment related to a diagnosis of hypertension. The goal was for the resident not to have cardiac complication and to have cardiac conditions treated per nursing staff and physician interventions. Staff was to observe for medication side effects and report to the physician, and to obtain vital signs as ordered. Review of orders for Resident #55 revealed a Midodrine order dated 12/22/25. The order read Midodrine HCL Oral Tablet 10mg Give 10mg by mouth two times a day for hypotension. Give only if systolic less than 100 and diastolic less than 60. Review of a Medication Administration Record for Resident #55 revealed Midodrine was administered to the resident twice on 03/03/26, in the evening on 03/04/26, twice on 03/05/26, in the morning on 03/06/26, in the evening on 03/08/26 and 03/09/26, twice on 03/12/26, in the evening on 03/13/26, in the morning on 03/14/26, in the evening on 03/17/26, in the morning on 03/23/26, twice on 03/24/26 and 03/25/26, in the evening on 03/26/26, in the morning on 03/27/26, and twice on 03/31/26 when the SBP was greater than 100 and the Diastolic Blood Pressure (DBP) was greater than 60. 4. Review of medical record for Resident #7 revealed an admission date of 09/29/25. Diagnosis included osteomyelitis of vertebra, lumbar, epistaxis, venous insufficiency, morbid obesity due to excess calories, moderate protein-calorie malnutrition, chronic respiratory failure with hypoxia, generalized anxiety disorder, delirium due to known physiological condition, depression, Alzheimer's disease with early onset, essential hypertension, paroxysmal atrial fibrillation, dermatophytosis, superficial mycosis, insomnia, muscle weakness, retention of urine, nausea, constipation, and pain. Review of orders for Resident #7 revealed an order dated 12/10/25 for Midodrine. The order read Midodrine HCL Oral Tablet 10mg. Give one tablet orally three times a day for hypotension. Hold is systolic blood pressure greater than 110. Review of a Minimum Data Sheet (MDS) version 3.0 for Resident #7, dated 12/31/25, revealed a Brief Interview for Mental Status (BIMS) score of 12 on a 0-15 scale. A BIMS score of 12 indicated moderate problems with thinking and memory. Review of the Medication Administration Record for Resident #7 revealed the resident was administered Midodrine three times on 03/03/26, in the evening on 03/05/26, in the morning and afternoon on 03/06/26, in the afternoon on 03/08/26, in the morning and evening on 03/12/26, in the evening on 03/13/26, in the morning and afternoon on 03/14/26, in the morning on 03/15/26, in the afternoon on 03/16/26, in the evening on 03/17/26, in the morning on 03/21/26, in the evening on 03/24/26, in the morning on 03/25/26, and in the morning and evening on 03/31/26 when the SBP was greater than 110. It was held in the afternoon of 03/28/26 when the SBP was less than 110. 5. Review of the medical record for Resident #5 revealed an admission date of 01/16/26. Diagnoses included but were not limited to peripheral vascular disease, hyperkalemia, muscle weakness, pain, essential hypertension, chronic obstructive pulmonary disease, and sepsis. Review of orders for Resident #5 revealed an order for Midodrine. The order read Midodrine HCL Oral Tablet 2.5mg Give six tablets by mouth three times a day. Hold for SBP greater than 101. Review of a Medication Administration Record (MAR) for Resident #5 revealed the resident was administered Midodrine in the morning on 03/03/26, in the evening on 03/05/26, in the morning and afternoon on 03/06/26, three times on 03/12/26, in the evening on 03/13/26, in the morning on 03/15/26, in the morning and evening on 03/17/26, in the afternoon on 03/18/26, in the morning and evening on 03/24/26, in then evening on 03/25/26 and 03/26/26, and in the afternoon on 03/27/26 when the SBP was greater than 101. It was held in the evening on 03/03/26 when the SBP was lower than 101. On 04/13/26 at 3:05 P.M., an interview with RN #956 confirmed there were five residents at the facility who took Midodrine. In review of the medication administration and accompanying vital signs, she confirmed there were multiple times throughout the month each resident had been given the medication when the vital sign parameters were not being met. Review of a facility policy titled Specific Medication Administration Procedures, dated 2006, revealed the purpose of the policy was to administer medications in a safe and effective manner. The policy indicated, when applicable, the nurse was to obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration. The policy further indicated held medication for pulse, blood pressure, low or high blood sugar, or other abnormal test results or vital signs which resulted in medications being held, the physician or prescriber should be notified.

Based on observation, review of the facility diet list, interview, and review of facility policy the facility failed to ensure food was prepared in accordance with the physician ordered diet consistency. This had the potential to affect six residents (Resident #11, #14, #30, #43, #53 and #55) who had physician ordered pureed diets. The census was 52.Findings include:Observation of pureed rice for lunch on 04/07/26 at 11:06 A.M. revealed the rice was in the warming table. Dietary Supervisor #315 verified the pureed rice was ready for the lunch meal, and the surveyor and Dietary Supervisor #315 taste tested a sample of the pureed rice. The rice was gritty in texture and had large clumps. The rice was not smooth like puree consistency was expected.On 04/07/26 at 11:07 A.M. interview with Dietary Supervisor #315 verified the rice was not the correct consistency for puree which should be smooth and without lumps.Review of the facility diet list revealed six residents (Resident #11, #14, #30, #43, #53 and #55) had physician orders for pureed diet consistency.Review of facility policy titled therapeutic diets revised 01/22/25 revealed a therapeutic diet is considered a diet ordered by a physician, practitioner, or dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet.This deficiency demonstrates noncompliance investigated under Complaint Number 2961570.

Based on record review and interview, the facility failed to provide and implement a comprehensive influenza and pneumonia vaccination program including education, assessment and documentation related to the immunizations. This affected five residents (Resident #5, #30, #65, #18 and #1) of five reviewed for immunizations. The facility census was 52. Findings include:1.Review of the medical record for Resident #5 revealed an immunization record which indicated she was administered a flu vaccination on 10/09/25, Pneumococcal Virus Vaccine (PCV) on 01/23/25. There were no consents on the resident's record which would cover these dates. This was confirmed by Registered Nurse (RN) #956 on 04/13/26 at 3:00 P.M. Review of the medical record for Resident #5 revealed a form titled 2024-2025 Influenza (Flu) vaccine form. The form was signed by Resident #5 on 01/08/26. The health screening on the form to determine if the resident was eligible for the vaccination was incomplete, the date of the vaccination information statement (VIS) being provided to the resident was left blank, and it was marked the resident refused the vaccination at that time. This was confirmed by RN #956 on 04/14/26 at 3:00 P.M. 2. Review of the medical record for Resident #30 revealed an immunization record which indicated she was administered the influenza vaccination on 10/23/25, the pneumococcal vaccination on 02/02/25. There were no consents on the resident record which would cover these dates. This was confirmed by RN #956 on 04/14/26 at 3:00 P.M. Review of a form titled pneumococcal vaccine informed consent dated 01/07/26 and indicated a verbal consent by Resident #30. The document did not indicate any medical contraindications or personal reasons for declining the vaccination. It contained only an x indicating the resident declined the immunization. This was confirmed by RN #956 on 04/14/26 at 3:00 P.M. Review of a form titled 2024-2025 influenza (flu) vaccination form dated 01/07/26 revealed the resident declined the vaccine. It had a verbal consent by Resident #30. The health screening was not completed. There was no documentation of the resident receiving education or information regarding the influenza vaccination. This was confirmed by RN #956 on 04/14/26 at 3:00 P.M. 3. Review of the medical record for Resident #65 indicated he had refused all vaccinations. Review of a form titled pneumococcal vaccine informed consent dated 01/013/26 and signed by Resident #65. The document did not indicate any medical contraindications or personal reasons for declining the vaccination. It contained only an x indicating the resident declined the immunization. This was confirmed by RN #956 on 04/14/26 at 3:00 P.M. Review of a form titled 2024-2025 influenza (flu) vaccination form dated 01/13/26 revealed the resident declined the vaccine. It was signed by Resident #65. There was no documentation of the resident receiving education or information regarding the influenza vaccination. This was confirmed by RN #956 on 04/14/26 at 3:00 P.M. 4. Review of the medical record for Resident #18 indicated she had refused all vaccinations. Review of a form titled pneumococcal vaccine informed consent dated 01/08/26 and signed by Resident #18. The document did not indicate any medical contraindications or personal reasons for declining the vaccination. It contained only an x indicating the resident declined the immunization. This was confirmed by RN #956 on 04/14/26 at 3:00 P.M. Review of a form titled 2024-2025 influenza (flu) vaccination form dated 01/08/26 revealed the resident declined the vaccine. It was signed by Resident #18. There was no documentation of the resident receiving education or information regarding the influenza vaccination. This was confirmed by RN #956 on 04/14/26 at 3:00 P.M. Review of a facility policy titled Influenza and pneumococcal vaccine Policy revised 01/20/20 revealed a policy to provide guidelines and indications for Influenza and Pneumonia vaccinations. The policy indicated all admitted residents would be assessed for pneumococcal vaccine status upon admission. If residents did not have proof of previous pneumococcal vaccination, the Center for Disease Control recommended one dose pf pneumonia vaccine if the resident consented. Educational material would be provided to the resident so an informed decision could be made. Annually, the resident or resident representative should be re-educated on influenza and given the opportunity to consent or refuse the vaccination. Residents refusing pneumococcal vaccine must be offered the vaccine annually. Influenza immunizations would be offered annually beginning in the fall when the vaccination was available. All new admissions would be assessed for flu vaccine and receive according to policy. 5. Medical record review revealed Resident #1 was admitted on [DATE] with diagnoses including metastatic right bronchus/lung cancer, obstructive sleep apnea, asthma, diabetes mellitus and pneumonia. Review of the medical record revealed a 2024-2025 Influenza (Flu) Vaccine Form dated 02/13/26. Review of the vaccine form revealed the screening questions were blank and not completed. The form indicated the resident refused and there was no signature by the resident or responsible party. The Director of Nursing signed the form. On 04/07/26 at 11:15 A.M., interview with Registered Nurse (RN) #751 verified the screening questions were not completed for Resident #1's Flu Vaccine. RN #751 stated the Director of Nursing that completed the forms was not available to answer questions about why the forms were not completed or signed by the resident and/or representative.

Based on record review, interview and policy review the facility failed to ensure a comprehensive COVID-19 vaccination program was implemented related to education and documentation of administration /refusal for four residents (Resident #5, #18, #30, and #65) of five residents reviewed for vaccination status and failed to ensure evidence of staff vaccination and education related to COVID-19 vaccination status was maintained. The facility census was 52.Findings include:Findings include: 1.Review of the medical record for Resident #5 revealed an immunization record which indicated she was administered a Covid-19 vaccination on 01/20/25. There was no consent located on the record and the immunization record did not indicate if the vaccine was administered at another location. Further review of the medical record for Resident #5 revealed a form titled 2024-2025 Formula Covid-19 Vaccine Form. The form was signed by Resident #5 but undated and only her name was written at the top of the form. The health screening on the form to determine if the resident was eligible for the vaccination was incomplete, the date of the vaccination information statement (VIS) provided to the resident was blank, and it was marked the resident refused the vaccination at that time. This was confirmed by (Registered Nurse (RN) #956 on 04/14/26 at 3:00 P.M. 2. Review of the medical record for Resident #30 revealed an immunization record which indicated she was administered the Covid-19 vaccination on 01/29/25. There was no consent found in the medical record. This was confirmed by RN #956 on 04/14/26 at 3:00 P.M. Review of the medical record for Resident #30 revealed a form titled 2024-2025 Formula Covid-19 Vaccine Form. The form was blank except for the resident's name and a check mark indicating she declined the vaccination. The health screening questions were incomplete. The note at the bottom indicated a verbal consent by Resident #30 and was dated 01/07/26. The health screening on the form to determine if the resident was eligible for the vaccination was incomplete, the date of the vaccination information statement (VIS) being provided to the resident was left blank, and it was marked the resident refused the vaccination at that time. This was confirmed by RN #956 on 04/14/26 at 3:00 P.M. 3. Review of the medical record for Resident #65 revealed an immunization record which indicated he had refused all vaccinations. Review of the medical record for Resident #65 revealed a form titled 2024-2025 Formula Covid-19 Vaccine Form. The form was signed by Resident #65 dated 01/13/26. The date of the vaccination information statement (VIS) being provided to the resident was left blank, and it was marked the resident refused the vaccination at that time. This was confirmed by RN #956 on 04/14/26 at 3:00 P.M. 4. Review of the medical record for Resident #18 revealed an immunization record which indicated she had refused all vaccinations. Review of the medical record for Resident #18 revealed a form titled 2024-2025 Formula Covid-19 Vaccine Form. The form was blank except for the resident's name and a check mark indicating she declined the vaccination. The health screening questions were incomplete. The note at the bottom indicated the resident's initials and was dated 01/08/26. The health screening on the form to determine if the resident was eligible for the vaccination was incomplete, the date of the vaccination information statement (VIS) being provided to the resident was left blank, and it was marked the resident refused the vaccination at that time. This was confirmed by RN #956 on 04/14/26 at 3:00 P.M. 5. Evidence of COVID-19 vaccination being offered to the staff was requested but not provided. On 04/13/26 at 2:49 P.M., an interview with Certified Nursing Assistant (CNA) #115 revealed the facility had no evidence of offering COVID-19 vaccinations to employees. There had been a binder holding this information at the facility, however no one had been able to locate the binder. This was confirmed at the time of the interview by the Assistant Director of Nursing. This information was not maintained in the personnel files. Review of a policy titled [NAME] Management/Monarch Covid Vaccination Policy revised 04/07/23 revealed a policy to reduce the presence and severity of COVID-19 cases in the healthcare setting, workplace, community and the nation as a whole through vaccination. Residents would be offered the COVID-19 vaccine/booster as recommended by the Centers for Disease Control and Prevention. Educational material would be provided to the resident or representative at the time of the offering. All declinations would be documented in the medical record. Facility staff would receive education regarding risk and benefits of the vaccine as well as resources to obtain the vaccine.

Based on observation, interview and record review, the facility failed to maintain the dignity of a resident by leaving her pants pulled down while she was in bed. This affected one resident (#30) of three residents reviewed for dignity. The facility census was 52.Findings include:Review of the medical record for Resident #30 revealed an admission date of 08/22/22. Diagnoses included unspecified dementia with other behavioral disturbance, generalized anxiety disorder, psycho-physiologic insomnia, unspecified mood disorder, weakness, history of falling, muscle weakness and difficulty walking. Review of the Minimum Data Set (MDS) version 3.0, dated 03/13/26, for Resident #30 revealed a Brief Interview for Mental Status (BIMS) score of 7 on a 0-15 scale. A score of 7 would indicate severe problems with thinking and memory. Per the MDS, the resident required a wheelchair for ambulation, and was dependent for all activities of daily living (ADLs). On 03/30/26 at 12:35 P.M., an observation of Resident #30 revealed she was lying in bed. She had on boots to protect her heels on each foot. Her pants were pulled down around the boots. Certified nurse aide (CNA) #700 confirmed at time of observation. On 03/30/26 at 12:35 P.M., an interview with CNA #700 revealed Resident #30's pants were kept down when she was in bed. This was done so the resident did not get her pants wet while lying in bed if she was incontinent and her brief would leak. It also would be easier to pull up the resident's pants when they get her up later, rather than leaving the pants on and having to do multiple clothing changes. The CNA verified this would make movement difficult for the resident and could pose a fall risk in addition to not being a dignified way for the reside to lie in bed. This process was confirmed by CNA #115 who was also present at the time of the observation.Review of a facility policy titled Dignity and Respect, updated 04/17/17 revealed the facility would treat all residents in full recognition of their right to dignity and respect. Staff should display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as a human being. Privacy of the resident's body should be maintained during toileting, bathing and other activities of personal hygiene.

Based on interview, policy review, and record review, the facility failed to notify residents of a change in Medical Director or provide residents with a choice of physician and failed to ensure a resident had the right to choose how their diabetes mellitus was managed. This affected two residents (#3, #9) . The census was 52.Findings include:Findings include: 1.On 04/01/26, Review of the medical record for Resident #9 revealed the physician of record had changed from 03/31/26. The physician of record on 03/31/26 had been Medical Doctor #750. On 04/01/26, the physician of record was noted to be MD #1122. This was confirmed by the Director of Nursing on 04/01/26 at 12:10 P.M. Review of a document titled Medical Director Agreement dated 01/19/26 and signed by all parties on 02/02/26 revealed MD #1122 would be contracted effective 01/19/26 as the Medical director for the facility. DON #540 confirmed this document on 04/01/26 at 12:38 P.M. and indicated it was effective 04/01/26. Review of an electronic communication dated 02/20/26 at 11:22 A.M., which included an attachment which could not be visualized, revealed the Administrator asked the recipient to please see attached letter to send out for Dover with billing. There was no evidence to indicate this letter was sent or the date it was sent to the residents or their representatives. This was confirmed by the Administrator during an interview on 04/01/26 at 1:18 P.M. Review of an undated letter to residents revealed the following: Dear Resident/Representative, I am writing to inform you of a change that we have made in regards to our Medical Director. As of 04/01/26, [MD #750] will no longer be the Medical Director. He will be replaced by [MD #1122]. This decision was not made lightly and we anticipate a smooth transition. The letter was signed by the Administrator. The Administrator confirmed this letter during interview on 04/01/26 at 1:18 P.M. An interview with the Administrator on 04/01/26 at 1:18 P.M. revealed she had asked for the letter advising of the change in Medical Director to be sent out to residents with the March billing statements. She did not know the date which the statements were sent, and could not confirm the letters had actually been sent to residents. She confirmed the new Nurse Practitioner had begun to see residents on 04/01/26. She did not believe the residents or their representative had been asked if they wanted to continue with the new practitioners or choose a practitioner of their own. On 04/02/26 at 2:35 P.M., an interview with Resident #9 revealed she was not aware her physician had changed. Indicated she had seen a new lady talking to people, but was not sure who she was. On 04/13/26 at 10:10 A.M., an interview with Registered Nurse (RN) #956 revealed when the Medical Director was changing at the facility, the residents were not given a choice to change or keep their current physician, and were automatically changed to reflect the new medical director as their physician of record. She indicated she confirmed this was a miscommunication between Administrator #725 and the [NAME] President of Operations (VPO) #957. 2. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, type two diabetes, major depressive disorder, anxiety, and acute and chronic respiratory failure with hypoxia and hypercapnia. Review of Resident #3 physician orders revealed an order for NovoLog (Insulin Aspart) pen subcutaneous solution cartridge 100 units/ milliliter (ML) to be given per sliding scale subcutaneously before meals. Review of Resident #3's orders revealed an order for NovoLog (Insulin Aspart) injection solution 100 units/ML, inject 14 units subcutaneously with meals for diabetes mellitus. Review of Resident #3's quarterly minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) score of 15. The resident received hypoglycemic medication. Review of Resident #3's medical record including progress notes revealed no documentation of the resident being notified of discontinuation of their continuous blood glucose monitoring sensor. There was no documentation of a rationale as to why the the resident's continuous blood glucose monitoring sensor was being discontinued. There was no documentation of the resident being given a choice of care related to blood glucose monitoring related to diabetes mellitus. Interview on 03/30/26 at 9:02 A.M. with Resident #3 revealed the Director of Nursing (DON) came around and took away his Libre (continuous blood glucose monitoring sensor). Resident #3 stated he was not told why this happened, she [DON] just came in one day and said the facility wasn't using them anymore, she didn't give him any other choice. Resident #3 stated now he has to get his finger poked multiple times a day, and it hurts, it hurts through the day and now his fingers are getting calluses. The blood glucose sensor monitored his blood sugar continuously, now they have to get a finger stick multiple times a day and only know their blood sugar when staff completes the manual blood glucose finger stick. Interview on 04/12/26 at 10:43 A.M. with Corporate Clinical Director #956 confirmed there was no documentation of residents or representatives being notified of the discontinuation of the continuous blood glucose monitoring sensors. Corporate Clinical Director #956 confirmed there was no evidence of an investigation regarding accuracy of the continuous blood glucose monitoring sensors versus the glucometers. Corporate Clinical Director #956 stated she is unsure why or when the continuous monitors were removed from residents or who made the decision to do so. Interview on 04/13/26 at 9:10 A.M. with Assistant Director of Nursing (ADON) #390 revealed the majority of residents who require blood glucose monitoring receive finger stick blood sugars at least four times a day, before meals and at bedtime, if not more. ADON #390 stated the DON discontinued the continuous blood glucose monitoring sensors due to inaccuracy. ADON #390 stated she was unsure if there was any testing to determine if the sensors were inaccurate, or to determine if it was the glucometers or continuous sensors that were inaccurate. ADON #390 confirmed there was no documentation they are aware of, of residents or their representative being notified of the discontinuation of the continuous blood glucose monitoring sensors. Review of facility policy revised 03/01/26 titled Diabetes Management revealed the purpose of the policy is to ensure safe, effective, and person centered diabetes management in accordance with the Ohio Department of Health licensure rules and federal long term care regulations. The facility will identify, monitor, treat, and reassess residents with diabetes through an individualized interdisciplinary approach designed to maintain glycemic stability, prevent complication, and promptly address changes in condition. Review of the facility admission packet revealed the resident agrees to be under the medical care of a licensed physician of the resident's choice. Each resident has the right to choose the medical director as his/her physician , but is not required to do so.

Based on record review, interview, policy review, and review of electronic communication, the facility failed to provide residents, families, and/or resident representatives with an explanation in advance, in writing, describing why a room or roommate reassignment took place. This affected two residents (#65, #52) of two residents reviewed for room change. The facility census was 52.Findings include:1.Review of the medical record for Resident #65 revealed he was admitted to the facility on [DATE] with diagnoses that included acute osteomyelitis of the left ankle and foot, type two diabetes mellitus with foot ulcer, repeated falls, pain in left and right hip and major depressive disorder. Review of a care plan for Resident #65, last updated 03/30/26 revealed a focus of care for behavioral concerns including inappropriate language, yelling out and making growling sounds. The goal was for the resident to have no episodes of inappropriate behavior. Interventions were to include providing support and encouragement and allow the resident to make choices with daily care when possible. Review of a facility document titled Concern Form dated 03/19/26 revealed resident had filed a grievance with Social Service Designee (SS) #275 indicating concern for themselves and the surrounding neighbors related to Resident #65.Resident #65 was noted as being loud at all times and was always yelling and barking. The document indicated no group discussion was held and SS #275 moved Resident #65, who had been in room [ROOM NUMBER] to room [ROOM NUMBER] on 03/19/26. There was no indication that notification or follow up with Resident #65 took place. Review of a facility document titled Resident Room Change form dated 03/19/26 revealed Resident #65 was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on 03/19/26 at 7:16 A.M. The document indicated Resident #65 was notified on 03/19/26 of the move and was adjusting to new room. The document was completed by SS #275, and was not provided to Resident #65 as it was an internal document. On 04/16/26 at 2:48 P.M., review of electronic communication from the Administrator confirmed there was no notification in writing given to Resident #65 regarding his room change. On 04/16/26 at 4:10 P.M., an interview with SS #275 revealed she did not provide Resident #65 with written notice in advance of moving him. She reported that on 03/19/26 at 7:16 A.M., Resident #65 was eating breakfast and she told him his room needed to change because we needed to move someone else into his room. She reported she had worked at the facility since 06/2025 and residents had never been given written notice of room change. 2. Review of a facility document titled Action Summary and dated 03/31/26 at 2:17 P.M. revealed Resident #52 had a room change on 03/11/26 from room [ROOM NUMBER]-A to room [ROOM NUMBER]-A at 6:31 A.M. The resident also had a room change on 03/20/26 at 8:56 P.M. from room [ROOM NUMBER]-A to room [ROOM NUMBER]-A at 8:56 P.M. There was no documentation provided to the resident to explain either room change. The facility's failure to provide Resident #52 with notification regarding the room changes was confirmed by electronic communication from the Administrator on 04/16/26 at 4:56 P.M. Review of a facility policy titled Room/Roommate and dated 11/01/16 revealed since residents would share space with others, the facility would notify the resident and/or residents of a room change and/or roommate change using a prepared document. The document attached was titled Notice of Room or Roommate Change. It included informing the resident they were to move or would receive a new roommate, the reason for the room and/or roommate change, and an orientation to the new room and situation. It required a resident and staff signature. This policy was confirmed by electronic communication with the Administrator on 04/16/26 at 4:56 P.M. At that time she further confirmed Resident #65 and Resident #52 did not receive this document.

Based on closed medical record review, policy review, and interview, the facility failed to ensure advanced directives were accurately documented per resident wishes. This affected one resident (#28) of three residents reviewed for death. Findings include:Closed medical record review revealed Resident #28 was admitted on [DATE] with diagnoses including a left hip fracture, metabolic encephalopathy, anxiety and heart failure. Review of paper and electronic medical record revealed the following Advanced Directives for Resident #28:a. The electronic Physician Orders revealed Resident #28's was a Full Code starting on [DATE] through [DATE]. b. The paper medical record revealed a signed Full Code form dated [DATE]. c. The paper medical record revealed DNR Comfort Care-Arrest (DNRCCA) form dated [DATE] was signed by the residents spouse, the physician's name was printed on the DNR form but not signed. The date signed indicated the year was '2029'.d. The hospice provider faxed to the facility on [DATE] a DNR Comfort Care (DNRCC) form that was signed at the time hospice services were elected. The DNRCC form was dated [DATE]. Review of Resident #28's code status care plan dated [DATE] and discontinued [DATE] revealed the resident was a Full Code and to provide CPR (cardiopulmonary resuscitation). On [DATE] at 12:09 P.M., interview with Registered Nurse (RN) #751 verified Resident #28's paper medical record had a DNRCC-A code status that was signed by the spouse of the resident (misdated for 2029) but not the physician, and both an electronic and a signed paper Full Code status form dated [DATE]. RN #751 stated Resident #28's hospice company sent over a signed DNRCC Form today ([DATE]) indicating the resident had elected a DNRCC code status as of [DATE]; however, this had not been transcribed or ordered at the facility until [DATE]. Review of the policy: Advance Directives dated [DATE] revealed the facility will provide each resident with information regarding the right to make his/her own decision about medical care and the right to sign an advance directive. The resident's right to determine a DNR/Full Code status with be honored and may change their decision about a DNR or Advance Directive at any time. The above information will be reviewed at least quarterly in the care plan meeting.

Based on medical record review, beneficiary notice review, and interview, the facility failed to issue beneficiary notices as required. This affected one resident (#43) of three residents reviewed for liability notices. The census was 52. Findings include: Medical record review revealed Resident #43 was admitted on [DATE] with diagnoses including cerebral vascular accident, hypertension and neurogenic bladder. Resident #43 was discharged from therapy on 01/28/26 and discharged home on [DATE]. Review of the record revealed no beneficiary notice was issued to Resident #43. Review of the Social Service Note/Narrative dated 01/29/26 revealed Resident #43 discharged home on this day with home health services and no medical equipment was needed upon discharge. The resident's son was to transport the resident and was supplied with a medication list, discharge summary, discharge notice and a reminder of scheduled appointments. Review of Resident #43's Occupational Therapy (OT) Notes revealed the following:a. On 01/19/26, Resident #43 required assistance for hygiene/grooming tasks for fingernail care and shaving. Resident #43 had an aide while at home that assists with these tasks. The Certified Occupational Therapy Assistant (COTA) spoke with Resident #43 and his son in regards to setting up a home assessment which was scheduled for 01/21/26 at 12:30 P.M b. On 01/21/26, Resident #43 completed functional mobility tasks at stand by assist level with standby assist (SBA) and completed car transfer training to/from son's truck with SBA/caregiver assist level. Resident #43 had all needed equipment for home going. OT recommended home health services/therapy and alert system. COTA collaborated with son and rehabilitation manager regarding discharge date . Plan for discharge home on [DATE]. Resident had an aide six days a week for two hours a day who completed housework, assisted with ADL's and prepared meals. c. On 01/28/26, Resident #43 was able to stand for 10 minutes and 10 seconds using a front wheeled walker (FWW) for support and completed functional transfers with SBA using FWW and grab bars. Resident #43 was assessed with dressing tasks and was able to demonstrate the ability to complete upper extremity dressing set up to don a pull over shirt and lower extremity dressing was completed with SBA with minimum verbal cues for management of catheter while using walker for support when standing. Resident #43 was able to don/doff non-skid socks and shoes with set up. Resident #43 was discharged from OT on this date with plans to return home on [DATE]. On 04/06/26 between 10:30 A.M. to 10:42 A.M. interview with Social Service Designee (SSD) #275 stated she did not think Resident #43 needed a liability notice issued because he initiated the discharge by wanting to go home. SSD #275 verified therapy completed a home visit and completed what was needed to safely discharge the resident; however, since the resident wanted to go home, she did not think a liability notice was required. On 04/08/26 at 8:36 A.M., interview with Therapy Manager #753 verified Resident #43 had been a planned discharge that the therapy team had been working towards over several weeks in January 2026. States he had met his goals and was discharged from therapy services prior to the planned discharge. Therapy Manager #753 stated he did not leave against medical advice and had not ran out of skilled days when discharged from therapy services.

Based on observation, record review, and policy review, the facility failed to ensure a pressure ulcer was comprehensively assessed and treatment orders were obtained timely for Resident #28 to prevent the further decline of an identified in-house obtained pressure ulcer.Actual Harm occurred on 12/12/25 when Resident #28, who had moderately impaired cognition, and was at risk for pressure ulcer development, developed a new, in-house acquired left buttock pressure ulcer. The ulcer was first assessed as an open area without proper prevention, treatment, and interventions implemented. This affected one resident (Resident #28) of three residents reviewed for pressure ulcers. The facility census was 56.Findings Include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included diabetes left buttock stage III (full thickness that extends into the fatty tissue but does not expose the bone or muscle) pressure ulcer, diabetic neuropathy, hyperlipidemia, adjustment disorder, hypertension, repeated falls, altered mental status, and atherosclerotic heart disease.Review of the care plan, dated 09/03/25, revealed Resident #28 needed assistance from staff for activities of daily living related to decreased mobility. Interventions included to assist the resident in ambulation as needed, assist the resident with incontinence care as needed, assist the resident with toileting as needed, assist the resident with transfers as needed, and assist the resident with bed mobility as needed.Review of the care plan, dated 09/03/25, revealed Resident #28 was at risk for skin breakdown related to decreased mobility, diabetes and incontinence. Interventions included encouraging turning and repositioning, staff to perform skin checks, assist resident with toileting as needed, and provide diet as ordered. New interventions included an air mattress to the bed dated 01/08/26 and a Roho cushion (a cushion used for pressure relief) for pressure relief dated 01/09/26.Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/13/25, revealed Resident #28 had moderately impaired cognition, required touching assistance for rolling side to side, required moderate assistance for transfers and ambulation, and did not have any pressure injuries.Review of the Braden Scale dated 11/28/25 revealed Resident #28 was at risk for pressure injuries.Review of the Weekly Skin Observation note dated 12/12/25 revealed Resident #28 had a new skin area to the right buttock. The area was reddened and hard to touch. It measured 0.5 centimeters (cm) in width.Review of the progress note dated 12/12/25 revealed Resident #28 had 0.5 (measurements were not noted) small open area to the right buttock. The area was hard and painful to touch. The area was cleaned and covered with a two-by-two border foam dressing. The area was reported to the Nurse Practitioner (NP) and the wound team; however, no treatment order was ever written.There was no further documentation of a right buttock pressure ulcer or treatments ordered or completed until 12/15/25.Review of the physician's orders dated 12/15/25 revealed Resident #28 received an order to cleanse the left (previously noted as the right) gluteal fold with normal saline (NS), apply triple antibiotic ointment, cover with a dressing, change twice a day and as needed and order doxycycline hyclate (an antibiotic) 100 milligrams (mg) twice daily for five days for wound care.Review of the Wound Care NP #300 note dated 12/18/25 revealed Resident #28 had an unstageable ulcer (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) that occurred due to prolonged pressure on a specific area of the skin, resulting in the lack of blood flow and oxygen to the tissue. It is a full thickness tissue loss where the depth of the wound or bed sore was completely obscured by eschar in the wound bed) pressure ulcer to the left buttock which measured 5.1 cm by 2.9 cm by an undetermined depth. The wound had 60 percent granulation (healthy tissue) and 40 percent slough (dead tissue), and scant drainage. Debridement was postponed due to the residents' high discomfort and pain concerns. A new order was received for Anasept gel (wound healing gel) and moist gauze daily.Review of the Progress Note dated 12/18/25 at 10:27 A.M., recorded as a late entry on 12/23/25 at 10:29 A.M. by Licensed Practical Nurse #110, revealed Resident #28 was seen by an unnamed Wound NP and received new orders to cleanse with normal saline, apply Anasept gel and a moist gauze, and apply a dry sterile dressing daily and as needed.Review of the physician's orders dated 12/22/25 revealed Resident #28 had an order for amoxicillin-potassium Clavulanate (an antibiotic) 875-125 mg twice daily for a bacterial infection to the left gluteal for seven days and a gel cushion to the resident's chair for preventative care.Review of the plan of care dated 12/23/25 revealed Resident #28 had an open area related to decreased mobility, diabetes, incontinence of bladder and bowel, and left buttock abscess. Interventions included administering medication as ordered, applying treatment to the area as ordered, encouraging the resident to turn and reposition, give supplements as ordered, and monitor for signs and symptoms of infection.Review of the physician orders dated 12/23/25 revealed the orders written on 12/18/25 were initiated, to cleanse with normal saline, apply Anasept gel and moist gauze, and apply a dry sterile dressing daily and as needed. Additionally, there was a new order for a wound culture to the left gluteal fold, and 30-gram protein shakes twice daily.Review of Resident #28's lab results revealed a wound culture was completed on 12/23/25 but there was no documentation obtained by the facility of what the wound culture results were.Review of the Wound Care NP #301 note dated 12/24/25 revealed Resident #28 had a Stage III pressure ulcer to the left buttock which measured 2.8 cm by 2.9 cm by 0.2 cm with 90 percent granulation and 10 percent slough, moderate drainage, and the wound was improving. Debridement was postponed due to the resident's high discomfort and pain concerns. A new order was given to apply Anasept gel and calcium alginate, and cover with a silicone bordered foam dressing daily was ordered with instructions that they may use Medi-honey gel until Anasept was available.Review of the physician's order dated 12/24/25 revealed Resident #28 received an order to cleanse the left buttock with normal saline, apply Anasept gel and calcium alginate with instructions to cover with a dry sterile dressing daily and as needed, though the Wound Care NP noted stated to cover with a bordered foam dressing.Review of the Wound Care NP #301 note dated 12/31/25 revealed Resident #28 had a Stage III left buttock pressure ulcer which measured 2.5 cm by 1.5 cm by 0.2 cm with undermining between 10 o'clock and 12 o'clock for a maximum depth of 0.3 cm. The wound had 90 percent granulation and 10 percent fibrin with moderate drainage. The wound was improved even though undermining was noted. It noted the wound would benefit from debridement though the resident declined. A new order was given to cleanse with normal saline, apply Mesalt and a silicone bordered foam dressing daily.Review of the physician's order dated 12/31/25 revealed Resident #28 received an order to cleanse the left buttock with normal saline, apply Mesalt dressing, and cover with bordered foam dressing daily and as needed.Review of the Wound Care NP #301 note dated 01/07/26 revealed Resident #28 had a Stage III left buttock pressure ulcer which measured 2.5 cm by 1.5 cm by 0.2 cm with undermining between 10 o'clock and 12 o'clock for a maximum depth of 0.3 cm. The wound had 100 percent granulation tissue with moderate drainage. There was no change in the treatment order.Review of the Wound Care NP #301 note dated 01/14/26 revealed Resident #28 had a Stage III left buttock pressure ulcer which measured 1.7 cm by 1.5 cm by 0.1 cm with undermining between 6 o'clock and 8 o'clock for a maximum depth of 0.2 cm. The wound had 100 percent granulation tissue with moderate drainage. Silver Nitrate was used to cauterize excess granulation tissue. There was no change in the treatment order.During an interview on 01/27/26 at 2:15 P.M., Resident #28 stated the nurses did not change her wound dressing daily. When asked why there was not a dressing on her wound at that time, Resident #28 stated it came off all the time and they did not replace it, even when she asked them to replace it. She stated she does not know how she got the wound but did say she sat in her high back chair in her room most of the time. She also stated the facility did get her a cushion for her chair.During an observation on 01/27/26 at 2:20 P.M., there was no dressing to Resident #28's pressure ulcer on the left buttock. Registered Nurse (RN) #107 verified at the time of the observation the dressing was not on the wound. RN #107 asked the resident where the dressing was, and the resident stated it fell off during the night. The nurse asked if the resident told anyone and the resident stated she told the previous nurse it was off, but she never replaced it. The wound was clean, the edges were well approximated but slightly reddened, and the wound bed was beef red with no observed slough. Additionally, for the completion of the dressing change, RN #107 placed the packaged dressing supplies and scissors on the resident's over-the-bed table without cleaning the over-the-bed table prior to placing the clean dressing supplies directly on the table with the residents personal items. The table was visibly soiled with a white substance. RN #107 then moved the resident's personal items off the over-the-bed table onto another table and moved the over-the-bed table in front of the bathroom door. RN #107 removed her gloves, washed her hands, redonned gloves and placed three paper towels from the bathroom dispenser on the over-the-bed table. She opened the dressings onto the paper towels on the over-the-bed table and placed the scissors directly on the table, not on the paper towels. She proceeded to clean the wound, remove her gloves, wash her hands, redonn gloves, open the Mesalt dressing, pick up the scissors from the dirty table, cut the Mesalt with the contaminated scissors and she applied it to the wound and covered it with the foam dressing.During an interview on 01/27/26 at 2:35 P.M. with RN #107 verified she had not cleaned the table prior to placing the paper towels on the table and she stated she had cleaned the scissor prior to the taking them to the room. However, she did verify she placed them directly on the soiled over-the-bed table.During an interview on 01/27/26 at 5:00 P.M., the Director of Nursing (DON) stated she had just taken over wound rounds at the facility. She stated Licensed Practical Nurse (LPN) #110 had been doing them prior to her. She stated she did not feel LPN #110 was assessing the wounds properly and comprehensively so that was why she took over. She verified at this time she believed the assessment on 12/12/25 indicating the right buttock was not corrected, and it should have been the left buttock because Resident #28 never had a wound or treatment orders to the right buttock. She also verified there were no treatment orders or interventions put into place until 12/15/25, three days after the wound was identified. She believed it was an abscess that opened but verified all the documentation stated it was a pressure ulcer.During an On 01/28/26 at 1:00 P.M., Resident #28 stated she had been suffering from some pain from her wound in the beginning, but it was not very bad. She stated she was able to tolerate it.During an interview on 01/28/26 at 1:30 P.M., LPN #110 stated he was previously the wound nurse for the facility up until about two weeks ago. He stated he usually completed his wound rounds on Wednesdays and Thursdays. He stated he also worked as the Assisted Living Wellness Director for the rest of the week. He stated he was notified of new skin concerns either by looking at the shower sheets or the wound tracking sheets at the nurse's station on the clip boards. He stated he would go to each nurse's station and look at those boards when he worked. He stated the right buttock documentation on 12/12/25 for Resident #28 was incorrect and it was always her left buttock.During an interview on 01/29/26 at 8:25 A.M., the Director of Nursing verified the wrong type of dressing was transcribed on 12/24/25. She verified it was supposed to be a silicone border foam dressing however the order was transcribed for a dry sterile dressing. She verified the Wound NP's order for 12/18/25 was not initiated until 12/23/25 for Anasept gel and moist gauze daily. She verified the facility never received the wound culture results. She stated she investigated the lab's result portal and it stated the lab received the results, however it never resulted. She stated she did not know if it was contaminated or what had happened, but they never received the results, and nobody followed up.Review of the policy titled Wound and Skin Care Program, undated, revealed any newly identified skin impairment will be reported to the nurse for assessment. Assessment findings will then be reported to the physician for treatment guidance and evaluation of further interventions. The policy stated the wound treatments/dressings will be supported by a physician order and wound dressing orders will be accompanied by a separate order for dressing monitoring to be conducted each shift. Review of the facility policy titled, Wound and Skin Care, dated 09/26/24 revealed the purpose was to ensure documentation, monitoring, and treatment of a dressing change. Step number three of the procedure stated to prepare a clean, dry work area at bedside and apply a barrier. Step six indicated to use clean or sterile scissors.

Based on record review, review of video camera footage, ambulance report, and hospital records, and interviews with residents, power of attorney, and staff, the facility failed to provide adequate assistance to prevent a fall for Resident #9 and failed to provide timely assistance following a fall for Resident #1. This resulted in Actual Harm on 09/28/23 when Resident #9, who required maximum assistance from two staff for bed mobility, fell from the bed while a staff member was providing incontinence care resulting in Resident #9 sustaining bilateral femur fractures. At the time of the incident, the facility failed to ensure staff had adequate training on the use of a low air loss and alternating pressure mattress to provide adequate assistance with incontinence care to the resident to prevent the fall with injury. This affected two residents (#1 and #9) of three residents reviewed for accidents. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #9 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation, morbid obesity, type II diabetes mellitus, and atrial fibrillation. Review of the physical therapy discharge summary dated 05/09/23 revealed Resident #9's current level of assistance required maximal assist of two staff for rolling left and right, sitting to lying, and lying to sitting. Review of the state tested nursing assistant (STNA) documentation from 07/29/23 to 08/03/23 revealed Resident #9 required extensive assistance of two staff for bed mobility, six out of the eight times bed mobility was documented. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact and required extensive assistance of two or more persons for bed mobility. Review of a nursing progress note dated 09/28/23 at 2:23 A.M. revealed Licensed Practical Nurse (LPN) #125 was called to Resident #9's room. Resident #9 was back in bed and LPN #109 was present when LPN #125 arrived. Resident #9 was crying when the left knee was touched. The left knee had an abrasion, edema, and light discoloration. Resident #9 requested an x-ray be done. Resident #9's power-of-attorney (POA) was contacted and requested Resident #9 be sent to the hospital. Resident #9 was transferred to the hospital on 09/28/23 at 1:45 A.M. Review of a fall scene investigation report dated 09/28/23 at 1:00 A.M. revealed Resident #9 was incontinent, in bed, and lowered by staff to the floor. A typed statement dated 09/28/23 by Licensed Practical Nurse (LPN) #109 revealed they heard staff call for assistance to Resident #9's room. Resident #9 was lying on the floor and had complaints of the pain lying on the floor. LPN #109 examined Resident #9's legs. Resident #9 was assisted back into bed. LPN #109 did not think Resident #9 was hurt due to STNA #141 stated Resident #9's feet were hanging out the left side of the bed and Resident #9's head was sliding out the right side of the bed so STNA #141 gently lowered Resident #9 to the floor. LPN #109 went to get Resident #9's nurse, LPN #125. A handwritten statement dated 09/28/23 by STNA #141 revealed Resident #9 had activated the call light. STNA #141 entered the room and found Resident #9 at a ninety-degree angle with the top part of Resident #9's body falling out of the side of the bed towards the window. STNA #141 pushed Resident #9 over and made the bed flat. STNA #141 messaged another STNA to come assist with Resident #9. STNA #141 went ahead and provided incontinence care while waiting for another STNA. STNA #141 rolled Resident #9 towards the door since Resident #9's body was in bed on the side by the window. When STNA #141 rolled Resident #9, Resident #9's feet and legs kept going out of the bed. STNA #141 called on the walkie/talkie for help as soon as possible (ASAP). STNA #141 held on to Resident #9 and jumped over the bed to lower Resident #9 onto the floor (Resident #9's knees were already on the floor). STNA #141 got Resident #9's legs out from under Resident #9 when other staff arrived at Resident #9's room. A written statement by LPN #125 revealed they heard STNA #141 call for help. LPN #109 and a STNA (unnamed) went to Resident #9's room. LPN #125 got the vital machine and went to Resident #9's room. LPN #109 came out of Resident #9's room and stated they thought Resident #9 should be sent to the hospital. Resident #9 was in bed and crying. Resident #9 would not let LPN #125 move or touch Resident #9's left knee. LPN #125 told Resident #9 they wanted to send Resident #9 to the hospital for evaluation. The facility's action plan summary revealed on 09/28/23, Resident #9 had a fall from bed during care. Resident #9 had a low air loss and alternating pressure mattress in place. Interviews revealed staff were unfamiliar with the use of the static feature (provides constant pressure redistribution and support allowing nursing to perform patient care) of the air mattress and the associated risk of falls during bed mobility while a low air loss and alternating pressure mattress was in place. On 09/28/23, only eleven of the 25 STNAs, four of the 11 LPNs and two of the seven registered nurses (RN) were provided education on the use of the static feature of the air mattress and associated risks of falls without the static feature being used. Review of the hospital discharge summary dated 10/02/23 revealed Resident #9 was transferred to Cleveland Clinic Akron General from Union hospital on 09/28/23 for treatment of injuries reportedly sustained during a fall at extended care facility. Resident #9 underwent extensive computed tomography (CT) and x-ray imaging which revealed bilateral distal femur fractures. Orthopedic surgery was consulted, given Resident #9's non-ambulatory status and multiple co-morbidities, non-surgical treatment with bilateral knee immobilizers during transfers was recommended. Review of the plan of care revealed Resident #9 was at risk for fall/injury. An intervention dated 11/09/23 revealed staff were to verify alternating pressure mattress was in static mode prior to assisting Resident #9 with bed mobility. Review of the STNA point-of-care (POC) shift dashboard dated 12/27/23 revealed Resident #9 required assistance with eating, bed mobility, toileting/incontinence care every two to three hours and as needed, and transferring with mechanical lift. The POC did not indicate how many staff were needed for each task. Interview of 12/27/23 at 6:55 P.M. with STNA #141 revealed Resident #9 was able to roll in bed with assistance and STNA #141 was providing incontinence care for Resident #9. The air mattress went flat on one side and Resident #9's legs went over the side of the bed. STNA #141 stated they jumped over the bed and lowered Resident #9 from being on their knees beside the bed to lying flat on the floor. STNA #141 stated everyone provided incontinence care for Resident #9 with just one STNA. STNA #141 stated therapy determined how many staff members were needed for care for each resident. STNA #141 stated they started working in February 2023 and were trained to provide care without assistance for Resident #9. STNA #141 verified the report sheets or POC did not show how much assistance each resident needed. STNA #141 verified the staff had reported to management several times over the last few weeks that the air mattress to Resident #9's bed was not working properly. Interview on 12/28/23 at 9:57 A.M. with the POA of Resident #9 revealed Resident #9 told the STNA they were slipping out of the bed. The POA felt two people should have been providing care due to Resident #9 requiring a mechanical lift for transfers and was not able to assist with most of the activities of daily living care provided. The POA felt the STNA was in a hurry and did not want to wait for another staff member to come assist with care and ended up rolling Resident #9 out of bed. Interview on 12/28/23 at 10:45 A.M. with Resident #9 revealed one STNA was providing care and kept pushing Resident #9 over until Resident #9 fell out of bed. Resident #9 stated two staff members were now required to provide care. Interview on 12/28/23 at 10:48 A.M. with Therapy Program Manager #151 revealed Resident #9 had physical therapy (PT) from 04/27/23 through 05/09/23. The PT discharge summary revealed Resident #9 was a maximum assist of two persons for bed mobility/rolling and for sitting to supine positioning. Interview on 12/28/23 at 1:07 P.M. with Corporate Clinical Director #500 verified after Resident #9 fell out of the bed, it was discovered that staff were not aware of the static feature on the air mattress pump to ensure adequate support while care was being provided to a resident. Corporate Clinical Director #500 verified there was not an order for the air mattress or to check proper function of the air mattress when Resident #9 fell out of bed. Corporate Clinical Director #500 stated if the STNA POC did not specify how many staff were needed for assistance, then only one person would be required. Corporate Clinical Director #500 verified the POC did not identify that two staff were needed for mechanical lift transfer, but the staff were aware that mechanical lifts always required two staff members. Corporate Clinical Director #500 was unable to provided manufacturer instructions or recommendations for the proper use of the air mattress. 2. Review of the medical record revealed Resident #1 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, acute myocardial infarction, neuromuscular dysfunction, spinal stenosis, type II diabetes mellitus, severe morbid obesity, and mood disorder. Review of the plan of care dated 04/04/23 revealed Resident #1 required assistance from staff to meet activities of daily living needs. Interventions included assisting with toileting, transfers, and bed mobility as needed. The plan of care dated 04/14/23 revealed Resident #1 was at risk of falls. Interventions included encouraging nonskid/gripper socks when shoes were off and staff to anticipate needs. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and had impairment to one side of lower extremities. Review of the weight history revealed on 11/08/23, Resident #1 weighed 389 pounds. Review of the facility's video camera footage dated 12/15/23 (observed on 12/26/23) revealed a staff member entered Resident #1's room on 12/15/23 at 10:38 A.M. Registered Nurse (RN) #107 was observed getting a vital machine and walking to Resident #1's room at 10:44 A.M. Emergency personnel arrived on 12/15/23 at 11:31 A.M. Resident #1 was transported to the hospital at 11:58 A.M. Review of the ambulance run report revealed a call was received on 12/15/23 at 11:25 A.M. The crew arrived at the facility at 11:29 A.M. Resident #1 reported right hip pain and was transported to the hospital at 11:58 A.M. Resident #1 arrived at the hospital at 12:00 P.M. The crew was delayed on scene for lift assist and additional personnel were sent to assist. Interview on 12/21/23 at 11:09 A.M. with Resident #1 revealed they attempted to self-transfer from wheelchair to bedside commode and fell . Resident #1 stated the STNAs were upset they were not permitted to call an ambulance to assist with getting Resident #1 off the floor. Resident #1 stated due to his size, the staff were unable to get Resident #1 off the floor. Resident #1 stated RN #107 checked Resident #1's vitals and then left the room. An STNA went to the Director of Nursing (DON) and asked for an ambulance to be called. Resident #1 stated the DON did not come to assess him. Resident #1 stated he was lying on his left arm, and it was turning purple so the STNAs turned him enough to get his arm out. Resident #1 stated he started developing pain after lying on the floor so when emergency personnel arrived, Resident #1 requested to be sent to the hospital. Resident #1 believed it was an hour or more before emergency personnel arrived at the facility. Interview on 12/21/23 at 2:02 P.M. with RN #107 revealed they assessed Resident #1 after the fall on 12/15/23. RN #107 stated the DON did not want an ambulance called for emergency personnel to assist with getting Resident #1 off the floor due to the ambulance company would charge the facility for assistance. RN #107 stated the DON wanted dietary staff, maintenance, and/or therapy to assist with getting Resident #1 off the floor. Dietary staff, maintenance, and therapy all refused to assist Resident #1. Interview on 12/26/23 at 9:39 A.M. with the DON verified Resident #1 was on the floor approximately 45-minutes before an ambulance was called. The DON stated they thought a mechanical lift or additional staff might be able to get Resident #1 off the floor. The DON verified she did not go to Resident #1's room to assess Resident #1 or to assist staff. Interview on 12/26/23 at 4:02 P.M. with STNA #105 revealed the DON did not want an ambulance called. RN #107 took Resident #1's vitals and then left the room. STNA #105 stated someone finally called an ambulance to assist with getting Resident #1 off the floor. STNA #105 stated Resident #1's hand started turning purple so the STNAs rolled Resident #1 and moved Resident #1's arm from underneath him. Resident #1 started complaining of pain after lying on the floor for approximately an hour. This deficiency represents non-compliance investigated under Complaint Number OH00149296 and OH00149293.

Based on observation, record review, facility policy and procedure review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of avoidable pressure ulcers, timely identify areas of new skin impairment, ensure pressure ulcer dressings were provided as ordered and/or prevent the risk of pressure ulcer infection for Residents #12, #38, #43, #47, #51 and #53. Actual Harm occurred on 08/11/22 when Resident #47, who was cognitively impaired, at moderate risk for pressure ulcer development, and dependent on staff for bed mobility, was found to have a deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration) pressure ulcer to the left heel and Stage III (full-thickness tissue loss into subcutaneous tissue but does not go into the muscle or bone) pressure ulcers to right buttock, right ischium, and left ischium without evidence of adequate and individualized pressure ulcer prevention interventions being in place prior to the development. Actual Harm occurred on 08/18/22 when Resident #53, who was at moderate risk for pressure ulcer development and dependent on staff for bed mobility, was found to have a Stage III pressure ulcer to the left buttock and coccyx without evidence of adequate and individualized pressure ulcer prevention interventions being in place prior to the development. Actual Harm occurred on 08/03/22 when Resident #51, who was cognitively impaired, at high risk for pressure ulcer development and dependent on staff for bed mobility was found to have a Stage III pressure ulcer to the sacrum without evidence of adequate and individualized pressure ulcer prevention interventions being in place prior to the development. Actual Harm occurred on 08/03/22 when Resident #12, who was cognitively impaired, at risk for pressure ulcer development and dependent on staff for bed mobility, was found to have a Stage III pressure ulcer to the right and left buttocks without evidence of adequate and individualized pressure ulcer prevention interventions being in place prior to the development. The resident had been identified to have an area of skin impairment on 06/23/22, however it could not be determined if the area on 08/03/22 was the same area or a different area based on the lack of assessment/monitoring. Actual Harm occurred on 08/04/22 when Resident #43, who was at high risk for pressure ulcer development and dependent on staff for bed mobility was found to have a Stage III pressure ulcer to the right ischium without evidence of adequate and individualized pressure ulcer prevention interventions being in place prior to the development. This affected six residents (#12, #38 #43, #47, #51 and #53) of six residents reviewed for pressure ulcers. Findings include: 1. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Clinical Admission Evaluation, dated 07/15/22 revealed no evidence/documentation of Resident #47 having any skin issues/open areas/pressure ulcers present on admission. Review of the skin risk/Braden Scale Assessment, dated 07/17/22 revealed Resident #47 was assessed to be at moderate risk for developing pressure ulcers. The resident was noted to have slightly limited sensory perception, her skin was very moist, she walked occasionally, had very limited mobility, and had problems with friction and shearing which contributed to the pressure ulcer development risk. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 07/21/22 revealed Resident #47 had severely impaired cognition, required extensive assistance from two staff for bed mobility and transfers and had no pressure ulcers. Review of the July 2022 nursing assistant skin TASK documentation revealed nursing assistant staff were to check the resident's skin condition every shift during all care provided and document the presence of any scratches, red areas, discolorations or open areas. The nursing assistant was to notify the nurse of any new areas. Review of Resident #47's Skin Task documentation revealed there was no documentation of the resident's skin during care on 07/18/22, 07/19/22, 07/23/22, 07/24/22, 07/25/22, 07/26/22, 07/27/22, 07/28/22, 07/30/22 or 07/31/22. In addition, on 07/29/22 at 12:44 P.M. the documentation indicated the resident had a red area. Record review revealed no additional documentation/assessment of this area on this date. Review of the plan of care, dated 08/02/22 revealed Resident #47 was at risk for skin breakdown related to decreased mobility, diabetes, and incontinence. Interventions included to administer medications as ordered, encourage the resident to turn and reposition, staff to perform skin checks, report any new areas, assist resident with toileting as needed, provide diet as ordered, pressure redistribution mattress, and consult a wound nurse as needed. Review of a nursing progress note, dated 08/11/22 at 10:05 A.M. revealed Resident #47 was seen by the wound nurse practitioner (NP). The resident was assessed to have a Stage III pressure ulcer to her right buttock, right ischium, and left ischium. New orders were obtained to apply triad paste (a [MEDICATION(S)] based hydrophilic paste for light to moderate levels of wound exudate/drainage used to help maintain an optimal wound healing environment) to all areas three times daily. The note revealed the resident was also found to have a deep tissue injury to her left heel with a new order to apply skin prep, cover with an abdominal dressing and Kerlix daily. The note also revealed orders were noted at that time for a low air loss mattress to the resident's bed, use of a pressure relief cushion in the wheelchair and recliner and a protein supplements twice daily. Review of the skin grids/wound assessment, dated 08/11/22 revealed Resident #47 had a deep tissue injury to her left heel which measured 3.0 cm width by 6.0 cm length with an undetermined depth. The wound was assessed to be a dried blister. The resident was assessed to have a Stage III pressure ulcer to the right buttock which measured 0.8 cm width by 0.5 cm length with 0.1 cm depth with a small amount of serosanguinous drainage and 100 percent granulation. A Stage III pressure ulcer to the right ischium measured 0.5 cm width by 0.3 cm length with 0.1 cm in depth with a small amount of serosanguinous drainage, 30 percent slough and 70 percent granulation. A Stage III pressure ulcer to the left ischium which measured 0.5 cm width by 2.0 cm length with 0.1 cm depth with a small amount of serosanguinous drainage and 10 percent epithelial bridge, 10 percent slough and 80 percent granulation. Review of a wound NP note, dated 08/11/22 revealed a visit for an initial evaluation and management of new wounds reported for Resident #47 to the resident's buttocks and left heel. The NP note revealed the same areas as on the skin grid above with the same measurements. Review of the August 2022 physician's orders revealed the following pressure ulcer prevention measures were ordered following the development of the above pressure ulcers: [MEDICATION(S)] (supplement) one packet two times daily (initiated 08/17/22), 30 milliliters (ml) of Pro-Heal protein supplement twice daily (initiated 08/11/22), a pressure relieving cushion to the wheelchair and recliner (initiated 08/11/22) and a low air loss mattress to bed (initiated 08/11/22). In addition, the resident had a treatment order to apply triad paste to the left buttock three times daily (initiated 08/11/22) and an order to apply skin prep to the left heel, cover with abdominal dressing and wrap with Kerlix daily (initiated 08/11/22). Review of the August 2022 treatment administration record revealed no evidence/documentation the pressure ulcer treatments were provided as ordered to the area to the left buttock on 08/12/22 afternoon shift, or on 08/26/22 day and afternoon shift; to the area on the left ischium on 08/12/22 afternoon shift, or 08/26/22 day and afternoon shift; or to the area on the right buttock on 08/12/22 afternoon shift, on 08/15/22 at bedtime, or on 08/25/22 day and afternoon shift. On 08/31/22 at 9:37 A.M., observation with Registered Nurse (RN) #54 revealed Resident #47 had a dressing to the left heel dated 08/30/22 with a large amount of serosanguinous drainage which had leaked through the dressing. The area to the left heel was observed with a large black scab. The resident was observed with an area to her left ischium that was pinpoint in size with a pink blanchable peri wound. On 09/01/22 at 12:20 P.M. interview with Wound Nurse Practitioner #83 revealed she believed a lack of staffing lead to numerous residents, including Resident #47 with skin breakdown in August 2022. The nurse practitioner did not elaborate or provide any additional information during the interview as to how/why she had this belief. On 09/19/22 at 4:50 P.M. during an interview with Registered Nurse (RN) #54, the concern related to the development of Resident #47's pressure ulcers were discussed. The RN was unable to provide any explanation as to why/how Resident #47 was found with a deep tissue injury to the left heel and the Stage III pressure ulcers to the buttocks/ischium area on 08/11/22. RN #54 verified the lack of written evidence to reflect interventions being in place (i.e. turning and repositioning, pressure reduction devices, toileting) prior to the pressure ulcer development. The RN indicated it was good nursing practice for staff to turn, reposition and toilet residents every two hours. On 09/19/22 at 4:55 P.M. interview with Licensed Practical Nurse (LPN) #12 revealed the skin documentation section under the TASK section in the electronic medical record was for the nursing assistants to document residents skin condition(s) when they provided daily care. She indicated the nursing assistants should have been documenting the resident's condition daily. LPN #12 verified the documentation was incomplete for Resident #47 for the dates noted above. On 09/20/22 at 1:50 P.M. interview LPN #12 verified there was no follow up or skin assessment related to the nursing assistant skin task documentation of a red area for Resident #47 on 07/29/22. On 09/20/22 at 1:55 P.M. during a follow up interview with RN #54, the RN revealed she had actually been notified by therapy staff of areas of skin breakdown for Resident #47 on 08/08/22. RN #54 revealed she notified the wound nurse and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled, Wound and Skin Care, dated 06/07/22 revealed the purpose of the policy was to ensure documentation, monitoring and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Clinical Admission Evaluation dated 04/28/22 revealed no evidence/documentation of Resident #53 having skin issues/open areas or pressure ulcers on admission. Review of the plan of care dated 04/29/22 revealed Resident #53 was at risk for skin breakdown related to decreased mobility, diabetes, and incontinence. Interventions included to administer medications as ordered, encourage the resident to turn and reposition, staff to perform skin checks, report any new areas, assist resident with toileting as needed, provide diet as ordered, pressure redistribution mattress, and consult a wound nurse as needed. Review of the July 2022 nursing assistant skin task documentation revealed the nursing assistants were to be checking the resident's skin condition every shift during all care provided and documenting whether the resident had any scratches, red areas, discolorations, and open areas. The nursing assistants were to notify the nurses of any new areas. Review of Resident #53's skin task documentation revealed there was no documentation of the resident's skin during care on 7/01/22, 07/02/22, 07/03/22, 07/04/22, 07/08/22, 07/09/22, 07/10/22, 07/11/22, 07/17/22, 07/24/22, 07/25/22, 07/26/22, 07/27/22, 07/29/22 or 07/30/22. On 07/28/22 at 10:11 A.M. the documentation indicated the resident had an open area. However, there was no additional assessment or information regarding this area at that time. Review of the quarterly MDS 3.0 assessment, dated 08/01/22 revealed Resident # 53 had intact cognition, required extensive assistance from two staff members for bed mobility and had no pressure ulcers. Review of a nursing progress note, dated 08/18/22 at 4:28 P.M. revealed Resident #53 had a Stage III open area to the left buttock which measured 2.0 cm width by 0.75 cm length with slough tissue present and minimal drainage, no odor. The peri wound was assessed to be reddened. The note revealed the resident also had a 2 cm round Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure area to the coccyx. The wound nurse practitioner was notified and ordered a treatment to cleanse with normal saline, apply a dime thick layer of triad paste daily and as needed, pressure relief cushion in the recliner and wheelchair, low air loss mattress and protein supplements twice daily. Review of the skin risk/Braden Scale Assessment, dated 08/19/22 revealed Resident #53 was assessed to be at moderate risk for pressure ulcer development. The resident had a very limited sensory perception, her skin was very moist, she walked occasionally, had very limited mobility, probably inadequate nutrition and had a potential problem with friction and shearing which contributed to the pressure ulcer risk. Review of the August 2022 had the following physician's orders initiated following the development of the pressure ulcer: On 08/18/22 an order was obtained for an [MEDICATION(S)] packet twice daily and Pro-heal supplement 30 milliliters two times daily. In addition, on 08/18/22 orders were obtained for a pressure relief cushion in the wheelchair and recliner and a low air loss mattress to the bed. On 08/26/22 an order was obtained for skin prep to the bilateral heels, leave open to air and an order (initiated 08/25/22) to cleanse left buttock with normal saline (NS), apply dime thick layer of triad paste three times daily and as needed Review of a Wound NP note, dated 08/25/22, revealed an initial evaluation and management of new wounds reported to the left buttock and coccyx for Resident #53. The resident was assessed to have a Stage III pressure ulcer to the coccyx which measured 1.5 cm width by 0.3 cm length with scant serosanguinous drainage. The wound bed had 100 percent viable tissue. The resident was also assessed to have a Stage III pressure ulcer to the left buttock which measured 1.5 cm width by 1.0 cm length by 0.1 cm depth with scant serosanguinous drainage, 30 percent slough tissue and 70 percent granulation. The resident's bilateral heels were assessed to be soft, blanchable. The note revealed the resident was at high risk for breakdown and orders were provided to apply skin prep to heels, leave open to air, offload heels and obtain a pressure relieving cushion for her chair. On 08/31/22 at 10:15 A.M. observation with RN #54 revealed Resident #53 had a nickel size open area to her left buttock. The wound bed was reddened, and the peri wound was pink. The resident was observed to have a low air loss mattress to her bed at the time of the observation. An interview at the time of the observation revealed Resident #53 stated her left buttock hurt. On 09/01/22 at 12:20 P.M. interview with Wound Nurse Practitioner #83 revealed she believed a lack of staffing lead to numerous residents, including Resident #53 with skin breakdown in August 2022. The nurse practitioner did not elaborate or provide any additional information during the interview as to how/why she had this belief. On 09/19/22 at 3:50 P.M. interview Resident #53 revealed she believed the pressure wounds she had were due to laying in bed all the time. The resident revealed she required staff to assist her out of bed and turn/reposition in bed and denied receiving this assistance. On 09/19/22 at 4:50 P.M. during an interview with Registered Nurse (RN) #54, the concern was shared related to the development of Resident #53's pressure ulcers. The RN was unable to provide an explanation as to why/how Resident #53 was found with the Stage III pressure ulcers on 08/18/22. RN #54 verified the lack of written documentation to reflect interventions being in place (i.e. turning and repositioning, pressure reduction devices, toileting) prior to the Stage III pressure ulcer developing. The RN indicated it was good nursing practice for staff to turn, reposition and toilet residents every two hours. On 09/19/22 at 4:55 P.M. interview with Licensed Practical Nurse (LPN) #12 revealed the skin documentation section under the TASK section in the electronic medical record was for the nursing assistants to document residents skin condition(s) when they provided daily care. She indicated the nursing assistants should have been documenting the resident's condition daily. She verified the documentation was incomplete for Resident #53 for the dates noted above. On 09/20/22 at 1:50 P.M. interview LPN #12 verified there was no follow up or skin assessment related to the nursing assistant skin task documentation of an open area for Resident #53 on 07/28/22. Review of the facility policy titled, Wound and Skin Care, dated 06/07/22 revealed the purpose of the policy was to ensure documentation, monitoring and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Clinical Admission Evaluation, dated 04/21/22 revealed no evidence documentation of Resident #51 having skin issues/open areas/pressure ulcers present on admission. Review of the plan of care, dated 04/22/22 revealed Resident #51 was at risk for skin breakdown related to decreased mobility, diabetes, and incontinence. Interventions included to administer medications as ordered, encourage the resident to turn and reposition, staff to perform skin checks, report any new areas, assist resident with toileting as needed, provide diet as ordered, pressure redistribution mattress, use lift sheet/pad for bed mobility and consult a wound nurse as needed. Review of the Braden Scale, dated 05/08/22 revealed Resident #51 was assessed to be at high risk for developing pressure ulcers. The assessment revealed the resident had very limited sensory perception, his skin was very moist, he was chair fast, had very limited mobility, probably inadequate nutrition and had a problem with friction and shearing which contributed to the pressure ulcer risk. Review of the quarterly MDS 3.0 assessment, dated 07/28/22 revealed Resident #51 had severely impaired cognition, required total assistance from two staff for bed mobility, transfers, dressing and toilet use. The MDS assessment revealed the resident was always incontinent of bladder and bowel and did not have a pressure ulcer. Review of the weekly Skin Observation document, dated 07/29/22 revealed Resident #51 had a new skin area noted. However, record review revealed no additional assessment/staging/description of the wound was completed on this date. Review of a nursing progress note, dated 07/31/22 at 3:24 P.M. revealed Resident #51 had an open area to the left side of the coccyx which measured 3.0 cm width by 3.1 cm length with 0.1 cm depth. The note did not include a stage of the ulcer at that time. The area was noted to have a red/pink wound bed. The wound nurse was notified and order to cleanse the areas with normal saline, apply triad paste and a foam dressing. Review of the July 2022 nursing assistant skin task documentation revealed the nursing assistants were to be checking the resident's skin condition every shift during all care provided and documenting whether the resident had any scratches, red areas, discolorations, and open areas. The nursing assistant was to notify the nurse of any new areas. Review of Resident #51's Skin task documentation revealed there was no documentation of the resident's skin during care on 7/04/22, 07/05/22, 07/10/22, 07/23/22, 07/24/22, 07/26/22, 07/30/22 or 07/31/22. Review of a wound NP note, dated 08/04/22 revealed a visit for an initial evaluation and management of a new wound reported to the sacrum of Resident #51. The resident was assessed to have a Stage III pressure ulcer to the sacrum with an onset date of 08/03/22. Nursing staff reported the resident slides down in the wheelchair causing shearing. The note revealed the resident was placed on an air mattress yesterday. Resident #51's sacral wound measured 3.0 cm width by 3.5 cm width with 0.1 cm depth and a small amount of serosanguinous drainage. The wound had 20 percent slough tissue with 80 percent granulation tissue present. Review of the August 2022 physician's orders revealed following the development of the pressure ulcers, Resident #51 had orders to encourage to turn and reposition (initiated 08/30/22), float heels as tolerated while in bed (initiated 08/30/22), cleanse sacrum with normal saline, apply a dime-thick layer of triad paste, cover with foam dressing daily and as needed, pressure relieving cushion in the chair (initiated 08/04/22), and a low air loss mattress to the bed (initiated 08/04/22). Review of the progress note, dated 08/23/22 at 4:28 P.M. revealed Resident #51 had a 2.0 cm by 1.0 cm blister to his right heel which was dark red in color. The skin around the blister was dark pink. A new order was received to apply skin prep, an abdominal (ABD) dressing and wrap in Kerlix daily. Review of the August 2022 TAR revealed no evidence the treatment to the sacrum was completed as ordered on 08/18/22, 08/20/22, 08/23/22, 08/25/22 or 08/28/22. On 08/31/22 at 10:00 A.M. observation and interview with RN #54 revealed Resident #51 had a quarter size open area to his coccyx. The wound bed was reddened. There was not a dressing to the area at the time of the observation. The resident also had a nickel size dried blister to his right outer heel. On 09/01/22 at 12:20 P.M. interview with Wound Nurse Practitioner #83 revealed she believed a lack of staffing lead to numerous residents, including Resident #51 with skin breakdown in August 2022. The nurse practitioner did not elaborate or provide any additional information during the interview as to how/why she had this belief. On 09/19/22 at 4:50 P.M. during an interview with Registered Nurse (RN) #54, the concern related to the development of Resident #51's pressure ulcer to the sacrum was shared. The RN was unable to provide an explanation as to why/how Resident #51 was found with a Stage III pressure ulcer on 08/03/22. RN #54 verified the lack of written documentation to reflect interventions being in place (i.e. turning and repositioning, pressure reduction devices, toileting) prior to the Stage III pressure ulcer developing. The RN indicated it was good nursing practice for staff to turn, reposition and toilet residents every two hours. On 09/19/22 at 4:55 P.M. interview with Licensed Practical Nurse (LPN) #12 revealed the skin documentation section under the TASK section in the electronic medical record was for the nursing assistants to document resident skin condition(s) when they provided daily care. She indicated the nursing assistants should have been documenting the resident's condition daily. LPN #12 verified the documentation was incomplete for Resident #51 for the dates noted above. Review of the facility policy titled, Wound and Skin Care, dated 06/07/22 revealed the purpose of the policy was to ensure documentation, monitoring and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Review of the medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS 3.0 assessment, dated 05/27/22 revealed the resident had severely impaired cognition, required extensive assistance from two staff members for bed mobility, transfers, dressing and toilet use and extensive assistance from one staff member for personal hygiene. The MDS assessment revealed no evidence the resident had any type of skin breakdown/wounds present on admission. Review of the plan of care, dated 05/27/22 revealed Resident #12 was at risk for breakdown related to decreased mobility and incontinence. Interventions included to administer medications as ordered, encourage the resident to turn and reposition, staff to perform skin checks, report any new areas, assist resident with toileting as needed, use a lift sheet/pad for bed mobility, provide diet as ordered, pressure redistribution mattress, and consult a wound nurse as needed. Review of the skin risk/Braden Assessment Scale dated 06/08/22 revealed Resident #12 was at high risk for developing pressure ulcers. The assessment revealed the resident had very limited sensory perception, her skin was very moist, she was chair fast, had very limited mobility, probably inadequate nutrition and had a problem with friction and shearing which contributed to the pressure ulcer risk. Review of a nursing progress note, dated 06/23/22 at 2:05 P.M. revealed during a skin assessment Resident #12 was found to have a 0.25 centimeter (cm) superficial open area to the left inner buttock. The area was not staged and did not contain any additional description/assessment. The note did document the resident refused to get out of bed often. There was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed no additional information or assessments were provided related to the identification of the superficial area to the left inner buttock or of monitoring of the area following the identification. In addition, there was no evidence the facility implemented additional pressure ulcer prevention or interventions at that time. Record review revealed no evidence the facility developed a plan of care related to the resident refusing to get out of bed. Review of a physician's order, dated 06/23/22 revealed Resident #12 had a treatment order for Chamosyn with Manuka Honey to bilateral buttock three times daily and as needed. Record review revealed from 06/24/22 to 08/02/22 there were no skin assessments or monitoring of the resident's skin by a licensed nurse or evidence of monitoring of the area to the left inner buttock first noted on 06/23/22. Review of the July 2022 nursing assistant skin task documentation revealed the nursing assistants were to be checking the resident's skin condition every shift during all care provided and documenting whether the resident had any scratches, red areas, discolorations, and open areas. The nursing assistants were to notify the nurse of any new areas. Review of Resident #12's Skin task documentation revealed there was no documentation of the resident's skin during care on 07/02/22, 07/09/22, 07/10/22, 07/14/22, 07/16/22, 07/19/22, 07/23/22, 07/24/22, 07/25/22, 07/26/22, 07/27/22, 07/29/22, 07/30/22 or 07/31/22. Review of a nursing progress note, dated 08/02/22 at 2:35 P.M. revealed Resident #12 received a bed bath and the wound on her bottom was starting to open and bleed. However, record review revealed no additional assessment or care provided on this date. A physician's order, dated 08/04/22 (two days later) revealed an order to cleanse bilateral buttocks with normal saline and apply dime-thick layer of triad paste three times daily and as needed. Review of a nursing progress note, dated 08/04/22 at 12:13 P.M. revealed the wound nurse practitioner (NP) visited. Resident #12 was assessed at that time (by the NP) to have a Stage III pressure ulcer to her left and right buttocks. A new order was received to cleanse areas with normal saline and apply a dime-thick amount of triad cream three times daily and as needed. The progress note also revealed to implement a low air loss mattress to bed, a pressure relief cushion to wheelchair and recliner and a protein supplement twice daily. Review of the skin grid/wound assessment, dated 08/04/22 revealed Resident #12 had a Stage III pressure ulcer to the left buttock which measured 1.0 centimeter (cm) in width by 1.0 cm in length with 0.1 cm in depth with 100 percent granulation and a small amount of serosanguinous drainage and a Stage III pressure ulcer to the right buttock which measured 0.9 cm width by 1.5 cm length with 0.1 cm depth with 30 percent slough tissue and 70 percent granulation with a small amount of serosanguinous drainage. Review of the Wound NP note, dated 08/04/22 revealed NP visited for an initial evaluation and management of new wounds reported for Resident #12 to the bilateral buttocks with an onset of 08/03/22. The NP note reflected the same measurements and description from the skin grid/wound assessment dated [DATE]. Review of August 2022 treatment administration record (TAR) revealed no evidence the treatment to the bilateral buttocks was completed as ordered on 08/18/22 afternoon shift, 08/20/22 day and afternoon shift, 08/23/22 day and afternoon shift or on 08/24/22 afternoon shift. On 08/31/22 at 10:45 A.M. observation of Resident #12's skin revealed an open area to the right buttock with granulation tissue present. The resident's skin was pink surrounding peri wound. On 09/01/22 at 12:20 P.M. interview with Wound Nurse Practitioner #83 revealed she believed a lack of staffing lead to the numerous residents, including Resident #12 with skin breakdown in August 2022. The nurse practitioner did not elaborate or provide any additional information during the interview as to how/why she had this belief. On 09/19/22 at 4:50 P.M. during an interview with Registered Nurse (RN) #54, the concern was shared related to the identification of Stage III pressure ulcers to Resident #12's bilateral buttocks. The RN was unable to provide an explanation as to why/how Resident #12 was found with a Stage III pressure ulcer on 08/04/22. RN #54 verified the lack of written documentation to reflect interventions being in place (i.e. turning and repositioning, pressure reduction devices, toileting) prior to the Stage III pressure ulcer developing. The RN indicated it was good nursing practice for staff to turn, reposition and toilet residents every two hours. On 09/19/22 at 4:55 P.M. interview with Licensed Practical Nurse (LPN) #12 revealed the skin documentation section under the TASK section in the electronic medical record was for the nursing assistants to document resident skin condition(s) when they provided daily care. She indicated the nursing assistants should have been documenting the resident's condition daily. She verified the documentation was incomplete for Resident #12 for the dates noted above. Review of the facility policy titled, Wound and Skin Care, dated 06/07/22 revealed the purpose of the policy was to ensure documentation, monitoring and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 5. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review, the facility failed to provide adequate supervision and/or medical intervention to prevent Resident #33 from pulling out his [CONDITION(S)] cannula (the tube inserted in his neck to maintain the opening to allow him to breath). Actual harm occurred on [DATE] when Resident #33 removed the [CONDITION(S)] cannula, required cardiopulmonary resuscitation (CPR) and was transferred to the hospital. This affected one resident (Resident #33) of three residents reviewed for tracheostomies. Findings include: Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #33's nursing admission assessment dated [DATE] revealed he was alert and oriented to person only and required the assistance of two staff members for transfers, bed mobility, toileting, hygiene, and bathing. Review of Resident #33's progress notes dated [DATE] at 3:46 A.M. revealed he pulled out his [CONDITION(S)] cannula shortly after his admission. The notes indicated the [CONDITION(S)] cannula was re-inserted, rescue breathing was administered, and he was sent via ambulance to the emergency room . Progress notes revealed Resident #33 returned to the facility on [DATE] at 6:23 A.M. Review of Resident #33's care plan dated [DATE] revealed he wished to be a full code, meaning all life-saving measures would be taken in the event his heart and/or breathing stopped. Interventions included to review advanced directives quarterly and as needed and to perform cardiopulmonary resuscitation (CPR) as needed. There was also a care plan dated [DATE] related to Resident #33 having inappropriate behaviors which included pulling at his [CONDITION(S)] tubing and his nutritional tube feed tubing. Interventions included for staff to administer medications as ordered, to approach the resident in a slow and calm manner, a behavior management program, to bring the resident to a quiet environment as needed, document behaviors, observe the environment for the possible cause of the behaviors, observe the resident for pain, provide the resident with diversional activities such as television, provide one to one supervision, toileting, or ambulation, provide support and encouragement, and to have a psychiatric consult. There was also a care plan dated [DATE] indicating Resident #33 had cognitive impairment with interventions which included for staff to ask the resident simple concrete questions, to anticipate the resident's needs, to approach the resident in a calm manner, to reorient as possible, and to explain all procedures and treatments to him. Resident #33's progress notes dated [DATE] at 10:51 P.M. revealed Resident #33 pulled out his [CONDITION(S)] cannula again. It was re-inserted at the facility but he was sent to the emergency room for further evaluation as the [CONDITION(S)] cannula had been difficult to re-insert. He returned to the facility on [DATE] at 3:48 A.M. Resident #33's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #33's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was also a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order listed interventions of redirection, removing from the environment, diversional activity, emotional support, and as needed medications. This order instructed outcomes to be documented as I=Improved, S=Same, W=Worse, with side effects to be documented as 0=No 1=Yes. The progress note dated [DATE] at 1:05 P.M. revealed Resident #33 was agitated and pulling at his nutritional tube feed tubing. This progress note revealed Resident #33 required one respiratory therapist, three state tested nursing assistants, and two nurses to change and reposition him. There was no information in the progress note to indicate any staff remained with Resident #33 to ensure he did not pull out any of his tubes/cannulas, including his [CONDITION(S)] cannula. There was no documentation that any other interventions were provided for his agitation or that his agitation resolved with the personal care provided. Review of Resident #33's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . For day shift, the behaviors/agitation from [DATE] at 1:05 P.M. was not documented. The nurse entered the word no with a checkmark and her initials, indicating Resident #33 had no behaviors. Review of #33's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. which was documented as effective. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #33's progress notes dated [DATE] at 1:25 P.M. revealed he was found with his [CONDITION(S)] cannula removed, no vital signs, and cardiopulmonary resuscitation (CPR) was initiated. The progress note revealed the resident was revived and transported by ambulance to the emergency room . He returned to the facility on [DATE] at 3:27 P.M. Review of Resident #33's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a memory problem and severe cognitive impairment and required a [CONDITION(S)]. This assessment indicated Resident #33 exhibited behavioral symptoms such as hitting and kicking others and rejection of care and required extensive assistance from staff for transfers, hygiene, and bathing. Interview on [DATE] at 3:56 P.M. with Resident #33's sister revealed she had asked the facility to place mittens on the resident's hands to prevent him from pulling out his [CONDITION(S)] cannula. She said the facility told her they could not do that because the facility had a restraint-free policy. Resident #33's sister revealed the resident had pulled at his tubing and had removed his [CONDITION(S)] cannula multiple times at the facility. Interview on [DATE] at 5:42 P.M. with Regional Registered Nurse (RRN) #901 revealed Resident #33 was agitated and confused and his actions led to complications. RRN #901 confirmed Resident #33 had coded multiple times at the facility and he pulled out his [CONDITION(S)] cannula multiple times. Interviews attempted on [DATE] at 11:47 A.M. and [DATE] at 8:37 A.M. with Nurse Practitioner (NP) #909 were unsuccessful. Messages were left with her receptionist and no return contact was made. Interviews attempted on [DATE] at 4:00 P.M. and [DATE] at 8:37 A.M. with Physician #910 were unsuccessful. Messages were left with his receptionist and no return contact was made. Interview was conducted on [DATE] at 4:26 P.M. with Licensed Practical Nurse (LPN) #905, the nurse on duty on [DATE]. LPN #905 said on [DATE] at 1:25 P.M. Resident #33 had removed his [CONDITION(S)] cannula and coded (absence of heartbeat/respirations). LPN #905 revealed CPR was performed and Resident #33 was revived and sent to the emergency room . LPN #905 said at times Resident #33 had a sitter but not at the time he removed his [CONDITION(S)] cannula and coded on [DATE]. LPN #905 verified there was no guidance from the facility as to when Resident #33 was to have a one on one sitter/supervision. LPN #905 said if Resident #33 showed signs of agitation she would have had a one to one sitter with him. Subsequent interview with LPN #905 on [DATE] at 5:00 P.M., confirmed she documented in the progress notes on [DATE] at 1:05 P.M., just twenty minutes before he removed his [CONDITION(S)] cannula and coded, that Resident #33 had been agitated and pulling at his tube feed lines and required a respiratory therapist, three state tested nursing assistants, and two nurses to change and reposition him. LPN #905 confirmed there was no documentation to indicate Resident #33 was calm and no longer agitated when staff left him alone in his room or that the repositioning and changing had been an effective intervention for his agitation. LPN #905 verified she did not have anyone provide one on one supervision and did not administer the as needed medication Resident #33 had ordered for agitation. Interview on [DATE] at 9:21 A.M. with Respiratory Therapist (RT) #907 revealed Resident #33 had pulled at his [CONDITION(S)] tubing and had pulled out his [CONDITION(S)] cannula more than once at the facility. RT #907 revealed the main interventions used were redirection and trying to talk to him and educate the resident. RT #907 confirmed Resident #33 had severe cognitive impairment and did not seem to understand this education. Interview on [DATE] at 9:25 A.M. with RT #908 revealed Resident #33 had pulled out his [CONDITION(S)] cannula more than once while at the facility. RT #908 revealed when he was on duty, he watched Resident #33 like a hawk and went past the resident's room frequently to check on him. RT #908 revealed he was a few blocks away from the facility at lunch on [DATE] when Resident #33 had pulled out his [CONDITION(S)] cannula and coded. RT #908 said he returned to the facility to find the [CONDITION(S)] cannula had been reinserted and two nurses were performing CPR on Resident #33. RT #908 revealed he took over bagging at that time, which provides breathing for someone not breathing on their own. RT #908 did not remember the name of the state tested nursing assistant who found Resident #33 unresponsive on [DATE]. Interview on [DATE] at 9:50 A.M. with the Administrator revealed the interventions attempted to prevent Resident #33 from removing his [CONDITION(S)] cannula were intermittent one on one supervision, medication changes, and laboratory studies (blood work). The Administrator revealed the facility felt they could effectively manage Resident #33's care with these interventions. The Administrator said Resident #33 was diagnosed with pneumonia on [DATE] when he was sent to the emergency room after removing his [CONDITION(S)] cannula and found without vital signs. The Administrator said that diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator revealed there was no written guidance for the nurses to specifically direct them as to which interventions were to be applied to each given scenario. This deficiency substantiates Complaint Number OH 386.

Based on record review and interview the facility failed to ensure one resident (Resident #152) was provided the necessary care and services to prevent the development of unstageable pressure ulcers. This affected one resident (#152) of three residents reviewed for hospitalization . Actual Harm occurred on 02/12/19 when Resident #152, who was identified to be at moderate risk for pressure ulcers, complained of increased pain to the right ankle and was subsequently identified to have developed three unstageable pressure ulcers when assessed by an orthopedic physician. Prior to the orthopedic identification of the pressure ulcers, the facility failed to adequately monitor the resident's skin and implement appropriate pressure relieving interventions to prevent the development of three unstageable pressure ulcers. Findings include: Review of Resident #152's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing assessment, dated 01/31/19 revealed no skin alterations were noted on admission except shearing to the resident's scrotum. The resident's skin was warm and dry. No skin alteration interventions were noted on the admission assessment. Review of the Braden Assessment for Predicting Pressure Ulcer Development, dated 01/31/19 revealed a score of 14 indicating the resident was at moderate risk for pressure ulcer development. Review of the physician's orders [REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 02/07/19 revealed the resident was cognitively intact and required extensive assistance of two staff with bed mobility, transfers and toilet use. The resident also required extensive assistance of one staff with dressing and personal hygiene. The resident was identified at risk for pressure ulcer development but did not have pressure ulcers, diabetic ulcers, venous or arterial ulcers upon admission. Review of the progress note, dated 02/11/19 at 9:53 P.M. revealed the resident had a skin check and the resident did not have any new skin issues documented to be addressed at this time. Review of an orthopedic progress note, dated 02/12/19 revealed the resident presented to the office with right ankle pain. The note revealed the resident was initially seen in consultation at the hospital on [DATE] after a fall that resulted in an obvious deformity of the right ankle. The resident was brought to the emergency department. X-rays revealed an ankle fracture and a fibula fracture. The resident had an open reduction, internal fixation of the right ankle on 01/25/19. The resident presented to the office on 02/12/19, non-weight bearing and with a knee immobilizer. There was an area of necrotic tissue on the right forefoot on the lateral side as well as a plantar ulcer. There was also an area of eschar (dark area) over the patella, likely a pressure sore from the knee immobilizer. The resident was taken out of the ankle orthotic splint and placed in a tall walker boot. The note indicated the resident would remain in this only to come out for daily range of motion exercises. The resident would remain non-weight bearing for the next four weeks and no longer needed to wear the knee immobilizer. It was suggested the resident see the podiatrist due to necrotic tissue on the lateral side of his right forefoot and a plantar ulcer that needed assessed. The area of eschar on the patella also needed assessed and the areas needed monitored by the facility to ensure they were not progressing to infection. Review of the progress note, dated 02/14/19 at 11:19 [NAME]M. revealed a facility skin assessment was completed and two areas of eschar were observed on the resident's right knee and the ball of the right foot and an area of discoloration to the right lateral bottom of the foot measuring 4.7 centimeters by 2.3 centimeters was also noted. The note revealed the Wound Certified Nurse Practitioner would follow starting the following week. An order was obtained to cleanse the right knee with normal saline and apply A&D ointment, cover with border foam dressing every other day and as needed. The area measured 3.5 cm by 3.0 cm. Preventative measures revealed the resident was non-weight bearing to the right foot and the resident was currently working with therapy. Review of a podiatry progress note, dated 02/15/19 revealed the resident had an ungradeable ulcer to the right (location not specified) without signs or symptoms of infection. Orders were written for wound care. Review of the physician's orders [REDACTED]. Review of the medical record revealed a weekly skin integrity review, dated 02/18/19 indicating necrotic areas to the bottom and lateral of the right foot. No measurements were documented at that time. Review of the Patient Visit Record, dated 02/19/19 revealed Resident #152 was evaluated by Certified Nurse Practitioner #500 due to wounds to the right lower extremity. The CNP evaluated the wound to the right knee with an etiology of abrasion/pressure and measuring 3.1 centimeters (cm) in length by 2.9 cm width with 0.1 cm depth. The visit record documentation revealed the right foot plantar area was identified as an unstageable pressure ulcer with 100% stable eschar with the wound measuring 2.4 cm in length by 3.0 cm width with 0.1 cm depth. The visit record documentation revealed an unstageable pressure ulcer to the right lateral foot measuring 3.1 cm in length by 4.5 cm width with 0.1 cm depth. The order obtained for all three areas was silver alginate, abdominal pad, gauze wrap three times a week and as needed. Record review revealed the resident had a current plan of care related to the risk for skin breakdown due to decreased mobility that was first initiated on 07/05/19. Interventions documented on the care plan included an air mattress (dated 03/15/19), encourage resident to turn and reposition (dated 02/21/19), staff to perform skin checks and report any new areas (dated 02/21/19) and pressure ulcer management program dated 02/21/19. Each of these interventions were noted to have been implemented after the resident was assessed to develop the unstageable pressure ulcers on 02/12/19. On 11/26/19 at 6:06 P.M. interview with Licensed Practical Nurse (LPN) #27 revealed the resident was admitted to the facility with post-operative surgical needs and had no skin alterations on admission but was wearing a splint/boot to the right foot and ankle. LPN #27 revealed the resident was to receive weekly skin assessments but verified the wounds were not identified by the facility until 02/14/19, two days after the alterations were identified by the orthopedic physician. LPN #27 verified the first facility pressure ulcer assessments were dated 02/14/19. LPN #27 stated the resident's boot should have been removed daily for bathing and a skin assessment and circulation check should have been completed daily due to the resident's potential to develop a pressure ulcer from the splint/boot. LPN #27 verified the resident developed three unstageable pressure ulcers to the right foot and knee from the right ankle splint and pressure was identified as the etiology by CNP #500. LPN #27 verified the resident was seen by the podiatrist on 02/15/19 but the podiatrist did not indicate the etiology or location of the unstageable wounds during his evaluation. Further interview verified no wound treatments were written the date the podiatrist visited. Lastly, the LPN verified the resident was identified to be at moderate risk for pressure ulcer development using the Braden assessment tool however, a plan of care was not implemented until 07/05/19. The plan of care included interventions that were dated before the plan of care was developed and the care plan was initiated well after the pressure ulcers were first identified. The LPN verified there was no evidence of pressure relieving interventions prior to the identification of the pressure ulcers on 02/14/19 or immediately after the ulcers were identified. Review of the Wound and Skin Care Policy, dated 09/23/1996 and revised 06/07/16 revealed all new admissions and readmissions would be placed on a skin program for four weeks. For new admissions who do not have a pressure area/ulcer, the resident's skin would be monitored weekly through the nurses' skin assessments. Identified issues would be followed through the skin program. If a pressure area/ulcer was present, the resident would be placed on the pressure ulcer monitoring program (PUMP) and the area would be measured/tracked weekly and as needed until the area was resolved. Further review revealed an unstageable pressure ulcer had an unknown depth. An unstageable pressure ulcer was defined as a full thickness loss where the base of the ulcer was covered with slough and/or eschar (dead tissue) in the wound bed. The stage could not be determined and the depth could not be obtained. All wounds would be assessed for etiology using predisposing factors, anatomic location, wound characteristics and resident assessment.

Based on record review and interview the facility failed to timely implement an effective and individualized pain management program for Resident #113 and failed to ensure a neurological consult was completed as ordered for Resident #20 to address pain experienced by the resident. Actual Harm occurred when the facility failed to timely administer narcotic pain medication as ordered and requested following Resident #113's admission to the facility resulting in increased pain rated an eight out of 10 on a scale of one to ten and limiting the resident's ability to sleep and participate in activities of daily living. This affected two residents (Resident #113 and #20) of three residents reviewed for pain management. Findings include: 1. Review of Resident #113's medical record revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the hospital discharge orders, dated 12/08/18 revealed Resident #113 had an order for [REDACTED]. Review of the physician's orders [REDACTED].#113 had an order for [REDACTED]. Review of the admission pain assessment dated [DATE] revealed Resident # 113 had pain present, it was an almost constant pain, the pain made it hard for him to sleep, the pain limited his day-to-day activity, and he rated his pain level an 8 out of ten on a scale of one to ten with ten being the most severe pain. Review of the call light audits from 12/08/18, Resident #113's day of admission, revealed Resident #113 used his call light on 12/08/18 at 8:08 P.M., 9:28 P.M., and 10:23 P.M. Review of a pharmacy delivery invoice dated 12/09/18 revealed Resident #113's [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg was delivered at 5:56 A.M. However, review of the facility starter kit list of medications revealed [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg was available in the starter kit onsite in the facility. An interview on 12/09/18 at 9:25 A.M. with Resident #113 revealed he was admitted the day before after having a left total knee replacement. He indicated he had used his call light after his admission and had asked numerous times the night before for a pain pill and never received one. He stated he had been in a lot of pain from his knee replacement. He indicated he finally received a pain pill this morning. Review of a daily skilled nursing note, dated 12/09/18 at 1:32 P.M. revealed Resident #113 was having pain at a level eight out of ten and on 12/09/18 at 7:31 P.M. he was having pain at a level of eight out of ten. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED].M. for moderate to severe pain rated a pain level of 10 out of 10 and his second dose on of two tablets on 12/09/18 at 3:18 P.M. for pain level of eight out of ten. An interview on 12/10/18 at 9:39 A.M. with Resident #113 revealed he asked for a pain pill at around 10:30 P.M. the night before and the nurse mumbled as she was walking out of the room, he could have one tomorrow. He indicated he was never going to be able to do therapy if they did not give him a pain pill. An interview on 12/11/18 at 10:10 A.M. with Registered Nurse #1 verified the nurse working the floor on 12/08/18 did not give Resident #113 his pain medication as the resident requested and as it was ordered and she should have. The nurse did not pull the pain medication from the starter kit and she should have. She indicated the nurse working thought the dosage was not the same as what was in the starter kit. She also verified the nurse working had not called the physician for an order for [REDACTED]. An interview on 12/11/18 at 12:51 P.M. with Resident #113 revealed his pain was good at that moment, but he was just sitting still. Review of the policy titled Pain Management Program, dated 10/18/18 revealed the goal of the program was to identify, assess, manage, and treat residents' pain. 2. Medical record review revealed Resident # 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/11/18 revealed Resident #20 had intact cognition, received a scheduled pain medication, received an as needed pain medication and received non-medication interventions for pain. Review of a physician's progress note dated 10/03/18 revealed the physician had ordered a consult with a neurologist for continued problems with her [MEDICAL CONDITION] (MS). Review of a physician's progress note dated 10/20/18 revealed the physician indicated Resident # 20 was seen three weeks ago by him at which time he had ordered a neurological consultation, unfortunately the order was never taken off and the appointment was never scheduled. The physician reordered the neurological consult at that time. The physician also indicated in his progress noted the resident has had a six-day history of severe headaches involving the right frontal temporal and parietal region in which she rates on a scale of 10 between five to eight. The physician's plan was to obtain a magnetic resonance imaging (MRI) of her brain without contrast and neurology consult. Review of a nurse's progress note dated 10/20/18 at 2:46 P.M. revealed the physician was in the see Resident #20 and ordered an MRI, a consult with a neurologist for her MS and increased headaches. The physician requested to be called when the consult was set up. Review of a nurse's progress note dated 10/23/2018 at 1:32 P.M. revealed a message was left with the physician regarding Resident #20's appointment with the neurologist. An interview on 12/10/18 at 3:45 P.M. the Licensed Practical Nurse #84 verified the order for the neurological consult was overlooked and had not been scheduled as ordered to follow up with the resident's MS and pain associated with headaches.

Based on observation, record review, family and staff interview and policy review the facility failed to address a significant weight loss for one resident (Resident #35). This affected one resident of three residents reviewed for nutrition. Actual Harm occurred to Resident #35 when the facility failed to implement nutritional interventions with an identified weight loss trend, subsequently resulting in a severe weight loss of 12.8 percent (%) in six months. Findings Include: Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nutrition risk assessment dated [DATE] revealed the resident was at moderate risk for nutritional deficits. The prescribed diet was for no concentrated sweets (NCS). Estimated nutritional needs indicated the resident required 1400 calories, 77 grams protein and 1400 milliliter (ml) of fluids a day. Review of the admission nursing assessment revealed the resident weighed 174 pounds (#) upon admission to the facility. Review of the plan of care dated 07/31/17 revealed Resident #35 was at risk for nutritional deficits. Goals were for the resident to remain free of unintended significant weight changes times one month, three months and six months and to consume at least 75% of her meals. Interventions included providing diet as ordered, obtaining weights as ordered, document meal intakes and offer a substitute if less than 51% of a meal was consumed. Review of the Minimum Data Set 3.0 (MDS) significant change assessment, dated 08/30/17, revealed the resident had impaired cognition and required supervision of one for eating. Review of physician's orders [REDACTED]. Review of the documented weights revealed Resident #35's weight on 04/06/17 was 164 pounds (#). The following weights obtained since then included: 05/04/17 at 162 #, 06/05/17 at 160#, 07/10/17 at 160#, 08/01/17 at 160#, 09/04/17 151#, 09/17/17 at 151#, 09/24/17 at 147#, 10/01/17 at 143, 10/06/17 at 134# and 10/12/17 at 144#. This indicated a significant weight loss of 20# (12.8 %) in six months and a significant weight loss of 5.3% from 09/17/17 to 10/01/17. On 10/06/17 a weight of 134# was obtained and no reweigh was obtained until 10/12/17, which was 144#. Review of the Nurse Practitioner (NP) notes dated 07/28/17 revealed the resident's blood sugars were trending low due to meal refusal. Notes dated 09/10/17 revealed the resident had a weight loss of 10# in one month. New orders included discontinuing [MEDICATION NAME] (insulin) due to risk for [DIAGNOSES REDACTED] (low blood sugar) decrease [MEDICATION NAME] (diuretic medication) to 20 milligrams (mg) and to monitor weekly weights times four. Review of the nurse's notes dated 09/01/17 to 10/12/17 revealed no evidence the physician, dietitian or family were notified regarding severe weight loss in the last 6 months. There was also no evidence found of such notification of a significant weight loss of a 5.3% in nine days from 09/17/17 to 10/01/17. Review of meal intakes from 09/01/17 to 10/12/17 revealed out of 127 meals offered the resident consumed less than 50% of her meals, 41 times, which equaled 30.9% of meals served during that time with less than 50% meal intake. Review of the dietary progress note dated 09/11/17 at 1:31 P.M. revealed Resident #35's weight was 151# on 09/04/17, will assess need for supplement upon reweigh results. Observation on 10/11/17 at 11:30 A.M. revealed Resident #35 was sitting in the dining room picking at her meatloaf. The resident was feeding herself with a staff member cueing her. Resident #35 ate approximately 50% of the meal. No alternative was offered. Interview on 10/12/2017 at 9:38 A.M. with Licensed Practical Nurse (LPN) #104 revealed the resident ate her meals in the dining room with staff cueing her. She had a good appetite and will eat most of her meals. LPN #104 was not sure if weekly weights were being done. Interview on 10/12/2017 at 10:00 A.M. with State tested Nurse Aide (STNA) #103 revealed Resident #35 would sometimes just forget what she was doing. The resident sat at the assist table and would eat most of her meals with encouragement. Interview on 10/12/2017 at 2:50 P.M. with Registered Dietitian (RD) #100 revealed the last documentation on Resident #35 was on 09/11/17. RD #100 reported if there was a problem with a resident's weights the facility would let her know. RD #100 verified that she had requested a reweigh on 09/11/17 for the weight done on 09/04/17 for Resident #35 of 151#. However, Resident #35 was not reweighed until 09/17/17 and the reweigh was still 151#. RD #100 stated that if she had been notified of the weight loss from 09/17/17 to 10/01/17, of 8# (5.3%) in 14 days she would have implemented a nutritional intervention to stabilize Resident #35's weight loss and prevent additional weight loss. RD #100 verified that from 04/24/17 to 10/12/17 there was a 20# weight loss (12%) for Resident #35 which indicated a significant weight loss in six months. RD #100 stated the facility could notify the physician and request a supplement if they could not get in touch with her. On 10/12/13 at 4:57 P.M. interview with RD #100 revealed she reviewed Resident #35's weights and updated her P(NAME) to include a health shake three times a day, which would add an additional 600 calories per day. The added intervention should stabilize Resident #35's weight and prevent further weight loss. RD #100 revealed Resident #35's current diet did not meet her current nutritional needs. RD #100 stated she felt the weight loss was actually desired and beneficial despite not having been addressed until today. However, had she known on 10/01/17 of Resident #35's weight loss she would have implemented nutritional intervention to prevent further weight loss. Interview on 10/12/2017 at 3:10 P.M. with the Director of Nursing (DON) revealed nurses should complete reweighs on residents if there was a significant weight difference. The DON stated if there was a significant weight loss, the physician, family and dietitian were to be notified. The DON verified Resident #35 should have been reweighed on 10/06/17 for a significant difference in weights from 143# to 134# in seven days, and then notified RD #100 and the physician. Interview on 10/12/17 at 4:45 P.M. with Resident #35's daughter revealed she had not been notified of Resident #35's weight loss. She stated she had noticed a weight loss but the nurses reassured her the resident was eating well. Resident #35's daughter stated she did not desire the weight loss and would like Resident #35's weight to be stable. Review of facility policy titled Weight Management Program and Weight Loss Policy, dated 05/05/17, revealed all residents will have their weight and nutritional status monitored and addressed as indicated. If there is a weight loss of five percent or more from the previous month, the resident will be reweighed and verified per designee before it is entered into point click care. The resident will then be added to weekly weights. A 5% weight loss/gain in 30 days, 7.5 % weight loss/gain in 90 days and a 10% weight loss/gain in 6 months will be considered a significant change. Physician and responsible party will be notified of weight loss per protocol. Dietician will be notified during routine visit of weight loss/gains, poor intakes and other condition changes pertaining to nutritional status.

Based on record review and staff interview, the facility failed to ensure adequate care was provided in regard to assessment and treatment of [REDACTED].#72). The census was 45. Harm occurred when Resident #72 had signs of a broken right hip and was moved from the floor into a wheelchair and then into bed. Documentation revealed the resident was ordered to be evaluated at the local emergency room (which was located next to the facility) at 9:00 P.M., but was not transferred until 10:36 P.M. Findings include: 1. Review of Resident #72's medical record revealed the resident was re-admitted to the facility on [DATE] after hospitalized for [REDACTED]. Review of Nurses's Notes dated 04/17/11 at 8:40 P.M., revealed Licensed Practical Nurse (LPN) #15 was alerted by a visitor that Resident #72 had fallen in the dining room. The resident was sitting with her back up against the wall by a bookcase and the men's restroom. Her right leg was turned outward and she couldn't lift her right leg. Resident #72 couldn't sit on the floor. She kept trying to get up. She was moved to a wheelchair and then put into bed. Resident #72's right hip was asymmetrical. According to the documentation, a physician's telephone order was received on 04/17/11 at 9:00 P.M., which directed to send Resident #72 to the emergency room . Further review revealed the resident was not sent out for an emergency evaluation until 10:36 P.M. On 04/18/11 at 1:51 A.M., according to the Nurses's Notes, Resident #72 was admitted to the hospital at 11:15 P.M. with a right [MEDICAL CONDITION]. On 01/12/12 at 2:10 P.M., LPN #15 was interviewed with the Director of Nursing (DON) present. LPN #15 stated she did move Resident #72 after she fell because she felt the resident was in danger of pulling the book case over on top of herself since she was so restless. According to LPN #15, Resident #72 exhibited signs of a possible broken hip. LPN #15 stated she used nursing judgement and moved the resident to the wheelchair then into bed. LPN #15 verified she waited until 10:36 P.M., before sending the resident to the emergency room . LPN #15 stated she may have used "poor" judgement.

Based on observation, clinical record review and staff interview, the facility failed to ensure comfort measures were provided in regard to a resident displaying pain during a dressing change. This affected one of three sampled residents (Resident #33). Harm occurred when Resident #33 did not receive a narcotic [MEDICATION NAME] prior to a dressing change. Resident #33 cried, moaned and had facial grimaces during a wound treatment completed 09/12/11. Findings include: On 09/12/11 at 10:15 A.M., observation of Licensed Practical Nurse (LPN) #145 completing a dressing change to Resident #33 revealed the resident was lying in her bed on her left side. Resident #33's right leg lateral aspect had an open area in the region of her knee and behind the knee. Resident #33's right leg was uncovered to expose the wound. The area had yellow slough. Pink tissue was in the center of the wound.According to review of the treatment administration record (TAR), Resident #33 was ordered on [DATE] to receive [MEDICATION NAME] AG (The dressing absorbs and interacts with wound exudate to form a soft, [MEDICATION NAME], gas-permeable gel that traps bacteria and conforms to the contours of the wound while providing a micro-environment that is believed to facilitate healing) to area at right knee. Cover with foam dressing and [MEDICATION NAME] (transparent film dressing). Change every three days. Throughout the dressing change, Resident #33 cried out in pain. Resident #33 either cried out, moaned, or stated "that hurts." When LPN #145 was applying the last layer of the treatment ([MEDICATION NAME]), Resident #33 stated "that hurts my leg." LPN #145 replied "I'm not touching your leg" as she patted down the dressing over the resident's wound. Resident #33 displayed evidence of both verbal and non-verbal signs of pain during the treatment. On 09/12/11 at 10:20 P.M., interview of LPN #145 after the treatment was completed, revealed LPN #145 stated Resident #33 frequently cried out or moaned on a daily basis. LPN #145 stated she had administered Tylenol approximately one hour prior to the treatment. LPN #145 verified the medication was the routine pain medication for the resident. She also stated the resident had an order for [REDACTED]. On 09/12/11 at 2:35 P.M., interview of State-tested Nurse Aides (STNAs) #150, #151 and #152, who were all familiar with Resident #33, stated she always cried out in pain, moaned or said her leg hurt. The STNAs stated the resident never seemed comfortable. Review of the Faces Pain Rating Scale (different faces were drawn to demonstrate 0 for no pain, 1/hurts a little bit, 2/hurts little more, 3/hurts even more, 4/hurts whole lot and 5/hurts worst). Review of the TAR for September 2011 revealed for the 10:00-6:00 shift, on 09/01/11, the resident rated a 3. One block was left blank and the other blocks up through 09/12/11 were all zeros. For the 6:00-2:00 shift, 09/01/11 through 09/03/11 were 3, 09/04/11 was 2, 09/05/11 through 09/08/11 were blank, 09/09/11 was zero and 09/10/11 through 09/12/11 were blank. Review of the pain rating scale for 2:00-10:00 shift revealed 09/01/11 through 09/03/11, the pain was identified at a 3. On 09/04/11, the pain was a 4, and zero on 09/05/11 and 09/06/11. A 3 on 09/07/11, blank on 09/08/11, zero on 09/09/11, blank on 09/10/11 and zero on 09/11/11. Review of the clinical record for Resident #33 revealed she had lived at the facility since 2007. According to the MAR indicated [REDACTED]. The record indicated Resident #33 had severely impaired cognition and had difficulty making her needs known; but could make concrete needs known. The record indicated the resident was dependant upon staff for care and services. Review of the plan of care for altered comfort (revised 03/02/11) indicated staff were to administer as needed (prn) pain medications as per physician's orders [REDACTED]. Review of Resident #33's MAR for September 2011 revealed she had last been medicated with a narcotic [MEDICATION NAME] 5-500 milligrams on 09/09/11 at 9:00 A.M. According to the prn [MEDICATION NAME] order, Resident #33 could have the medication every 4-6 hours as needed for pain. On 09/12/11 at 12:50 P.M., interview with the Director of Nursing (DON) verified Resident #33 needed to have the narcotic medication prior to the completion of the wound treatment to decrease her pain. This certification deficiency was an incidental finding identified during investigation of Complaint Number OH 194.

Based on observation, clinical record review, review of the facility's Pressure Areas/Ulcers and Skin Integrity Policy and staff interview, the facility failed to ensure a resident identified at risk for the development of pressure sores received care and treatment to ensure pressure sores did not occur. This affected one of three sampled residents reviewed for pressure sores (Resident #33). Harm occurred when Resident #33 developed an unstageable pressure area to her right lower extremity (RLE) /right calf lateral aspect after the facility failed to modify the resident's splint or obtain orders for evaluation of the splint. The resident had already developed pressure sores to her RLE foot and ankle on 02/03/11. Findings include: Clinical record review for Resident #33 revealed she was admitted to the facility in 2007 and was readmitted [DATE] with [DIAGNOSES REDACTED]. A spiral [MEDICAL CONDITION] occurred in December 2010. Review of Resident #33's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was identified as having severely impaired cognition, was totally dependant upon staff for all care and services, was incontinent of both bowel and bladder function, and had a Stage II (Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater) pressure sore. Review of Resident #33's skin assessment dated [DATE] revealed she was identified at high risk for the development of pressure sores. At the time of the assessment, Resident #33 did not have any identified pressure sores. In December 2010, Resident #33 was identified with a spiral fracture to the right leg. A splint was applied on 12/03/10. An order was written 02/03/11 to remove the splint daily to examine the skin of the resident. According the nursing documentation dated 02/03/11 at 5:54 P.M., multiple new wounds were noted when the splint was removed. The licensed practical nurse called the registered nurse to the resident's room to assess the resident's right lower extremity (RLE) after the new order was received to remove the splint to the RLE. The resident was assessed with [REDACTED]. The right heel was identified with epidermis intact but with nonblanchable purplish discoloration. New orders were received to apply foam dressing to areas and cover with transparent dressing, (there were no measurements documented in the nursing progress notes, nor was the surveyor provided with copies of the skin tracking with measurements for those areas when requested). There was no documentation that evidenced any modifications were made to Resident #33's splint. When the splint was removed on 02/10/11, there were red areas noted to the right ankle and foot. However, there was no evidence at that time any changes were made to the splint to prevent further skin breakdown. Review of the facility's Pressure Areas/Ulcers and Skin Integrity most recent revision date 10/16/09 under the heading documentation of pressure areas/ulcers staff were directed to measure the pressure area/ulcer in centimeters width, length, depth, wound margins, undermining, hands of the clock measurements for tunneling and describe the surrounding skin. Under the heading of Stages of pressure areas/ulcer revealed: A. Stage I: described as a persistent area of skin redness (without a break in skin that does not disappear within 30 minutes after pressure has relieved. A nonblanchable [DIAGNOSES REDACTED] of intact skin; B. Stage II: was described as a partial thickness loss of skin layers that presents clinically as an abrasion,blister or shallow crater. C. Stage III: described as a full thickness of skin loss, exposing subcutaneous tissues may include or be covered by necrotic tissue. Presents as a deep crater with or without undermining adjacent tissue usually not painful, may have infection present. D. Stage IV: A full thickness of skin and subcutaneous tissue is lost, exposing or into muscle and/or bone. The nursing progress notes dated 02/11/11 revealed all wounds continued as a Stage I; however, the right heel was assessed as dark purple nonblanching discoloration continues scant decline. Review of nursing documentation dated 02/19/11 revealed the right heel pressure ulcer had progressed from Stage I to Stage II. Epidermis now broken and integrity was compromised. Wound bed was red, nongranular with scant murky serosanquinous drainage. Periwound with nonblancying redness intact but frail epidermis. New orders were received for silvermed gel and foam cover dressing to the right heel. Review of the Treatment Administration Record (TAR) revealed the splint was removed daily from 02/02/11 to 03/02/11. According to the nursing documentation in the progress notes dated 03/02/11 at 7:44 A.M., a new area to the right calf lateral aspect was noted with assessment today. Pressure ulcer unstageable. It was a circular area with 100% soft, black slough, that remains stable. The periwound was identified with slow blanching [DIAGNOSES REDACTED] (redness). During the same assessment, another new pressure ulcer Stage II was identified at the right lateral ankle. It was described as circular with tacky, dry, pink nongranular wound bed.Review of the physician's progress notes dated 03/02/11 revealed Resident #33 had four wound areas. On 03/11/11, the physician identified the wounds were healing slowly. On 04/20/11, the physician documented multiple pressure areas were steadily improving. According to nursing documentation dated 03/12/11 at 11:22 A.M., all RLE wounds previously logged as pressure ulcers were now identified as vascular wounds. It was documented the new [DIAGNOSES REDACTED]. However, there was no documentation in the medical record that evidenced the [DIAGNOSES REDACTED]. Review of the most recent skin documentation dated 09/06/11 revealed the right calf wound measured 0.6 centimeters (cm) in length (l) by 0.4 cm width (w) by 0.25 depth (d). The color was light red, no drainage was present, the edges were well defined On 09/12/11 at 10:15 A.M., observation of Resident #33's right calf wound revealed the resident had an open area to the right leg lateral aspect by and behind the knee. The area had yellow slough and pink tissue in the center. The wound was identified as Stage II. On 09/12/11 at 2:10 P.M., interview with the director of nursing verified the area to Resident #33's right leg was a pressure ulcer. On 09/12/11 at 4:35 P.M., interview of Licensed Practical Nurse #146 verified there were no modifications to the splint to prevent further wounds from developing. This certification deficiency substantiated allegations contained in Complaint Number OH 194.