Every finding on record at Cumberland Pointe Care Center

Based on record review, including review of facility billing/financial information, interview, and review of the Administrator Job Description, the facility failed to be administered in a manner to prevent potential interruption in service or delay in receipt of inspection reports as a result of not following up timely to failed generator testing. This had the potential to affect all 66 residents residing in the facility. Findings include: In an interview on 09/11/2025 at 7:56 A.M. with Maintenance Director (MD) #501 revealed he had been employed by the corporation for three years. During the interview, MD #501 shared the concurrent life safety code survey had identified a concern related to the diesel generator system not being properly maintained following the inspection by the contracted company, Western Branch Diesel because he had not received the report from the company. The MD revealed someone at corporate had not paid the bill, therefore the report was not generated. He thought they had to pay $500 before it was able to be completed. Additional review revealed the last fuel analysis report for the diesel fuel in the emergency generator by the contractor was dated 08/14/24 and the fuel sample had failed the testing requirements. Further review revealed an interview with the Maintenance Director verified they had not received the results of the testing until they requested them from the generator contractor on the day of the survey, 09/08/25.On 09/11/2025 at 9:45 A.M., a phone interview with a Western Branch Diesel account representative revealed the facility had been delinquent with their account which had caused delays in service of the diesel generator, and the facility was currently waiting on samples which took approximately three or four days to complete. He indicated the facility accounting department and Western Branch accounting department got together this week and brought the account to current with an open line of credit. On 09/11/2025 at 11:15 A.M., an interview with the Administrator revealed he did not directly pay all facility bills. Local bills, including the local grocery, the water bill and whatever other small ones, were paid directly by the facility after he approved them. Other bills, including [NAME] Food Services and [NAME], which included larger volume services, were paid from a global account with corporate services and he never had to approve or see these invoices. During the interview, the Administrator revealed he believed there was a miscommunication with Western Branch Diesel resulting in non-payment of their outstanding bill. He reported Western Branch always used a biller for their account and indicated the biller had changed at some point in the recent past and the new biller had been sending invoices to an incorrect email, resulting in the facility not paying the past due account. Review of an invoice dated 03/13/25 to be paid to Western Branch Diesel revealed a balance due of $1,522.95. The date of service was 02/21/25 for a sister facility, owned and operated by the same corporation as [NAME] Pointe.Review of a copy of a check dated 07/30/25 revealed the check was made to the order of the Western Branch Diesel, Inc. in the amount of $1,522.95. There was no evidence the check had been cashed by the company.Review of the contract between the facility and Western Branch Diesel revealed Western Branch Diesel was responsible for routine/annual generator preventative maintenance.Review of the Administrator job description revealed the facility administrator would be responsible for all financial transactions for the facility.

Based on record review, observation and interviews, the facility failed to ensure dignity was maintained related to urinary catheter drainage bags and mealtime. This affected two residents (Resident #2 and #70) of three residents reviewed for dignity. The facility census was 66.Findings include: 1. Record review for Resident #2 revealed an admission date of 06/12/25 with diagnosis of obstructive uropathy, diabetes mellitus, congestive heart failure, and severe malnutrition.A review of the admission minimum data set assessment dated [DATE] revealed Resident #2 had moderate cognitive impairment and required maximum assistance for hygiene and was totally dependent upon staff for dressing, bed mobility, transfers, and nutrition.Review of the physician's orders revealed an order dated 06/12/25 for an indwelling urinary catheter to closed drainage related to a diagnosis of obstructive uropathyAn observation on 09/08/2025 at 10:27 A.M. revealed Resident #2 was lying in bed with an indwelling catheter. The urinary drainage bag was hanging on the bed frame without a private bag covering the drainage bag, with urine visible in the bag and the drainage bag was visible from the doorway.An interview 09/08/2025 at 11:15 A.M. with Licensed Practical Nurse (LPN) # 563 verified Resident #2's urinary catheter drainage bag did not have a privacy cover on it at the time of observation.2. A record review of Resident #70 revealed an admission date 10/09/12 with diagnosis of Alzheimer's disease, and need for assistance for personal care.A review of the quarterly minimum data set assessment dated [DATE] revealed that Resident #70 had severe cognitive impairment and required moderate to maximum assistance for eating and was dependent upon staff for performance of all other activities of daily living.An observation on 09/08/2025 at 12:42 P.M. revealed Certified Nursing Assistant (CNA) #556 approached Resident #70 and asked her to eat. CNA #556 stood over Resident #70 and attempted to feed Resident #70 some pears from her lunch tray while standing next to the resident. Resident #70 ate one bite and refused to open her mouth for more food. An interview on 09/08/2025 at 12:50 P.M. with CNA #556 verified they did attempt to feed Resident #70 while standing. CNA #556 verified they were aware staff should be seated while assisting residents with eating.

Based on medical record review, observations, and interviews the facility failed to ensure orders for restorative therapy were implemented timely. This affected one (Resident #12) of five residents reviewed for positioning. The facility census was 66. Findings include: Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including myocardial infarction, Parkinsonism, diabetes, muscle weakness, need for assistance with personal care, lack of coordination, muscle wasting and atrophy, tremors, difficulty walking, peripheral vascular disease, dementia, and other abnormalities of gait and mobility. Review of Resident #12's Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) was 12 (moderate cognition impairment) out of a possible 15 score, the resident had rejected care one to three days and had daily verbal behavior. The resident was dependent for mobility, supervision or touching assistance for eating, and had limited range of motion of both lower extremities. The resident did not receive restorative therapy. The resident had received speech, occupational, and physical therapy from 03/12/25 to 04/10/25. Review of Resident #12's assistance with activities of daily living (ADL) plan of care dated 02/11/20 revealed the resident may require assistance with ADL's and may be at risk for developing complications associated with decreased ADL self-performance related to dementia, dysphagia (difficulty swallowing), stroke, hemiplegia, weakness, psychiatric diagnoses physical limitations, unsteadiness, weakness, and fatigue. Assistance may vary from day to day, situation, and time of day. Resident was able to take a few steps a short distance, will do this when she is agitated/frustrated. The resident resists taking showers, out of bed some days. Experiences normal fluctuations in her mood/behavior/cognition affecting her participation in ADL's, socialization, and staff interactions. The resident's participation levels may vary according to mood/behavior. On 07/15/25 poor participation in restorative program was added to the plan of care. The resident's intervention included restorative nursing to evaluate and treat as needed, to encourage activity during daily care, explain all procedures prior to care, make adjustments to programs as necessary, monitor decline in care and report to clinical staff as needed, therapy to screen and provide treatment as indicated.Review of Resident #12's neurological note dated 07/29/25 revealed the resident was seen for a follow up. Per nursing staff, the resident had been stable and had no seizure activity. Tremors and memory were stable. The plan included continuing medications and may increase Exelon patch at next visit for impaired memory and chronic encephalopathy. For the deconditioning, impaired walking, with abnormal sensory exam the plan was restorative physical therapy for upper extremities three times per week due to the resident having maxed out physical therapy. Review of Resident #12's task revealed no evidence the resident had received restorative therapy from 07/29/25 to 09/11/25.Interview on 09/08/25 at 4:57 P.M., with Resident #12's brother revealed he had concerns with staff not getting his sister out of bed and assisting her with meals. Resident #21's brother reported he had spoke with the facility regarding these concerns, however every time he visited, she had been in bed, and he had to assist her with meals.Interview on 09/11/25 at 3:13 P.M., with Director of Nursing (DON) #512 confirmed Resident #12 was not receiving restorative services per the neurologist orders on 07/29/25. The DON reported the resident had refused restorative services in the past. Interview on 09/11/25 at 3:13 P.M., and 09/15/25 at 11:03 A.M., with Therapy Manger/Physical Therapy Assistant (PTA) #601 confirmed she was not aware the neurologist had made recommendation for restorative on 07/29/25. PTA #601 reported therapy had performed a quarterly therapy screen on 08/11/25, however staff had not reported any changes, or the neurologist had ordered restorative therapy therefore the resident was not picked up for therapy or restorative services. The PTA confirmed during the quarterly screen the therapist does not touch the resident and just performed observations and interviews to determine if the residents need evaluation for services. The PTA reported the resident had a history of refusing restorative, however if she had known the neurologist had ordered restorative service, the facility would have attempted to provide restorative services. The PTA reported therapy had screened the resident on Friday (09/11/25) and speech and occupation therapy had picked up the resident for services. The resident had refused the physical therapy screen on Friday 09/12/25, however the physical therapist was going to try again today, 09/15/25.

Based on medical record review, review of fall incident report, interview, observation the facility failed to ensure fall interventions were in place per plan of care and failed to ensure in use wheelchairs were maintained without cracks, tears and exposed padding. This affected two residents (Resident #5 and #8) of three residents reviewed for accidents. The facility census was 66.Findings include: 1. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including fracture of rim of left pubis and left acetabulum, repeated falls, cognitive communication deficit, hallucinations, disorientation, weakness, and end stage renal disease. Review of Resident #5's fall report dated 09/10/24 to 09/10/25 revealed the residents had fifteen falls in one year. Review of Resident #5's fall plan of care dated 10/01/24 revealed the resident was at risk for falls due to debilitation, weakness, dementia, impaired cognition, memory impairment, pain, poor decision making, use of psychotropic medication, rare episodes of incontinence, difficulty walking, abnormal gait/mobility, and repeated falls. The fall intervention included on 02/19/25 visual reminder to wear non-skid footwear was added and 04/29/25 motion sensor in room was added. Observation on 09/10/25 at 7:55 A.M. of Resident #5's room with the Maintenance Director (MD) revealed the motion detector was not alarming/sounding and no evidence of a visual reminder to wear non-skid footwear. The surveyor and MD were walking around in the resident room without the motion detector alarming. Observation on 09/10/25 at 8:05 A.M., of Resident #5's room with Registered Nurse (RN) #541 revealed the motion detector was not alarming/sounding and no evidence of a visual reminder to wear non-skid footwear. The RN was walking around the room and removed a dressing from the resident's left leg without the motion detector alarming. Observation on 09/10/25 at 8:20 A.M., of Resident #5's room with Certified Nursing Aide (CNA) #554 revealed the motion detector was not alarming/sounding. The CNA confirmed the motion detector was not functioning properly. The CNA attempted to reset the motion detector several times; however, it continued to not function. Observation on 09/10/25 at 2:33 P.M., of Resident #5's room with Director of Nursing (DON) #512 confirmed there was no visual reminder to wear non-skid footwear per the resident's plan of care. The DON reported that the resident was recently moved to this room and maybe the visual reminder was left in the other room. Observation of the resident's previous room revealed no evidence the visual reminder remained in that room. Interview on 09/10/25 at 8:26 A.M., with RN #541 confirmed during observation on 09/10/25 at 8:05 A.M., the motion detector was not alarming when the surveyor and herself were in the room. Observation on 09/11/25 at 8:01 A.M., of Resident #5's room revealed Restorative Aide #800 was providing services to Resident #5. The motion detector was not alarming. The Restorative Aide reported she did not touch the motion detector. RN #552 entered Resident #5's room during observation and confirmed the motion detector was turned on but not functioning. Observation on 09/11/25 at 9:28 A.M., of Resident #5's room with Maintenance Director (MD) confirmed the motion detector was on however it was still not functioning. The MD reported he was not aware the motion detector was malfunctioning, and he would replace the detector. 2. Review of Resident #8's medical record revealed an admission date of 04/14/16, a re-entry date of 02/03/25 and diagnoses including, but not limited to, schizoaffective disorder bipolar type, hypertension, paroxysmal atrial fibrillation , anemia, anxiety, major depressive disorder, and unspecified intellectual disabilities. Review of Resident #8's significant change Minimum Data Set (MDS) assessment, dated 08/12/25, revealed a Brief Interview for Mental Status (BIMS) score of nine, out of a possible score of 15, indicating the resident had impaired cognition. The resident used a wheelchair for mobility and required supervision for wheelchair use. An observation on 09/08/2025 at 3:30 P.M. revealed Resident #8 was seated in a manual wheelchair with the vinyl of the top left hand side of the seat back cracked and torn and the inner padding of the wheelchair seat back visible, where it attached to the metal frame of the wheelchair. The tear was about an inch long. An observation on 09/11/2025 at 8:40 A.M. revealed Resident #8 was seated in a manual wheelchair with the vinyl on the of the top left hand side of the seat back cracked and torn and the inner padding of the wheelchair seat back visible, where it attached to the metal frame of the wheelchair. The tear was about three inches long. In an interview on 09/11/2025 at 8:45 A.M. Licensed Practical Nurse (LPN) #564 verified Resident #8 was seated in a manual wheelchair with the vinyl on the of the top left hand side of the seat back cracked and torn and the inner padding of the wheelchair seat back visible, where it attached to the metal frame of the wheelchair.

Based on medical record review, review of resident counsel minutes, observation, interviews, and policy review the facility failed to ensure residents received adequate hydration and changes in nutritional status were addressed timely. This affected two (Resident #9 and #12) of two reviewed for hydration and two (Resident #12 and #38) of eight reviewed for nutrition. The facility census was 66. Findings include: 1.Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Ogilvie's syndrome, bipolar, depression, anxiety, chronic obstructive pulmonary disease, type two diabetes mellitus, Parkinson disease, heart failure, muscle weakness, need for assistance with personal care, lack of coordination, muscle wasting and atrophy, encephalopathy, tremors, dementia, anemia, fatigue, heart disease, heartburn, gastric reflux, and hemiplegia. Review of Resident #12's Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognition impairment, required supervision or touching assistance with eating. The resident was a therapeutic mechanically altered diet and had no signs or symptoms of swallowing difficulties. Review of Resident #12's alteration in nutrition and hydration plan of care dated 10/13/22 revealed monitor weights, monitor of signs and symptoms of dehydration, offer alternative fluids, offer meal substitutes when foods are refused, provide assistance with meals/snacks, registered dietician and speech referral as needed. Review of Resident #12's orders dated 09/2025 revealed the resident was ordered a low concentrated sweet and no added salt mechanical soft texture diet with thin consistency fluids. Two handled cups and built-up utensils for meals since 04/25/25. a. Observation on 09/08/25 9:58 A.M. of Resident #12 revealed the resident was in bed and had no fluids available. Interview with Certified Nursing Assistant (CNA) #554 confirmed findings and reported the resident was on fluid restriction in the past but she was not sure about now. Observation on 09/09/25 at 12:32 P.M., of Resident #12 revealed the resident was in a low bed with one side of the bed against the wall and a floor mat on the other side of the bed asleep. The resident ' s bedside table was across the room with a Styrofoam cup however it was not in the resident ' s reach. Observation on 09/10/25 at 8:41 A.M., 11:23 A.M., and 2:21 P.M., of Resident #12 revealed the resident was in bed. The resident had Styrofoam cup, however no straw in the cup. Observation on 09/11/25 at 9:07 A.M., of Resident #12 revealed the resident was in bed. The resident had a Styrofoam cup on the bedside table that was located across the room not in the resident ' s reach. The cup had little ice but no water. Registered Nurse (RN) #552 confirmed the resident was non ambulatory and would not be able to reach the cup that was on the bedside table across the room. The RN confirmed the cup only contained a small amount of ice and no water or straw. The RN confirmed the resident was ordered handled cups for meals but was not sure why she had foam cup in her room and not handled cups. Interview on 09/11/25 at 9:54 A.M., with CNA #553 revealed she was usually assigned to Resident #12's hall. The CNA reported the resident was not ambulatory and would require the bedside table to be near her bed to reach fluids. The CNA reported that the resident can use foam cups with straws, however for meals the resident receives handled cups due to her tremors and risk of spilling the fluids. Interview on 09/11/25 at 11:26 A.M., with Registered Dietary Technician (RDT) #600 revealed the facility doesn't monitor fluid intakes and she assumes the fluid provided to Resident #12's via meal [NAME] and the twenty ounces that were provided during water/ice pass each shift would meet the resident needs. The RDT confirmed she had no documented evidence to ensure the resident was receiving adequate hydration. The RDT confirmed she was not aware there as issues with ice water not being passed on dayshift per the resident council meeting the last two months. b. Observation on 09/08/25 at 9:59 A.M., of Resident #12 revealed the resident was lying in bed with large pieces of pancakes lying on her chest and abdomen. The residents ' breakfast [NAME] was no present in the room. Review of Resident #12's weights on 09/08/25 revealed on 08/07/25 the resident weighed 207.2 pounds and 09/05/25 192.2 pounds indicating a 12.2-pound weight loss (7.2%). There was no evidence that the resident was re-weighed. Review of Resident #12's medical record on 09/08/25 revealed no evidence an intervention was implemented, the resident, family, or provider was notified of significant weight loss that was noted on 09/05/25. Interview on 09/08/25 at 4:57 P.M., with Resident #12's brother revealed the staff don't encourage Resident #12 to get up for meals or assist her with meals. Resident #12's brother reported he had voiced concerns to the facility, however every time he visits the resident was in bed and he has to assist her with meals to get her to eat. Interview on 09/11/25 at 9:54 A.M., with CNA #553 revealed the resident usually eats in her room and doesn't require much staff assistance. Interview on 09/11/25 at 11:26 A.M., with Registered Dietary Technician (RDT) #600 revealed she typically only visited the facility weekly on Wednesday and Fridays. RDT #600 confirmed she was responsible for entering weights into the electronic medical record and notify the providers of weight gains or loss. The RDT reported she was not aware of Resident #12's significant weight loss until 09/09/25. This week she had been in the facility daily due to the dietary manger being on vacation. The RDT reported she was trained she had seven days to address significant weight loss and seven days to notify the provider. The RDT confirmed the facility did not have a policy regarding the seven-day notification and it was just part of her training. The RDT reported if weights were obtained on Friday after she left, she would not address them until the following Wednesday when she returned to the facility. The RDT reported when she entered the weights into the electronic medical record she changed the date to reflect the date the weight should have been obtained. The RDT confirmed there was no documented evidence the resident was re-weighed after 09/05/25 to ensure the weight was accurate. The RDT reported usually, a second weight should be obtained within 24 hours to confirm accuracy. The RDT confirmed Resident #12 had a significant weight loss on 09/05/25, however she did not notify the doctor or implement new interventions for Resident #12 until 09/09/25. The RDT reported she had requested the staff to re-weigh the resident today for accuracy. The RDT confirmed she had not observed the resident eating a meal or interview the resident at this time. She had spoke to the Administrator and Director of Nursing on Monday regarding the resident and ensuring the resident was up for all meals however she never documented or notified the floor staff of the recommendations. The RDT reported she had talked to speech this morning regarding a referral. The RDT confirmed there was no documentation the resident had refused to be weighed, or the resident had skin alterations. The RDT reported that the resident was on ProSource daily and she increased it on 09/09/25 to three times daily due to the resident was accepting the ProSource prior and it was the least amount of fluids with high concentration of protein and calories. The provider accepted the recommendation on 09/10/25 to increase the ProSource. Interview on 09/11/25 at 12:08 P.M., with Director of Nursing (DON) #512 revealed she had overheard the conversation with RDT #600 indicating the resident had not been re-weighed after 09/05/25 to the surveyor and she wanted to provide documented evidence the staff had re-weighed Resident #12 on 09/09/25. The DON showed the surveyor on her phone documented evidence the RDT was notified of the re-weight on 09/09/25 of 195 pounds. Interview on 09/11/25 at 12:50 P.M., with RDT #600 revealed the DON had brought it to her attention that the resident was re-weighed on 09/09/25 and she had entered the weight today, however the documentation would indicate it was added on 09/09/25. Interview on 09/15/25 at 9:58 A.M.,11:15 A.M., and 12:08 P.M. with Registered Dietician (RD) #602 confirmed the RDT was responsible for entering weights and the electronic medical record and notifying family and the providers. The RD reported the RDT was only in the facility twice weekly because she had other facility's she visited. The RDT usually provided the facility with a list of residents that needed weighed. The RD reported part of the nutritional assessment should include interviews with staff, families, and residents as well as observation of meal intakes. The RD reported the RDT had other homes to provide care for, and she believed a week to address significant weight loss was acceptable. The RDT confirmed the facility's policy did not include a timeframe on weighing nor did the facility have any policy on nutritional assessments. The facility utilizes a systemic approach to optimize each resident's nutritional status. The process may include identifying and evaluating nutritional status and risk factors, developing and implementing pertinent approaches, monitoring the effectiveness of interventions and revising them as necessary. A comprehensive nutritional assessment is completed upon admission to identify those at risk for unplanned weight loss/gain or compromised nutritional status. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional needs, including the resident's personal goals and preferences. Intervention are implemented, monitored and modified, consistent with the residents' assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. A weight monitoring schedule is developed upon admission for all residents. Newly recorded weights are compared to the previous recorded weights. A significant weight change was defined as 5% change in one month and 10% change in six months. Significant changes in weight are reported to the practitioner. 2. Review of the medical record of Resident #09 revealed admission to facility on 06/17/23 for diagnosis including moderate protein-calorie malnutrition, Alzheimer's disease, depression, bipolar, schizoaffective disorder (paranoid thoughts), diabetes, pain, anxiety, history of falls, parkinsonism (tremors of extremities and balance problems), and atrial fibrillation (irregular heart rate). Review of the most recent quarterly Minimum Data Set 3.0 (MDS 3.0) dated 06/23/25 revealed Resident #09 was admitted to hospice services. Further review of the MDS 3.0 revealed the brief interview of mental status (BIMS) indicated Resident #09 had a score of 00/15 indicating severe cognitive impairment. MDS 3.0 indicated Resident #09 required meal set up and supervision with feeding self and was able to walk independently with supervision. Review of the physician orders summary revealed Resident #09 was prescribed a regular diet with thin liquids. Further review of order summary revealed Resident #09 was prescribed a 1500 milliliter (ml) fluid restriction that was discontinued on 02/14/25 by the physician. Review of the hospice care plan dated 06/16/25 through 09/13/25 revealed Resident #09 was on thin liquids with no fluid restriction ordered. Observation on 09/10/25 at 8:39 A.M. of Resident #09 revealed the resident was sleeping in their room with no fluids on their bedside table noted. Observation on 09/10/25 at 2:55 P.M. of Resident #09 revealed the resident was sleeping with music playing in their room and the lights out. There was a Styrofoam cup on the bedside table with orange colored drops of fluid on it and a 240 ml unopened can of cola. The bedside table was on the opposite side of the room from the resident while in bed and not with in reach of Resident #09. Interview on 09/10/25 at 9:58 A.M., with Certified Nursing Assistant (CNA) #554 confirmed Resident #09 did not have fluids available and believed the resident was on fluid restriction in the past but not sure about now. Interview on 09/10/25 at 9:13 A.M. with CNA #553 revealed Resident #09 had not been feeling well and the last two days she was incontinent of urine, sleeping more, and talking less. Interview on 09/10/25 at 3:00 P.M. with RN #544 revealed the CNAs and Nurses pick up resident trays after meals and record meal consumption percentage in the medical record but do not record fluid intake. Interview on 09/11/2025 at 09:33 A.M. with Registered Diet Technician (RDT) #600 revealed the facility resident diet list is printed weekly on Mondays. RDT #600 further verified the diet list printed on 09/08/25 indicated Resident #09 was on a regular diet with a fluid restriction of 1500 ml per day allowing for 720 ml per day to be provided from the kitchen on meal trays the resident received during the day and 780 ml to be provided by nursing staff at bedside. Review of the lunch ticket for Resident #09 revealed 1500 ml fluid restriction with 240 ml to be provided at lunch. RDT #600 verified the lunch ticket indicated a 1500 ml fluid restriction and 240 ml of allotted fluids for the lunch meal. Interview on 09/11/25 at 9:40 A.M. with CNA #507 revealed she was unsure of which residents on the 100 hall were on fluid restriction and she believed it was one or two residents, but she would get further clarification. CNA #507 returned and reported she went to the kitchen and checked the master diet list and verified with the RDT #600 that Resident #09 was one of two residents on the 100 floor with a fluid restriction. CNA #507 reported she tried to pass water and ice twice a shift but definitely did it at least once every shift and as needed if residents requested. Interview on 09/11/25 at 9:55 A.M. with RN # 552 revealed Resident #09's care plan indicated a regular diet with thin liquids and no fluid restrictions. RN #552 verified Resident #09's fluid restriction was discontinued in February of 2025. RN #552 reported that Resident #09 had been sleeping more and less active for the past two days and hospice had increased services to daily RN visits for three days in a row to monitor. Interview on 09/11/25 at 11:26 A.M., with Registered Dietary Technician (RDT) #600 confirmed the meal ticket was inaccurate and Resident #09 was not currently ordered a fluid restriction. The RDT confirmed the fluid restriction order was discontinued back in February of 2025 and didn't know why it was not removed from the resident meal ticket. The RDT confirmed the meal ticket was updated and she notified staff the resident was not on fluid restriction. Interview on 09/11/25 at 1:08 P.M. with the primary hospice nurse revealed the resident was on a pleasure diet and currently had no fluid restrictions. The hospice aides would offer and encourage fluids during their time spent with the resident. Review of Resident Council meeting minutes dated July and August of 2025 revealed residents voicing concerns about day shift not passing ice and fresh water and they only get it on night shift. The facility response action taken section of the memo dated 08/11/25 included auditing CNA two times a week for ice water pass for two weeks and addressing any concerns as needed. 3. Review of the medical record for Resident #38 revealed an admission date of 08/12/25 . Diagnoses included but were not limited to subacute osteomyelitis, right ankle and foot; type 2 diabetes with foot ulcer; muscle weakness; type 2 diabetes mellitus without complications; unspecified asthma; other abnormalities of gait and mobility, unspecified systolic (congestive) heart failure; obstructive sleep apnea; hereditary and idiopathic neuropathy; anxiety disorder; bipolar disorder; essential hypertension; hyperlipidemia; pain; unspecified atrial fibrillation; gastroesophageal reflux disease; chronic rhinitis; constipation; personal history of malignant melanoma of the skin; personal history of transient ischemic attack and cerebral infarction without residual deficits; hereditary motor and sensory neuropathy; post traumatic stress disorder. Review of medical record for Resident #38 revealed a care plan, dated 08/16/25, which indicated a focus was initiated for nutrition and hydration related to nutritional risk, diabetes, congestive heart failure, gastroesophageal reflux disease, presence of diabetic ulcer and pressure ulcer. The interventions for the nutrition and hydration focus item included a Registered Dietician referral as needed. An update of this care plan on 09/01/25 indicated the facility was to provide supplement as ordered. Review of the medical record for Resident #38 revealed a malnutrition risk assessment, dated 08/18/25. The assessment was completed by Registered Dietary Technician (DTR) #600. The assessment revealed the resident scored a 10.0, which indicated the resident was at moderate risk for malnutrition. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 08/19/25, revealed a Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 13 to 15 points indicated cognitive intactness. The resident was identified as using a motorized wheelchair prior to admission. On admission, Resident #38 was reported to be using a walker, requiring supervision or touch assistance to eat, for upper body dressing, and for personal hygiene. She required setup or clean-up assistance to perform oral hygiene, substantial/maximal assistance for lower body dressing, and was dependent in toileting and bathing. The MDS also indicated the resident was on a therapeutic diet. Review of the medical record for Resident #38 revealed an initial dietary assessment, dated 08/18/25, which indicated the resident was at moderate risk for decline in nutrition or malnutrition as evidenced by the malnutrition risk assessment. The assessment, completed by DTR #600, recommended Prosource (a ready to serve concentrated liquid protein) 30 milliliters (mL) twice daily, which, according to the assessment would provide 200 kilocalories and 30 grams of protein to the resident daily. Review of the medical record for Resident #38 revealed an order for Prosource, dated 08/29/25. The order was for the resident to receive Prosource 30 mL twice daily. Review of the medical record for Resident #38 revealed on 08/13/25, the resident weighed 197 pounds (lbs). On 09/05/2025, the resident weighed 187 lbs., which was a -5.08% loss. A 5% weight loss in one month indicated severe weight loss. On 09/11/2025 at 10:23 A.M., an interview with Director of Nursing (DON) #502 revealed once DTR #600 completed a dietary assessment, any recommendations would be sent via email to DON #502 for follow up with the physician. She indicated she received an email from DTR #600 on 08/28/25, which said Resident #38 required Prosource 30 ml twice daily. Review of an email from DTR #600, dated 08/28/25 at 10:30 P.M., to DON #502, which confirmed these findings. On 09/15/25 at 9:45 A.M., an interview with Dietician #602 revealed her expectation for dietary assessments and follow through with recommendations would be two days. She indicated the Registered Dietary Technician (RDT) would complete assessment on admission, send a text to the nurses, and the nurses would take care of the orders with the doctor. She indicated the follow up from day of assessment should be within a week, however she also indicated significant weight loss (5% in one month, 7.5% in three months, or 10% in six months) should be addressed within two days. On 09/15/2025 at 10:38 A.M., an interview with DTR #600 confirmed there had been a 10 day delay between the date the nutritional assessment for Resident #38 was completed to when recommendations were relayed to nursing. She confirmed the nutritional assessment was completed on 08/18/25, recommendations were not sent to nursing until 08/28/25, and an order was entered on 08/29/25 for Prosource 30 mL twice daily. Review of the facility's policy titled Weight Monitoring dated 02/15/24 revealed based on the resident's comprehensive assessment, the facility would ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicated otherwise.

Based on observation, interview, review of manufacture guidelines, and policy review the facility failed to provide post-inhaler care per guidelines to prevent potential complications due to use. This affected one resident (Resident #22) of two residents observed for medication administration. The facility census was 66.Findings Include: Review of the medical record for Resident #22 revealed an initial admission date of 06/29/18 with diagnosis including tumor of kidney, lung disease, heart failure, stroke, difficulty swallowing, weakness, moderate intellectual disability, epilepsy, high blood pressure, and depression.Review of Resident #22 physician order summary for September 2025 revealed an order for QVAR Redihaler 80 micrograms (mcg) inhale one puff twice a day.On 09/09/25 at 7:55 A.M. Licensed Practical Nurse (LPN) #544 was observed to prepare medications, including the QVAR Redihaler for Resident #22.On 09/09/25 at 8:04 A.M. LPN #544 was observed to administer the oral medications to Resident #22. The resident was observed to drink four ounces of water provided, following the medications. LPN #544 handed Resident #22 the QVAR inhaler to self-administer. Resident #22 shook the inhaler then inhaled one puff of the inhaler medication as ordered. Resident #22 gave the inhaler back to LPN #544. Resident #22 was not observed to rinse his mouth following use of the inhaler and LPN #544 did not advise the resident to rinse his mouth after the inhaler use. Review of the medication administration record for September 2025 revealed instruction for the resident to rinse their mouth with water and do not swallow the water after using QVAR Redihaler. Interview on 09/09/25 at 9:53 A.M. with LPN #544 confirmed she did not advise or instruct Resident #22 to rinse his mouth after the inhaler was used and stated, he will do it later.Review of the Teva (manufacturer) medication information insert (located with the inhaler inside the medication box) for the QVAR Redihaler revealed warnings and precautions on page one as follows, oropharyngeal candidiasis infection of the mouth and throat may occur. Monitor patients periodically for signs of adverse effects on the oral cavity. Advise patients to rinse their mouth with water without swallowing after inhalation to reduce risk.

Based on staff observation, record review, staff interviews, and policy review the facility failed to prepare and administer medications in a sanitary manner for Resident #55. This affected one (Resident #55) of two residents observed for medication administration. The facility census was 66.Findings include: Review of medical record review for Resident #55 revealed admission to facility on 08/21/22 for diagnosis including: chronic lung disease, vascular dementia (narrowing of blood vessels in brain leading to forgetfulness and confusion), bipolar disorder, diabetes mellitus, major depression, difficulty in walking, high blood pressure, weakness, and low back pain.Further review of the medical record revealed physician orders for Farxiga (diabetes medication) 10 milligrams by mouth daily in additional to other medications to be administered in the morning for Resident #55.Observation on 09/09/2025 at 7:35 A.M. of Registered Nurse (RN) #541 revealed the nurse prepared medication for Resident #55. The RN was observed to drop the Farxiga directly on top of the medication cart and using her bare hand, picked up the pill from the medication cart and placed the pill in the medication cup to be administered with other medication. Once preparation of medications was completed, RN #541 was observed to administered the medications to Resident #55.Interview on 09/09/2025 at 7:44 A.M. with RN #541 confirmed she picked up the Farxiga pill after dropping it on the medication cart and placed the pill in the medication cup using her bare hand. and administered the medication to Resident #55. RN #541 reported she should have gotten a new Farxiga pill but did not. Review of the Medication Administration Policy dated 06/21/2017 revealed all tablets and capsules are to be poured into the medication cup. Never touch medication with fingers.

Based on review of the medical record, review of the facility menus, review of incident logs, resident interviews and staff interviews, the facility failed to ensure Resident #47 #53, and #57 were able to make meal choices which aligned with their preferences. This affected three residents (Resident #47, #53, #57) of five reviewed for residents rights with meal preferences.Findings include:1. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, shortness of breath, chronic pain, dysphagia, major depressive disorder, anxiety disorder, osteoarthritis, presbyopia, hearing loss, insomnia, and osteoporosis.Review of the endoscopy results dated 01/14/25 revealed no observed deficits and recommended upgrading Resident #53's diet from mechanical soft to regular consistency and thin liquidsReview of the physician's orders revealed Resident #53 had a regular diet with regular texture and thin liquids dated 01/14/25. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #53 had intact cognition, was not on a mechanically altered diet, and the resident had no swallowing disorders.Review of the plan of care dated 03/25/25 revealed Resident #53 had alteration in chewing, swallowing related to dysphagia-oral phase, oropharyngeal phase dysphagia, and tracheal deviation. Interventions included educating the resident and family on chewing and swallowing precautions, encouraging the resident to eat slowly and chew thoroughly, follow up with an Ear, Nose and Throat Specialist, monitor weight loss, dehydration, and aspiration pneumonia, monitor for chewing or swallowing difficulties, place the resident in a sitting or upright position during meals, and speech therapy to evaluate and treat as indicated.Review of the progress notes from 02/12/25 to 08/12/25 revealed no documentation of Resident #53 choking on food. An interview on 08/12/25 at 9:45 A.M. with Resident #53 revealed about a year ago they stopped serving them hot dogs and kielbasa. She stated they were told they were a choking hazard. She stated any food item could be a choking hazard if that were the case. She stated she wanted hot dogs especially during the summer cook outs. She stated she was told she could have someone bring her one in, however she had no way of doing that. She stated she had asked numerous times for a hot dog and was always told no.2. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease, renal dialysis, diabetes, decreased white blood count, neutropenia, cardiomyopathy, hypertension, and peripheral vascular diseases.Review of the physician's orders revealed Resident #47 had an order for a low concentrated sweet, no added salt, regular texture with thin liquid diet and a 1500 milliliter fluid restriction dated 11/17/23.Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #47 had intact cognition and had no swallowing disorders.Review of the progress notes from 02/12/25 to 08/12/25 revealed no documentation of Resident #47 choking on food.An interview on 08/12/25 at 12:50 P.M. with Resident #47 revealed the facility had a lot of stuff he did not eat so he would order hot dogs instead, then he was told he could not have hot dogs anymore. He stated he had been ordering cheeseburgers and grilled chicken from the alternate menu, but it would be nice to have a hot dog occasionally.3. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, nontraumatic intracerebral hemorrhage, acute kidney disease, heart failure, major depressive disorder, intermittent explosive disorder, polyneuropathy, peripheral vascular disease, insomnia, anorexia, mood disorder, hypertension, benign prostatic hyperplasia, and edema.Review of the physician's orders revealed Resident #57 had an order for a regular diet with regular texture and thin liquids dated 05/20/23.Review of the Quarterly Minimum Data Set assessment revealed Resident #57 had intact cognition and had no swallowing disorders.Review of the progress notes from 02/12/25 to 08/12/25 revealed no documentation of Resident #57 choking on food.Review of the Always Offered Menu revealed there were no hot dogs listed on the menu.Review of the four-week menu rotation revealed no encased-link meat on the menu.Review of the incident log from 02/12/25 to 08/12/25 revealed no incidents of choking in the facility.An interview on 08/12/25 at 10:05 A.M. with Dietary Manager #300 revealed she received an email about a year ago stating they were to stop serving encased-meat links. She stated they were not given a reason except that it was corporate wide. She stated she was able to find no-casing sausage links for breakfast and bratwurst patties, but there was not a substitution for hot dogs. She stated several residents had asked for them at resident council. She stated she had to tell them that the facility could not serve them and they must pick something else as their meal of choice. She stated they had also complained to her about hot dogs not being on the alternate menu.An interview on 08/12/25 at 10:10 A.M. with the Administrator revealed the facility was not telling the residents they could not have hot dogs, the facility was just not serving them anymore. He stated the residents were more than welcome to have someone bring them in a hot dog or they could order one to be delivered. He stated they did not serve them filet [NAME] either so he did not understand why not serving them hot dogs would be any different. He stated they could use their monthly allowance to order a hot dog from the community if that was what they really wanted to do. An interview on 08/12/25 at 11:35 A.M. with the Administrator revealed they facility did not have a policy on not serving encased-meat links, however they stopped serving them on 01/01/25. He stated the residents were still able to choose something for the alternate menu, so they were not restricting their right to choose. He stated the facility was just not offering them a hot dog as an alternative. An interview on 08/12/25 at 12:00 P.M. with the Administrator revealed he did not know why they eliminated hot dogs and would assume it was due to them being a choking hazard or liability concern. He stated he did not believe they were violating any resident rights and did not know of any regulatory tags which stated they had to offer all foods to the residents. He stated they had offered the resident items in place of hot dogs on the menu and that was what the regulation stated. He stated Dietary Manager #300 has worked with the residents to provide alternatives to hot dogs. He verified they were previously on the menu prior to 01/01/25. An interview on 08/12/25 at 12:50 P.M. with Resident #57 revealed the facility had a lot of stuff he did not eat so he would order hot dogs instead, then he was told he could not have hot dogs anymore. He stated he had been ordering cheeseburgers and grilled chicken from the alternate menu, but it would be nice to have a hot dog occasionally.This deficiency represents non-compliance investigated under Complaint Number 2584123.

Based on review of the facility Payroll Based Journal (PBJ) submission data for the third quarter of 2024, review of the facility assessment, review of medical records, review of shower sheets, and staff and resident interviews, the facility failed to maintain sufficient levels of direct care staff to meet the total care needs of all residents. This affected five residents (#16 , #25, #27, #31, and #52) and had the potential to affect all 62 residents residing in the facility. Findings include: 1a. Record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, dysphagia, muscle weakness, dyspnea, contractures of right and left upper arm muscle, right and left foot drop, contractures of right and left knee, Ogilvie syndrome, dry mouth, quadriplegia, pain, and history of falling. Review of a social service note dated 09/25/24 revealed the resident can make his wants and needs known. He has a BIMS of 15. Review of Resident #27's minimum data set (MDS) assessment dated [DATE] revealed no behaviors including rejection of care. The resident was dependent on staff for self-care and had impairment of range of motion on both upper and lower extremity. Review of Resident #27's activities of daily living (ADL) plan of care dated 10/18/23 revealed the resident may require assistance with ADL's and may be at risk for developing complications associated with decreased ADL self-performance related to quadriplegia, chronic obstructive pulmonary disease, physical limitation, weakness, hard of hearing, congestive heart failure, contractors, and respiratory failure. The resident refuses showers at times. Review of the shower schedule revealed the resident was scheduled for shower on Monday, Wednesday, and Friday. Review of the paper shower sheets, and electronic medical record revealed no evidence the resident received a shower on 09/25/24. Review of Resident #27's progress notes dated 09/01/24 to 10/03/24 revealed no evidence of refusals of a shower/bath on 09/25/24. Interview on 10/03/24 2:36 P.M., with Resident #27 confirmed he did not get a shower one day last week and was told it was because a staff member had called off and there wasn't enough staff. The resident reported lately there hasn't been enough staff, and the facility keeps sending staff home due to low census. The resident also reported he required more assistance because he can't use his hands, so he has to call for assistance to even get a drink of water. The resident reported on Monday (09/30/24) he did refuse his shower because he was nauseated and sick, but he did not refuse last week. Interview on 10/03/24 at 2:55 P.M., with the Director of Nursing #101 and #102 confirmed there was no documented evidence Resident #27 had received a shower on 09/25/24, however it was not related to staffing shortage. The facility had a call off that day, but the call off was covered. The facility felt it was a communication issue and the aides were provided education. b. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including heart failure, muscle weakness, dysphagia, need for assistance with personal care, adult failure to thrive, dementia, pain, anxiety, and shortness of breath. Review of Resident #31's Minimum Data Set (MDS) assessment dated [DATE] revealed no evidence the resident had behaviors including rejection of care. Review of Resident #31's assistance with activity of daily living plan (ADL) of care dated 04/18/22 and revised 07/17/22 revealed the resident may require assistance with ADL and may be at risk for developing complications associated with decrease ADL self-performance, weakness, unsteadiness, needs assist with personal care, adult failure to thrive, dementia, without behavioral disturbances, pain, shortness of breath, experiences behavioral episodes at times. Participation levels may vary day to day, time of day or situation. Refuses to get out of bed most days. Interventions included assist as needed for grooming (nails/shave/hair). Monitor decline in care and report to clinical staff as needed. Review of Resident #31's progress notes dated 07/01/24 to 10/03/24 revealed no evidence of refusal of care. Review of Resident #31's task for nail care dated 09/03/24 to 10/03/24 revealed the last time the resident received nail care was on 09/26/24, however the task did not include what type of nail care was provided. Review of Resident #31's paper shower sheets for the month of September 2024 revealed the resident had a bed bath and nail care on 09/06/24. There was no documented evidence the resident received nail care on the paper shower sheets after 09/06/24. Interview and observation on 10/03/24 at 9:55 A.M., revealed Resident #31 was sitting up in a wheelchair watching television. The resident's hair was not combed and was laid flat on the back of her head. The resident's nails were long and jagged and most of her fingernails had a brown substance under them. The resident reported her nails needed trimmed and cleaned because she didn't have anything long enough to clean under her nails since they were so long, and her hair needed fluffed. The resident reported she already had her bed bath this morning because she doesn't like showers. The resident reported the facility didn't have enough staff to meet her needs including assisting with ADL's (hair and nails) and answering call lights timely. Interview and observation on 10/03/24 at 10:15 A.M. of Resident #31 with Licensed Practical Nurse (LPN) #200 confirmed the resident's nails were long and had a dark substance under her nails and her hair needed combed/fluffed. The LPN stated she would have staff come in and trim and clean the resident's nails and fluff her hair. c. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, bipolar, schizoaffective disorder, diabetes, drug-induced tremors, and atrial fibrillation. Review of Resident #16's ADL plan of care revealed the resident may require assistance with ADL's due to cognitive impairment, disease process/condition, mood/behavior problems, Alzheimer's disease, bipolar, diabetes, restlessness/agitation, tremors, pain, and anxiety. Participation levels may vary day to day, time of day, or situation related to cognitive deficit. Normal fluctuations in her mood/behavior may affect her participation levels and continence. Bathing assistance needed and dependent at times. The resident prefers a shower. Review of the shower schedule (undated) revealed the resident shower days were Thursday and Sunday. Record review revealed no evidence Resident #16 had refused showers the month of September 2024. Review of Resident #16's electronic medical record (bathing task) dated 09/03/24 to 10/03/24 revealed the resident did not receive a shower on 09/29/24. Review of paper shower sheets for September 2024 revealed no evidence Resident #16 received a shower/bed bath on 09/29/24. Observation of Resident #16 on 10/03/24 at 3:40 P.M., with Registered Nurse (RN) #134 at 3:40 P.M. confirmed the resident's fingers nails were clean but jagged. Interview on 10/03/24 at 3:46 P.M. and 4:24 P.M., with State tested Nurse Aide (STNA) #200 confirmed on 09/29/24 she was not able to perform a shower for Resident #16 due she was the only STNA on the floor that day and there was a resident fall that day and she was still new and still wasn't comfortable to be on her own. She did wash the resident's face and hands (partial bath). The STNA reported she doesn't feel there is enough staff to provide ADL care such as showers and nail care. The STNA confirmed the facility has been sending staff home due to low census and she had been usually the one sent home since she was just hired. The STNA reported she feels there needs to more than one STNA on the secured unit. She had volunteered to stay and help to noon, however, was told no and sent home. The STNA confirmed the facility asked her to fill out a shower sheet today (10/03/24) for 09/26/24. Interview on 10/03/24 at 4:22 P.M. with DON #101 revealed the facility found a shower sheet for 09/29/24 that indicated the resident had a bed bath. The DON did not know where the ADON found the shower sheet due to it was not in the folder with September's shower sheets when the surveyor reviewed all the resident shower sheets for September. d. During the onsite investigation, interviews with additional residents revealed the following: Interview on 10/03/24 at 1:29 P.M., with Resident #52 revealed there was not enough staff at times. It takes staff 1/2 hour to answer call lights. The weekends were worse due to staff call offs. Interview on 10/03/24 at 1:45 P.M., with Resident #25 revealed there isn't enough staff at times. It takes staff 25-30 minutes to answer his call light. There was no particular shift. e. During the onsite investigation, interviews with staff from 7:05 A.M. to 4:29 P.M. revealed the following: Interview with Staff Member (SM) #154 confirmed there was not enough staff to meet the residents needs including providing showers and nail care. Staff were being sent home due to low census. Staff have volunteered to come in and help and are told no. Interview with SM #148 confirmed there was not enough staff to meet the resident needs. The SM reported residents were not provided incontinence care timely, screaming to get up, call lights not answered timely, and not enough staff to supervise residents to prevent falls. Interview with SM #138 confirmed there was not enough staff to meet the resident needs. The facility was pulling staff to work other buildings or sending them home due to low census. The SM reported showers were not being done, nail care not being performed, call lights were not answered timely, and there was not enough staff to supervise to prevent falls. Interview with SM #201 revealed yesterday and over the weekend there was not enough staff on the secure unit to meet the resident's needs. There was only one nurse and one STNA which was not enough staff to supervise the residents on the secure unit. There was two residents that have fallen and required increased supervision. The facility was sending staff home according to the census and not considering the acuity required to provide care to the residents. f. Review of the facility assessment (last updated 01/21/24) revealed the facility provided staffing levels based on resident acuity levels for each side of the facility. These acuity levels help determine the number of direct care and indirect care needed based on the residents' needs instead of raw number or residents. Interview on 10/03/24 at 8:34 A.M., with DON #101 confirmed the facility was sending staff home due to low census. Interview on 10/03/24 at 12:07 P.M., with the Administrator revealed the facility doesn't have a policy or procedure for staffing and the facility would follow the facility assessment. The Administrator reported she was not aware of PBJ results from last quarter. She was currently responsible for the schedule. The Administrator reported staffing levels depended on the census. She tries to schedule three nurses on dayshift and two on nightshift, four to five STNA's on day shift and four on night shift. On the schedule some days there are staff with Asterix (*) that indicate the staff member could be mandated for a certain number of hours to cover call off's if needed. The STNAs were union and in the contract if they call off in the past three months they can be put on the mandating list. If there was a call off, they try to replace the call off depending on the census if it needs replaced. If someone was mandating that day, they will stay over to cover the approved number of hours. If no one was on the mandating list or will come in management staff will come in and work. The facility has no open nursing shifts and two STNA day shifts just opened up in the last 2 weeks. One STNA went to as needed and one resigned. g. Review of the facility PBJ submission data (staffing data submitted to the Centers for Medicare and Medicaid) revealed the facility was identified to have excessively low weekend staffing during the third quarter (April through June 2024) of 2024. This deficiency represents non-compliance investigated under Complaint Number OH00157948.

Based on review of the criminal background check log, interview, and policy review, the facility failed to ensure all staff had a completed criminal background check. This had the potential to affect all 65 residents. Findings include: Review of the facility's criminal background check log revealed notations beside entries for Registered Nurse (RN) #521 (hired 07/20/22), Admission Director #526 (hired 04/20/23), and State tested Nursing Assistant (STNA) #547 (hired 04/23/24) indicating fingerprint submissions to the Bureau of Criminal Investigations had been rejected. There was no evidence fingerprints had been re-submitted. On 06/18/24 at 3:55 P.M., Human Resources (HR) Director #500 verified there had been no completed criminal background checks for RN #521, Admission Director (AD) #526, and STNA #547. Once the fingerprints were rejected, there was no evidence the facility attempted to re-submit fingerprints. HR Director #500 verified if results were not received within 30 days, employees were not supposed to continue to work. On 06/18/24 at 4:04 P.M., HR Director #500 stated after speaking with the Administrator, she was going to obtain and re-submit fingerprints for the three employees (RN #521, AD #526 and STNA #547) that day. On 06/20/24 at 6:36 A.M., the Administrator stated results had been received for the criminal background checks for AD #526 and STNA #547 on 06/18/24 and both employees were retained. Review of the updated criminal background log revealed the fingerprints for RN #521 were submitted 05/18/24 but no results were received. RN #521 continued to work. On 06/20/24, RN #521's fingerprints were resubmitted and results received. RN #521's employment was retained. On 06/20/24 at 8:50 A.M., HR #500 verified AD #526 also had resident contact as she greeted residents on admission and sometimes took them to their rooms. AD #526 also met with residents to complete paperwork, as appropriate and would pass ice at times. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy(dated 11/21/16) revealed prior to hiring a new employee the facility would conduct a criminal background check in accordance with state law and the facility's policy. This deficiency represents non-compliance investigated under Complaint Number OH00153674.

Based on review of the facility Payroll Based Journal (PBJ) submission data for the first quarter of 2024, review of the facility assessment, and staff and resident interviews, the facility failed to maintain sufficient levels of direct care staff to meet the total care needs of all residents. This affected six residents (#46, #44, #2, #39, #28 and #51) and had the potential to affect all 65 residents residing in the facility. Findings include: Review of the facility PBJ submission data (staffing data submitted to the Centers for Medicare and Medicaid) revealed the facility was identified to have low weekend staffing during the first quarter (October through December of 2023) of 2024. Review of the facility assessment (last updated 01/21/24) revealed the facility provided staffing levels based on resident acuity levels for each side of the facility. These acuity levels help determine the number of direct care and indirect care needed based on the residents' needs instead of raw number or residents. Nurse managers/Interdisciplinary Team (IDT) were responsible for reviewing/coordinating assignments as needed. The on-call manager functioned in this capacity when the IDT was off duty. a. During the onsite investigation, resident interviews revealed the following: Interview on 06/17/24 at 10:05 A.M., with Resident #46 and Resident #46's son revealed staffing concerns. The resident and son reported there were not enough staff on the weekends. The resident reported she must stay in bed until noon because it takes two staff to assist her with transfers and with insufficient staff, she had to stay in bed later than she preferred. Resident #46 stated her preference was to get out of bed early. Interview on 06/17/24 at 10:46 A.M., with Resident #44 revealed staffing concerns. The resident indicated (in general) the facility needed more aides. If the aides were super busy, she stated she had to wait 45 minutes for help. Interview on 06/17/24 at 10:57 A.M., with Resident #2 revealed staffing concerns. The resident indicated there was not adequate staffing on the midnight shift. The resident stated (in general) sometimes he had to wait one and half hours for someone to answer his call light. Interview on 06/17/24 at 11:03 A.M. with Resident #39 revealed concerns with the facility staffing. The resident indicated at times there were not enough staff and it takes 15-20 minutes for assistance. Interview on 06/17/24 at 11:13 A.M., with Resident #28 revealed staffing concerns. The resident stated the facility needed extra help on all shifts. Interview on 06/17/24 at 11:15 A.M., with Resident #51 revealed concerns related to the facility staffing. The resident indicated night shift staff didn't answer call lights timely and he usually had to wait until dayshift arrived before anyone came to answer his call light. b. During the onsite investigation, interviews with staff revealed the following: Interview on 06/17/24 at 11:40 A.M. with State tested Nursing Assistant (STNA) #547 revealed there was not enough staff, and it takes longer than usual to get things done. The STNA reported there were supposed to be three aides on A unit; however, they often worked with only two. A follow-up interview on 06/18/24 at 6:49 A.M., STNA #547 revealed the STNA worked both day and night shift. The STNA reported there were not enough staff on night shift to provide proper supervision. Last night there were four resident falls (two on each unit) that occurred due to a lack of adequate staff to properly supervise the residents. In addition, the STNA indicated there were two male STNAs working last night and there were some residents who don't like males to provide care, so they pull a female staff member from B hall to help, leaving the other male by himself on the other unit. The STNA stated A wing staffing was worse due to the residents requiring more assistance and there were 10-11 showers required to be done on night shift leaving only one staff on the unit. The STNA revealed the facility had a mandating system for call offs, but the facility doesn't follow the system. Interview on 06/18/24 6:55 A.M., with night shift STNA #571 revealed there were not enough staff on night shift. The aide reported A hall needed at least three STNAs (one for each hall) and two on B hall and there was usually only three to four aides on night shift for the entire building. The STNA stated A hall was rough at night. Usually someone from B hall must go over to help A hall at night at night. This STNA also voiced concerns related to an increase in the number of resident falls on the night shift the previous night. On B hall one resident rolled out of bed, and one slipped on toilet paper in the bathroom. The STNA revealed dayshift staffing was no better. The facility was offering $25 an hour to pick up open shifts but stated there weren't enough staff to pick up due to the facility being short staffed and already working 12-hour shifts. Interview on 06/18/24 at 11:39 A.M. with Housekeeper #519 revealed staffing concerns. The housekeeper revealed there were not enough staff to answer call lights timely and sometimes it takes 20-25 minutes for staff to respond to call lights. Interview on 06/20/24 at 6:13 A.M., with Registered Nurse (RN) #541 revealed management was aware of staffing concerns and just keep saying they were trying to get five aides and three nurses at night. The RN indicated increased supervision/staffing could assist in reducing those falls. Interview on 06/20/24 at 6:25 A.M., with STNA #547 and STNA #568 revealed there was not adequate staffing. The STNA staff indicated extra staff were needed on night shift to give resident showers. When one of the STNAs were in the shower it left the other aide to monitor the hall by themselves and answer call lights. Some of the residents required two assistants (for care). And only a few nurses help. The STNAs voiced concerns related to the staffing on 06/17/24 when there were four falls with some of the falls occurring when staff were doing showers and only one staff was trying to monitor A and C hall. In addition, the secured unit had residents with behaviors who needed increased supervision, so it was difficult to monitor the residents at risk of falls, residents with behaviors, and other residents with one aide available. Interview on 06/20/24 7:02 A.M. STNA #536 and STNA #537 revealed concerns related to staffing and indicating there was not enough staff. The STNAs revealed staff run all shifts then try to document in a hurry at the end of the shift. Night shift had 8-12 resident showers to do with some of the residents requiring more than 45 minutes for a shower. That left the other aide to monitor A and C hall, respond to call lights. Multiple residents want to go to bed but require two assists. They must wait on the other side to get done in the shower, so residents were not able to be assisted to bed upon request and then they get angry. The STNAs reported management had told them they had been working on getting staff for more than two years. It was rare there were more than two aides per hall on night shift and staff were told there were no shifts to pick up on nights. These STNAs revealed they also felt insufficient staffing had contributed to falls for lack of supervision. On 06/24/24 at 4:05 P.M. interview with the Administrator revealed the facility had been attempting to schedule an additional nurse on night shift from 7:00 P.M. to 11:00 P.M. to assist with medication and treatment administration, however the facility did not have sufficient staff to schedule that position in a consistent manner. The Administrator revealed when nurses reported off for their shift and staff were unavailable to cover, nursing management were expected to cover the shift. On 06/25/24 at 7:22 A.M. an additional interview with the Administrator revealed the facility was trying to hire additional staff by posting positions through online ads and offering sign on bonuses. This deficieny represents non-compliance investigated under Complaint Number OH00153674.

Based on observations, review of personnel records, policy review, review of time punches, and interview, the facility failed to ensure staff were adequately tested for signs of tuberculosis prior to resident contact and failed to maintain infection control protocols during medication administration and incontinence care. This affected Residents #10 and #15 and had the potential to affect all 65 residents. Findings include: 1. On 06/20/24 at 2:00 P.M., State tested Nursing Assistant (STNA) #567 was observed providing incontinence care to Resident #15. After turning Resident #15 over to provide incontinence care to the buttocks, STNA #567 started cleaning from the top of the buttocks toward the vaginal area. After completing the care, multiple surfaces were touched including the bed remote and blankets while wearing the same gloves worn to provide incontinence care to the resident. On 06/20/24 at 2:13 P.M., STNA #567 verified she had not implemented appropriate incontinence care procedures when she cleaned Resident #15 (from the top of the buttocks toward the vagina). Review of the facility's Skin: Incontinence Care Protocol (revised September 2017) revealed no instruction regarding the proper method to cleanse the skin (front to back). The protocol did not address at what point gloves were to be removed and hand hygiene completed after incontinence care was provided. Review of the facility's Hand Hygiene policy (revised 11/28/17) revealed staff was to perform hand hygiene (even if gloves were used) before and after contact with a resident, after contact with body fluids or other objects and surfaces in the resident's environment, and after removing personal protective equipment such as gloves. 2. During review of personnel files on 06/18/24 starting at 10:05 A.M. with Human Resources (HR) #500, it was noted STNA #546 was rehired on 09/13/23. HR #500 verified there was no evidence a mantoux (tuberculosis) skin test was provided upon re-hire. HR #500 stated STNA #546 had worked at the facility between 03/03/22 to 02/04/23 with a two step mantoux completed upon hire in March 2022. Review of the facility's Tuberculosis Testing and Screening- Healthcare Workers policy (revised July 2016) revealed if a previous negative Tuberculosis Skin Test (TST) result was obtained greater than 12 months before new employment a two step baseline TST was to be administered. 3. During review of personnel files on 06/18/24 starting at 10:05 A.M. with Human Resources (HR) #500, it was noted STNA #547's hire date was 04/23/24. After reviewing time punches, HR #500 verified STNA #547 worked with resident contact made on 04/29/24. The first step mantoux was administered 05/02/24 with results read 05/04/24. HR #500 stated STNA #547 had been working at a hospital as a STNA but did not have the hospital mantoux results. On 06/25/24 at 11:10 A.M., Registered Nurse (RN) #573 provided employee post-offer procedure which indicated the initial mantoux test was required prior to resident contact. Review of the facility's Tuberculosis Testing and Screening- Healthcare Workers policy (revised July 2016) revealed if a prospective employee had a documented negative TST result 12 months or less before new employment a single TST was to be administered for baseline testing. The most recent TB (tuberculosis) risk assessment dated [DATE] indicated there was no incident of TB in the facility or surrounding community. 4. On 06/18/24 at 7:28 A.M., Registered Nurse (RN) #534 was observed entering Resident #13's room with medications including an insulin syringe. At 7:33 A.M., RN #534 left Resident #13's room with gloves on. After removing the gloves, RN #534 prepared and administered medications for Resident #10. On 06/18/24 at 7:51 A.M. , RN #534 verified she had not performed hand hygiene between residents. Review of the facility's Hand Hygiene policy (revised 11/28/17) revealed staff was to perform hand hygiene (even if gloves were used) before and after contact with a resident, after contact with body fluids or other objects and surfaces in the resident's environment, and after removing personal protective equipment such as gloves. This deficiency represents non-compliance investigated under Complaint Number OH00153674.

Based on review of documents from the facility's food supplier and interview, the facility failed to ensure provisions were made to have water available in the event of an emergency. This had the potential to affect all 65 residents. Findings include: During the entrance conference on 06/17/24, the Administrator was asked what provisions the facility had made to ensure the availability of water in the case of an emergency. A document from the facility's food service supplier dated 11/01/23 was provided. The agreement indicated in the event that an emergency affected the facility, the food supplier might not be able to provide the facility with the recommended amount of water needed during an emergency situation and recommended the facility ensure they had an alternate vendor set up. On 06/18/24 at 11:59 A.M., the Administrator verified the facility had not made alternate arrangements for the provision of water in the event of an emergency.

Based on observation, facility worksheet review, interviews and policy review the facility failed to ensure medication was properly secured and accessible only to authorized staff and failed to ensure insulin was dated upon opening and/or discarded after expiration. This affected five residents receiving insulin (Resident #23, #26, #29, #50, #63) but had the potential to affect all residents residing in the facility. The facility census was 65. Findings included: 1. Observation on [DATE] at 8:22 A.M., with Registered Nurse (RN) #563 revealed a ring of keys were hanging on the wall at the nurse's station, which was not a locked or secured area. The RN retrieved the keys off the wall and opened the medication room door and obtained insulin out of the refrigerator for a resident. The RN then hung the keys back on the wall at the nurse's station before she returned to the medication cart. The RN confirmed the keys were kept on the wall due to the A hall nurses had to share a key and there was only one medication storage room in the facility. A second observation of the medication room keys on [DATE] at 8:41 A.M., RN #562 confirmed the keys for the only mediation room in the building were hanging at the nurses' station and accessible to staff, residents, visitors, etc. The RN retrieved the keys from the wall and opened the medication room door for the surveyor. The RN confirmed there was a key on the keychain that also opened the emergency narcotic cabinet, which she demonstrated for the surveyor. 2. Observation on [DATE] at 9:13 A.M., when walking down A front hall with Therapy Director (TD) #513 revealed the medication cart for A front was unlocked and unattended. This observation was confirmed with TD #513 at time of observation and TD went to find the nurse. Licensed Practical Nurse (LPN) #535 confirmed she left the medication cart unattended and unlocked. Review of the medication carts and keys policy dated [DATE] revealed the facility would maintain and control access to medication carts for licensed and approved personnel. Review of the Medication Storage policy and procedure dated [DATE] revealed medications and biologicals are stored safely, securely and properly following manufacture's recommendations or those of the supplier. The medications supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members authorized to administer medications. Medication rooms and carts are locked or attended to by people with authorized access. 3. Observation on [DATE] at 8:07 A.M. of front A medication cart revealed Resident #23's Busuglar pen was ,d+[DATE] used and not dated, Resident #63's Humalog was opened and not dated, and Resident #26 Lantus was opened on [DATE]. Interview on [DATE] with Registered Nurse (RN) #563 confirmed Resident #23's and #63's insulins were opened and not dated. The RN reported she would discard the insulins and get new ones due to she had no evidence when they were open and according to the pharmacy, insulin expired usually ,d+[DATE] days after being opened. The RN also confirmed Resident #26 Lantus needed discarded due to it was open on [DATE] and it was past the 28 days and was expired. 4. Observation on [DATE] at 8:37 A.M. of medication cart A back revealed Resident #50's Fiasp flextouch insulin pen was dated [DATE] on the outside of the package and [DATE] on the actual pen. Interview on [DATE] at 8:37 A.M., RN #562 confirmed the insulin should have been discarded because she was not sure when it was open since the package and pen had two different dates and it was open greater than 28 days. 5. Observation on [DATE] at 8:46 A.M., of the secure unit medication cart revealed Resident #29's Deglude insulin pen had 200 units remaining and Euthalia Orend Lispro insulin had 120 units remaining were not dated when opened. Interview on [DATE] at 8:46 A.M., with RN #540 confirmed the insulins should have been discarded do she was not able to determine when the insulins were opened. Review of the facilities worksheet undated titled Medication with Shortened Expiration Dates revealed Fiasp, Basaglar, Lantus, Humalog, expired 28 days after opened. Review of the medication administration policy dated [DATE] revealed insulin is a high risk drug and warrants additional precautions for safe and effective administration. Follow the manufacture's instructions for storage and expiration. Ensure that the opened date is documented on the vial or pen. Refer to Policy 6.2 dating and discharging of multidose vials. Check the expiration date prior to administration to ensure it was within the usage date. Expired insulin should be immediately discarded. Vials and pens without an open dated recorded should be discarded.

Based on review of a facility investigation, review of personnel files, medical record review and interview, the facility failed to ensure all residents were treated with dignity and respect. This affected one (Resident #36) of five residents reviewed for dignity. The facility census was 65. Findings include: Review of Resident #36's medical record revealed diagnoses including vascular dementia, depression, and impulse disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was able to make himself understood and was able to understand others. The MDS indicated Resident #36 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of eight (out of 15 total). On 06/18/24 at 10:05 A.M., during the review of State tested Nursing Assistant (STNA) #546's personnel file with Human Resource (HR) Director #500, disciplinary action indicated STNA #546 was found cursing in a resident room and not being professional to co-workers. The discipline form indicated STNA #546 was expected to act in a professional and respectful manner with residents. On 06/18/24 at 2:56 P.M., the Administrator stated when the disciplinary action for STNA #546 was written up on 05/06/24, it due to additional information obtained in the process of a facility investigation. The Administrator provided a packet of papers indicating concerns with professionalism and care. A typed statement dated 05/08/24 indicated STNA #537 reported about one week prior to the interview she asked STNA #546 to change Resident #36 for her and she overheard STNA #546 stating to Resident #36 she could not believe he would let someone else see his [NAME] besides her. STNA #537 reported Resident #36 laughed. STNA #537 reported she told STNA #546 she could not be making inappropriate comments like that to residents and STNA #546 became defensive and stormed off. STNA #537 stated she reported the incident to the nurses but did not know if there was any follow through regarding the inappropriate comments made by STNA #546. Another typed statement indicated the social worker was present during the interview of STNA #546 in which she admitted she might have cursed in front of residents before. There was no documentation regarding response to the allegation related to Resident #36. A typed statement dated 05/10/24 indicated Resident #36 was interviewed with social services present. Resident #36 verified he had heard the statement alleged about why he would let someone else see his [NAME] and he reported it was STNA #546 who said it. Resident #36 reported he just snickered and laughed it off. Resident #36 reported it did not bother him. On 06/20/24 at 10:43 A.M., Resident #36 was interviewed and was able to recount the statement made by STNA #546 regarding his private parts. Resident #36 indicated it did not upset him as he used to date STNA #546. On 06/20/24 at 12:15 P.M., STNA #546 was interviewed and stated she worked both day shift and night shift but was usually assigned to Resident #36's unit. STNA #546 stated she could have very possibly used foul language in front of residents and visitors. STNA #546 denied she ever dated Resident #36 but he was inappropriate and handsy with staff. STNA #546 did not directly respond to questions regarding any inappropriate comments she did or did not make to Resident #36 but stated she felt another employee was attempting to get her terminated. The employee she named was not the employee who reported the incident.

Based on observations and staff interviews the facility failed to ensure resident rooms on the secure unit were clean, safe, and a homelike environment was maintained. This affected three residents (#47, #53, and #60) of six residents observed on the secure unit during the initial survey process. The census was 65. Findings included: 1. Observation on 06/17/24 at 10:15 A.M. of Resident #60's room revealed the electric outlet cover to the left of the resident's bed was noted to be missing. Observation on 06/24/24 at 4:15 P.M., of Resident #60's room with Housekeeping/Laundry Supervisor #525 revealed the electric outlet cover had been placed over the outlet, however the outlet cover did not cover the entire area cut out of the wall. The Supervisor reported the Life Safety Surveyor had already notified the facility of the concern regarding the missing cover; however, she would let the Administrator know the cover did not fit the entire electrical outlet properly. Interview on 06/25/24 at 7:52 A.M., with the Administrator confirmed the Housekeeping/Laundry Supervisor #525 notified her of the concern regarding the electrical outlet not fitting properly and she had sent staff out to purchase a cover that would fit the area. 2. Observation on 06/17/24 at 2:23 P.M. of Resident #47's room revealed the resident's room was not clean. There was an opened bag of chips on the floor beside her nightstand with crumbs on the floor. There was a roll of toilet paper on the floor. The bathroom smelled of feces and there was feces observed smeared on the floor and used toilet paper in her trash can. There were dirty clothes noted in her sink. Observation on 06/24/24 at 4:15 P.M., of Resident #47's room with Housekeeping/Laundry Supervisor #525 confirmed there was feces smeared all over the resident bathroom floor and on the toilet. The supervisor reported the resident places food on the floor to feed nonexistent animals and she uses the sink to wash out her dirty linens. 3. Observation on 06/17/24 at 2:41 P.M., of Resident #53's room revealed the wall beside the bed was gouged and in need of being repaired. The nightstand had the veneer coating peeling off the front of it. Observation on 06/25/24 at 7:52 A.M., of Resident #53's room with the Administrator confirmed there was an area approximately one foot by one foot area on the wall near the head of the bed that was gouged and in need of repair and the veneer coating on the nightstand was peeling off the front of the nightstand.

Based on record review, review of missing item reports, review of dental appointment visit lists, family interview, staff interview, and policy review, the facility failed to ensure a resident and her resident representative's concerns of missing dentures were addressed by the facility. This affected one (Resident #47) of two reviewed for personal property. The facility census was 65. Findings include: Review of Resident #47's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, dementia with behavioral disturbances, anxiety disorder, intermittent explosive disorder, and major depressive disorder. Review of Resident #47's ancillary consent form revealed the resident's representative consented to have her receive dental services as a resident with Medicaid, while in the facility. The consent form was signed on 10/21/21, around the time of her original admission. Review of Resident #47's consultation reports revealed she was last seen by the dentist on 03/14/23. The dentist completed a comprehensive oral evaluation and indicated she was edentulous. The dentist indicated dentures were not applicable in his visit note and did not address whether she had them or not during that evaluation. Review of Resident #47's re-admission assessment dated [DATE] revealed the resident was assessed upon her return following a hospitalization . She was noted to be confused, disoriented, and agitated/ restless. An assessment of her oral status indicated she was edentulous and had full upper and lower dentures. Review of Resident #47's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech and was able to make herself understood and understood others. Her cognition was indicated to be moderately impaired. Her assessment did not indicate whether she had problems with her dentures, as it was only assessed as part of a comprehensive assessment (admission, annual, or significant change assessment). Review of Resident #47's care plans revealed the resident had impaired dentition and was at risk for oral problems (i.e. pain, infection, difficulty chewing/swallowing, poor self image) related to her being edentulous. She was identified on the care plan as having full upper and lower dentures and wore them as she desired. The interventions included the need to clean her dentures daily and to encourage her dentures to be worn for meals as she desired. On 06/18/24 at 8:10 A.M., an interview with Resident #47's resident representative revealed the resident was missing her dentures and had been for several months now. He stated he had informed the facility about the missing dentures and they were supposed to have her seen by the dentist. He stated the resident was known to refuse to be seen by the facility's visiting dentist and he wanted them to coordinate the dental visit with him so he could be there to ensure the resident complied with being seen. He felt if he was able to be present, the resident would be more likely to allow the dentist to see her and she could get new dentures. Review of the facility's missing item reports for the past 12 months revealed there was no evidence of Resident #47 being known to have missing dentures. She was not one of the residents that had a missing item report filled out for missing property, despite the resident's representative stating he had reported her dentures missing several months ago. The facility did not maintain a missing item log and only had individual reports for residents reporting missing property. Review of the facility's dental appointment lists for past and future appointments revealed the dentist had visited the facility on 04/19/24 and again on 06/11/24. Two residents had been seen by the dentist on those dates, but did not include Resident #47. There was a future appointment with the dental hygienist scheduled for 07/10/24, but no future appointments were scheduled for the dentist yet. On 06/25/24 at 9:43 A.M., an interview with the facility's Director of Nursing (DON) revealed the facility did not utilize a personal inventory sheet to record the residents' belongings that would show whether or not someone had dentures when they were first admitted or during the course of their stay. She thought Resident #47 had dentures at some point and she had talked with the resident's representative about that. She was not sure if she was confusing that with another resident or not. The facility's medical records employee was the one that coordinated ancillary services, such as dental. On 06/25/24 at 9:44 A.M., an interview with State tested Nursing Assistant (STNA) #569 revealed she was not aware of Resident #47 having had dentures. She was asked to check the residents room for evidence of her having dentures. She searched her room and her bathroom and did not see any evidence of the resident having dentures in her possession. There were no denture cups for the storage of any dentures and she did not see any denture related supplies such as denture adhesive or cleaning tablets. On 06/25/24 at 9:45 A.M., an interview with STNA #557 revealed she was not aware of Resident #47 having dentures either. She had not seen her wear any and had not assisted her in the care of her dentures. She stated, if dentures were reported as missing, she would notify the nurse. On 06/27/24 at 9:48 A.M., an interview with Housekeeping/ Laundry Supervisor #525 revealed Resident #47 did mention to her that she was missing her dentures. She stated they looked around to see if they could find them in the resident's room or in other resident's room, but did not have any luck finding them. She recalled it was a month and a half to two months ago, when the resident reported them missing. She stated she thought she informed the facility's Administrator about it and sent a group text out about the reports of the missing dentures, when they could not be found. On 06/25/24 at 10:44 A.M., an interview with Social Service Director (SSD) #515 revealed she was not aware of Resident #47 having any reports of missing dentures. She thought the son may have been looking at getting her new ones, at one point, but she would need to double check to make sure that was accurate. The medical records employee coordinated ancillary service appointments and the facility's receptionist handled missing personal items. She confirmed Resident #47 had dentures in the past and was under Medicaid (MCD). On 06/25/24 at 10:50 A.M., an interview with Medical Records Employee #512 revealed she was the staff member that was responsible for the coordination of ancillary services to include dental. She reported the dentist was at the facility last in March 2024 and was due back sometime in September 2024. She was not aware of Resident #47 having any missing dentures. She knew they wanted her on the list to be seen, but may have misunderstood why she was needing to be seen. She stated, if she was aware of the resident having had misplaced her dentures, she would have sent an email to the dental company to get them to come in as soon as possible to get impressions made for new dentures. She stated she would go ahead and send an email over to the dental company to have them come in. The dental company would contact MCD to determine when the last time was that the resident had dentures made. If an item such as dentures were reported missing, they should fill out a paper for it. That would be done by the facility's Administrator or their receptionist, who handled missing personal items. She reported she would have been the one to address the need to replace missing dentures, but stated again she must have misunderstood. On 06/25/24 at 11:05 A.M., an interview with the facility's Administrator revealed she did not recall Resident #47 having had reports of missing dentures. She would have been covering for the receptionist at that time, as the receptionist was off work and had only recently come back. Reports of missing dentures would have required a missing item report to be completed and she denied that she completed one. The Administrator was informed the resident's son did say the resident had been missing her dentures for several months now and the housekeeping/laundry supervisor confirmed she had been informed about the missing dentures about a month and a half to two months ago. She was further informed the housekeeping/ laundry supervisor said she reported it to the Administrator and sent out the report of missing dentures over a group text, with no evidence any follow up was completed regarding the resident's and her resident representative's concerns of missing dentures. She was asked to provide the facility's policy on missing items. She denied they had a policy specific to missing personal items and was to follow the instructions on the missing item report. The directions at the top of the missing items policy/ report indicated when there was an allegation of misappropriation of resident property, a complete investigation would be completed and reported to the State Survey Agency. Review of the facility's policy on Grievances dated 11/22/16 revealed the facility recognized that residents had the right to voice grievances to the facility, or other agencies or entities that hear grievances, without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment that has been furnished, the behavior of staff and other residents and any other concern regarding the resident's stay. The facility will make available to all residents information of the right to file grievances orally or in writing; the right to file grievances anonymously; contact information for the Grievance Official; a reasonable time frame for completing the review of the grievance; the right to obtain a written decision regarding the grievance. The Grievance Committee / Grievance Official shall complete an investigation of the resident's grievance. This may include a review of facility processes, programs and policies, as well as interviews with staff, residents and visitors, as indicated, and any other review deemed necessary by the Grievance Committee. The grievance review will be completed in a reasonable time frame consistent with the type of grievance (e.g., a concern regarding resident conduct will be addressed more quickly than a concern that involves activity programming or meals), but in no event will the review exceed thirty (30) days. Upon completion of the review, the Grievance Official will complete a written grievance decision that includes the following: the date the grievance was received; a summary of the statement of the resident's grievance; the steps taken to investigate the grievance; a summary of the pertinent findings or conclusions regarding the resident's concern(s); a statement as to whether the grievance was confirmed or not confirmed; whether any corrective action was or will be taken; if corrective action was or will be taken, a summary of the corrective action. If corrective action will not be taken, then an explanation of why such action is not necessary; the date the written decision was issued. The Grievance Official will meet with the resident and inform the resident of the results of the investigation and how the resident's grievance was resolved or will be resolved, if applicable. A copy of the written grievance decision will be provided to the resident, upon request. The facility will keep evidence of the resolution of all grievances for a period of three (3) years from the date the grievance decision is issued.

Based on record review, staff interview, and policy review, the facility failed to ensure a resident had a new resident review completed after a newly diagnosed mental illness was added to their diagnoses. This affected one (Resident #5) of one residents reviewed for Preadmission Screening and Resident Review (PASRR) assessments. Findings include: Review of Resident #5's medical record revealed she was admitted to the facility from another nursing facility on 04/12/24. Her diagnoses included unspecified psychosis (05/02/24), delusional disorder (05/02/24), anxiety disorder (04/11/24), and vascular dementia with behavioral disturbance (05/28/24). Review of Resident #5's Pre-admission Screening and Resident Review (PASRR) identification screen dated 05/05/23 (completed at prior nursing facility) revealed the resident was indicated to have the diagnosis of dementia under section (D.) Medical Diagnoses. The only mental illness (MI) diagnoses included under section (E.) Indications of a Serious Mental Illness was a mood disorder. Review of a Preadmission Screening and Resident Review Result Notice dated 05/05/23 revealed Resident #5 did not have any indications of a serious mental illness and/ or a developmental disability at the time that PASRR identification screen had been completed. Further review of another PASRR Identification Screen completed on 07/28/23 (prior to Resident #5's admission) revealed the resident was identified as having had the diagnosis of dementia under section D. and she was indicated to have mood disorder and panic or other severe anxiety disorder under section (E.). No other mental illness diagnoses were included as being a known diagnoses for the resident under section (E.). No PASRR Identification Screens had been completed upon or after Resident #5's admission to the facility. There was no evidence of a new PASRR being completed, after the resident was known to have the diagnosis of a delusional disorder on 05/02/24. On 06/24/24 at 10:10 A.M., an interview with Social Service Director (SSD) #515 revealed she was the facility's SSD at the time Resident #5 was given a new diagnosis of delusional disorder on 05/02/24. She confirmed she did not complete a new PASRR Identification Screen, after the diagnosis of delusional disorder was given. She denied they had any other PASRR Identification Screens that had been completed that were not the ones that had been completed while at the other nursing facility. She further confirmed a new PASRR Identification Screen should have been completed for the resident, after the diagnosis of delusional disorder was given. She stated she would have to submit a new PASRR to include the diagnosis of delusional disorder for the resident.

Based on record review and staff interview, the facility failed to ensure residents bowel movements were properly monitored and those residents who went without a bowel movement for greater than three days received appropriate intervention to promote a bowel movement to occur. This affected two (Resident #5 and #20) of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #5's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of vascular dementia with behavioral disturbances, unspecified psychosis, delusional disorder, anxiety disorder, cognitive communication deficit, difficulty walking, chronic pain, and constipation (passing less than three stools a week or having a difficult time passing stool). Review of Resident #5's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was able to make herself understood and was able to understand others. Her cognition was severely impaired. She was known to have delusions, hallucinations, physical behaviors directed at others, and other behaviors not directed at others. A substantial to maximum assist was needed with toileting. She was always incontinent of her bowel. Review of Resident #5's care plans revealed she had a care plan in place for an alteration in elimination as she was usually incontinent of her bowel and bladder. The care plan also indicated the resident was known to have constipation. She required assistance with bathroom location at times and rarely made needs known prior to incontinence. The goal was for the resident to have a bowel movement per her usual pattern. Interventions included assisting with the bathroom location as needed, monitor and record bowel movements every shift, and administer medications as ordered. Review of Resident #5's physician's orders revealed the resident had an order to receive Senna Plus (stool softener) 8.6 milligrams (mg)- 50 mg with instructions to give one tablet by mouth (po) one time a day related to constipation. There was not an order for the resident to receive any prn laxatives for constipation. Review of Resident #5's bowel movement report for the past 30 days (05/22/24- 06/20/24) revealed the resident was not noted to have had a bowel movement recorded between 05/22/24 and 06/05/24 (15 days). Findings were verified by Director of Nursing (DON) #514. On 06/20/24 at 2:10 P.M., an interview with State tested Nursing Assistant (STNA) #557 revealed Resident #5 was an extensive assist with toileting. She indicated the resident's continence status just depended on the day. Bowel movements (BM's) were recorded on the computer when they occurred. She denied they wrote any of the resident's bowel movements on paper. She reported the resident was pretty regular when it came to her having bowel movements and she tended to go a lot. She would think it was a documentation error, if she was not documented as having had a BM in 15 days. She reported the resident's normal bowel pattern was for her bowels to move every other day. On 06/20/24 at 2:13 P.M., an interview with DON #514 revealed she was able to determine Resident #5 was out of the facility at theER on [DATE] and again on 05/25/24. She was then hospitalized between 05/28/24 and 05/31/24, explaining why BM's were not recorded on those days. She was asked to provide any documented evidence of any BM's the resident had between 05/31/24 and 06/05/24 to show they were monitoring the resident's bowel movements and were intervening as needed, if she was without a BM for three or more days. She later returned at 3:15 P.M. and indicated that she was able to determine that the resident had a bowel movement on 05/31/24, as was indicated in the report they received from the hospital. She then stated they had a three day bowel and bladder tracking that showed the resident smeared on 06/02/24. She was not able to find evidence of a bowel movement of substance occurring between 06/01/24 and and 06/04/24 (four days). She acknowledged that was a four day period without documented evidence of the resident having had a substantial BM. She was asked what the facility's policy or protocol was regarding bowel movement tracking and when to intervene with a laxative to promote the resident to have a BM. She denied they had a bowel protocol and did not have any specific timeframe in which they intervened with a prn laxative. She indicated it would depend on how the resident was feeling. On 06/20/24 at 3:22 P.M., an interview with LPN #555 revealed it was on the dashboard in the computer where they received alerts regarding the resident's bowel movements and need for intervention. They received an alert at 48 hours and again at 72 hours. If the resident was without a BM at 72 hours, they would assess the resident and would review the resident's orders to see if they had a prn laxative. If not, they would call the physician to get an order. She confirmed the resident had an order for scheduled Senna Plus, but currently did not have an order to give a laxative as needed for constipation. 2. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, dementia with anxiety and other behavioral disturbances, intermittent explosive disorder, restlessness and agitation, anxiety disorder, and constipation. Review of Resident #20's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues. She was able to make herself understood and was able to understand others. Her cognition was severely impaired and she was not indicated to have displayed any behaviors nor was she known to reject care during the 7 days of the assessment period. Review of Resident #20's care plans revealed she had a care plan in place for an alteration in elimination. The care plan indicated she was usually continent of her bowel and was known to have constipation. She had episodes of incontinence with behaviors. The goal was for the resident to have soft bowel movements per her normal pattern. The interventions included the need to assist her with the location of the bathroom and toileting as needed. They were to monitor and record bowel movements every shift. Review of Resident #20's physician's orders revealed she had an order to receive Docusate Sodium (stool softener also known as Colace) 100 mg po once daily as needed (prn) for constipation. The order had been in place since 03/16/23. Review of Resident #20's BM record for the past 30 days (05/20/24-06/18) revealed she did not have a documented BM occurring between 05/27/24 and 06/02/24 (seven days). She was noted to have had a large BM on 05/26/24 and not further BM's were recorded until a medium sized BM on 06/03/24. Findings were verified by DON #506 and #514. On 06/18/24 at 3:08 P.M., an interview with DON #506 and #514 revealed residents' BM's were documented under the task tab of the EMR. They denied they would have documentation of a BM that occurred on a paper sheet to support Resident #20 had any other BM's that were not already noted under the task tab of the EMR. They could not provide any additional evidence of the resident having a bowel movement during that seven day period. They further confirmed there was no documented evidence to show the nurses had administered the resident a stool softener (Colace) as was ordered daily on an as needed basis for the resident between 05/27/24 and 06/02/24. DON #506 stated she did not feel the resident was likely to have went without a BM for seven days. She felt it was more likely the resident may have taken herself to the bathroom and had a BM, without the staff being aware. She reported she would check the shift report to see if they had any additional documentation of a BM occurring. On 06/18/24 at 4:10 P.M., a follow up interview with DON #506 revealed she had talked to a couple staff members who indicated Resident #20 had a BM on 06/01/24 that was not recorded. She obtained statements from the two employees with one claiming the resident had a large BM on 06/01/24 and the other indicated the resident had a medium sized BM on 06/01/24. She acknowledged even with a BM occurring on 06/01/24, the resident would have been five days without a recorded BM between 05/27/24 and 05/31/24. She confirmed the resident's MAR's for May 2024 did not reflect the resident was given Colace 100 mg po that was ordered on a daily basis as needed for constipation. DON #506 denied the facility had a policy for bowel movement monitoring, nor did they have a bowel protocol they followed.

Based on observation, record review, interview, and consult notes review the facility failed to ensure Resident #4 was provided orthotic devices and/or restorative exercises for decreased range of motion (ROM) to the right lower extremity. This affected one (Resident #4) of two residents reviewed for positioning. The facility census was 65. Findings included: Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including history of falling, heart failure, sequelae of cerebral infarction, hemiplegia and hemiparesis following a cerebral infarction affecting right dominate side, muscle weakness, unsteadiness on feet, history of traumatic brain injury, osteoarthritis, dysphasia, need for assistance with personal care, epilepsy, and lack of coordination. Review of Resident #4's discontinued orders revealed on 08/16/18 an order was written that the resident may use a knee brace with ambulation at his request. The order was discontinued on 11/11/19. Further review of Resident #4's discontinued orders dated 03/06/20 and discontinued 04/28/20 revealed to refer for consult for ankle/foot orthotic (AFO) to the right lower extremity. Review of Resident #4's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had limited ROM on one side of the lower extremities. Review of Resident #4's ROM assessment dated [DATE] revealed Occupational Therapy (OT) participated in the assessment and the staff and resident believe he (the resident) could do more. The resident had limited ROM on the right lower side and arm. To maintain strength and endurance, the resident was to perform active range of motion of the right upper extremity using the left upper extremity with a three-pound weight for 10 repetitions three times. Staff were to encourage slow controlled movements and verbal cues for proper pace/technique and task segmentation as needed. There was no documented evidence the limited ROM of the right lower side was addressed or a program was implemented. Review of Resident #4's current orders revealed no evidence of orders for restorative, knee braces, or ankle/foot orthotic (AFO). Review of Resident #4's current plan of care revealed no evidence of a comprehensive/individualized plan of care for range of motion or restorative services. Review of Resident #4's activity of daily living (ADL) plan of care dated 07/09/18 and revised on 05/03/24 revealed the resident required assistance with ADLs and may be at risk for developing complications associated with decreased ADL self-performance related to: behaviors, disease process, cognition problems, stroke, hemiplegia of the right side, chronic obstructive pulmonary disease (COPD), aphasia (difficulty speaking), weakness, and noncompliance. Intervention included assisting the resident with ADL's. Restorative nursing to evaluate and treat as needed. The resident was dependent at times with toileting and transfers Review of Resident #4's comprehensive plan of care including discontinued interventions revealed the intervention for an AFO to the right lower extremity was removed on 03/16/23. The intervention removed indicated to ensure the resident had a knee length sock to the AFO to the right lower extremity and to check the skin prior to application and after removing the AFO. Review of a therapy note dated 05/17/24 revealed active and passive range of motion would be completed to bilateral upper extremity in all planes as tolerated with weights to maintain strength. There was no evidence of a program/recommendation for the limited ROM of the lower extremities. Interview on 06/17/24 at 3:57 P.M. with Resident #4, revealed he lost his right leg brace and then reported therapy had taken his other brace (knee)). The resident reported staff were not providing ROM to his lower extremities and he needed exercise. The resident had difficulty communicating/expressing himself due to dysphasia (difficulty speaking). The resident was noted to propel in a wheelchair by using his left foot to propel himself in his room. Interview on 06/20/24 at 8:15 A.M. with Housekeeping/Supervisor #525, revealed the resident had reported his leg brace was missing over the weekend, however they were not missing because therapy had discontinued the brace. The staff member confirmed the resident had braces because she can recall moving the braces when she cleaned his room. Interview on 06/20/24 8:18 A.M., with Therapy Director (TD) #513 revealed the therapy department was newer in the last year and half and had limited access to previous medical records. TD #513 reported she was unaware the resident ever had an ankle-foot orthotic (AFO); however, the resident had seen an AFO in the therapy room and kept telling staff it was his, but it belonged to another resident. TD #513 reported the resident had an over-the-counter knee brace like you would buy at the drug store that was all stretched out and was not providing any support. The therapy department had bought him a new one, but he didn't like it and the knee brace was returned. Therapy did not try any other type of brace, nor could she recall why he didn't like it for sure. Observation on 06/20/24 at 9:30 A.M., with TD #513 revealed she had gone to follow up with Resident #4 regarding his concerns related to the AFO and braces. She was able to find one of the elastic/compression knee braces. Further observation revealed the resident had a second knee brace that was soft and had straps, however it had missing hardware in the bend of the knee. The TD reported she was not able to find the AFO. The resident kept reporting therapy took it (the AFO). TD reported to the resident that she took the compression knee brace they had bought in April because he kept refusing to wear it and she was not aware he had an AFO. The TD reported therapy had screened the resident, had picked him up for services as a result of the screen and referred him to orthotics to be fitted for a new AFO and knee braces. Interview on 06/20/24 at 9:55 A.M., with Restorative Aide (RA) #536 revealed the resident was receiving active range of motion through the restorative program, when he was compliant, to the upper extremity. RA #536 reported the resident used to wear a compression knee brace; however, it was stretched out and therapy had ordered a new knee brace, but it was too small due to the resident's legs being swollen. The resident's weights were changed to two pounds instead of three pounds as originally recommended due to the facility didn't have three-pound weights. Interview on 06/20/24 at 10:29 A.M., with Registered Nurse (RN) #520 confirmed Resident #4 did not have orders or a comprehensive plan of care for restorative. RN #520 revealed the facility doesn't write orders for restorative and they don't do an individualized plan of care for restorative programs. RN #520 reported staff were to refer to the task section of the medical record to see if residents were on a restorative program and to document participation with restorative programs in the electronic medical record. RN #520 reported she would have to do some investigating regarding the resident's past use of the AFO and knee braces and why he was no longer using them. Review of therapy screening notes dated 06/20/24 revealed the resident had a knee brace, however the lateral hinges had been removed. The resident would benefit from a consult for orthotics to address deficits, as needed, including possible right AFO and knee brace. Review of Resident #4's orthotics consult and order dated 06/20/24 revealed the resident was evaluated and ordered a right AFO to prevent drop foot and bilateral knee orthotics to stabilize his knees while standing and ambulating. Interview on 06/24/24 at 7:53 A.M., 8:05 A.M., and 8:26 A.M., with RN #520 confirmed the resident had an AFO and knee brace plan of care that was discontinued in 2023. The only thing she could determine was the resident had discharged and upon return the AFO and brace were not re-ordered or addressed upon re-admission. RN #520 reported therapy had screened the resident on 06/20/24 (after concern was identified) and picked the resident up for treatment. Therapy had also called an orthotic provider to evaluate the resident, which they had recommended an AFO and braces and were just waiting for insurance authorization.

Based on observation, review of a closed medical record, facility investigative notes, emergency medical services (EMS) report, facility elopement policy and procedure, staff and family interview and observation/review of facility video camera footage, the facility failed to prevent an incident of elopement for one resident (Resident #75), who was assessed to be cognitively impaired and exhibited wandering behaviors. This resulted in Immediate Jeopardy on 08/04/19 at 3:52 P.M. when Resident #75 exited the facility unsupervised and unknown by staff from the 200 unit. The resident was found by State tested Nursing Assistant (STNA) #403 laying on the ground at the bottom of a steep embankment between the facility and a neighboring building on 08/04/19 at approximately 4:21 P.M. Actual Harm occurred as a result of the incident when the resident was transported to the local hospital and diagnosed to have two cervical (neck) fractures and multiple skin abrasions. The resident did not return to the facility following the incident. This affected one of three sampled residents. The facility identified 14 current residents (Resident #1, #11, #13, #15, #17, #18, #20, #40, #42, #49 #54, #55, #61 and #69) at high risk for elopement. The facility census was 71. On 08/07/19 at 12:09 P.M., the Administrator, Director of Nursing (DON) and Manager of Clinical Services, Registered Nurse (RN) #701 were notified Immediate Jeopardy began on 08/04/19 at 3:52 P.M. when Resident #75 eloped from the facility. Video camera footage showed a resident, identified by the DON to be Resident #75 independently exiting the 200 unit exterior door towards the adjoining [MEDICAL TREATMENT] center on 08/04/19 at 3:52 P.M. The resident was found laying on the ground at the bottom of a steep embankment, next to the facility at approximately 4:21 P.M. The resident was subsequently transported by Emergency Medical Service (EMS) staff to a local hospital where he was assessed to have two cervical (neck) fractures and multiple abrasions. The Immediate Jeopardy was removed on 08/08/19 when the facility implemented the following corrective action: · On 08/04/19 at 4:44 P.M. Resident #75 was transported to the hospital for treatment. The resident did not return to the facility. · On 08/04/19 the DON, Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #402 completed new elopement risk assessments for all 71 in-house residents, which included staff interviews and behavioral tracking documentation on Point Click Care (the facility electronic medical record documentation system). · On 08/04/19 the DON, Assistant Director of Nursing (ADON) and LPN #402 reviewed elopement prevention plan of care records for the 14 current residents, Resident #1, #11, #13, #15, #17, #18, #20, #40, #42, #49 #54, #55, #61 and #69 who were identified to be at risk for elopement to ensure appropriate interventions were in place. · On 08/04/19 the DON/designee completed wander guard audits to ensure physician orders were in place for wander guard devices as ordered for seven residents, Resident #11, #15, #20, #42, #49, #61 and #69 who were at high risk for elopement and who did not reside on the facility secured (locked) unit. · On 08/04/19 LPN #402 completed egress door audits to ensure all locks, alarms, and/or wander guard devices were functioning correctly. On 08/05/19 the Maintenance Director re-evaluated the egress doors to ensure all locks, alarms were functioning. · On 08/04/19 the elopement kits, which contained flashlights and walkie-talkies were checked by the DON ensuring all components were available and in good working order. · Beginning on 08/04/19 the DON, ADON and LPN #402 initiated staff education on elopement prevention. Education was conducted on 08/04/19, 08/05/19, 08/07/19 and 08/08/19 with all staff education completed on 08/08/19 with emphasis on the following: a. The admitting licensed nurse would complete an elopement assessment for all residents upon admission gathering information from the resident, family, hospital and other outside sources as appropriate. If there was not enough information to complete a comprehensive assessment, the nurse would contact the on-call administrative nurse for directives. b. The facility licensed nursing staff would reevaluate residents with mobility and behavioral changes such as wandering and exit seeking behaviors. If identified, the nurse would complete a new assessment gathering information from staff, family, therapy and other members of interdisciplinary team. c. Interventions would be immediately implemented by licensed nurses upon recognition of increased risks for elopement. Interventions would be individualized for each resident and might include, but were not limited to, increased supervision, implementing a wander guard, resident centered diversional activities, care conference with family to identify person-centered care activities, increased outing with family, pharmacological and routine scheduled visits. d. Current facility residents would be assessed for elopement risk by the Director of Nursing on a quarterly and ongoing basis as well as with significant changes. e. Elopement Policy and Procedure Recognizing and responding to increased elopement risks (e.g., wandering, pacing, exit seeking, increased mobility) f. Immediate communication in changes to risk g. Documentation of elopement risk behaviors h. Accurate completion of elopement risk assessments (e.g., routine and PRN) i. Elopement kits and Elopement Book The facility identified all staff included 31 STNAs, 1 Hospitality Aide, 14 LPNs, 10 RNs, 8 department heads, 1 maintenance staff, 9 laundry and housekeeping staff, 13 therapy staff, 13 dietary staff and three activity staff who were provided the above education as of 08/08/19. · On 08/08/19 the DON/designee initiated daily audits to identify residents with exit seeking behaviors and staff response. The DON/designee would monitor for compliance through daily clinical meetings, nurse shift to shift change report, 24-hour reports on Point Click Care, and daily monitoring of behavior documentation and staff response. Audits would be completed 5 times weekly for 4 weeks or as directed by the QAPI committee. · On 08/08/19 the DON/designee initiated audits of all new admissions to ensure elopement risk assessments were accurately documented and care plans initiated where indicated. A plan for audits to be conducted three times weekly for four weeks or as directed by the QAPI committee was implemented. · On 08/08/19 a special AD H[NAME] QAPI committee meeting was held to review the investigation, audits and internal action plans. All audits will be reviewed on a weekly basis in conjunction with the risk meeting until substantial compliance is achieved and/or as directed by the QAPI committee. Members include Administrator, DON and the Medical Director. Although the Immediate Jeopardy was removed on 08/08/19, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of evaluating the current policy and procedures for new admissions, completing additional staff training and conducting audits to ensure effective staff training was in place. Findings include: 1. Medical record review revealed Resident #75 was admitted to the facility for a respite care stay on 08/02/19 with [DIAGNOSES REDACTED]. The resident was admitted to a bed on the facility skilled nursing unit. The admission assessment revealed the resident was confused at the time of admission. Record review revealed the resident had a 24-hour plan of care, dated 08/04/19 which indicated the resident was new to the facility and his needs would be met and care provided based on the admission physician's orders and professional standard of quality care. A fall plan of care revealed staff would encourage and remind the resident ask for assistance, have commonly used articles within easy reach, a low bed and maintain clear pathway. There was no evidence of a baseline plan of care for additional safety measures related to the resident's [DIAGNOSES REDACTED]. Review of an Elopement Risk assessment dated [DATE] revealed Resident #75 was not assessed to be at risk for elopement as it noted the resident was not physically capable of leaving the facility. Review of a Physical Function Assessment, dated 08/02/19 revealed Resident #75 was unsteady and only able to stabilize with staff assistance with standing, walking, moving on/off toilet and surface to surface. The assessment revealed the resident had no mobility devices and was only at the facility for respite care. Review of a nursing progress note, dated 08/04/19 at 4:21 P.M. revealed at approximately 3:40 P.M. hospitality aide (HA) #314 reported Resident #75 needed assistance to the restroom. At approximately 3:45 P.M., the resident was sitting on the commode. At approximately 3:47 P.M. STNA #808 entered the room to assist the resident off the commode. Per the progress note, at approximately 4:00 P.M., LPN #120 went to the resident's room to administer medication and he was not in his room. The nurse and other staff members began looking for the resident. The resident was found outside of the building in the grassy area on the ground and his wheelchair was tipped over. Resident #75 was assessed to have multiple skin tears and abrasions to his bilateral hands and knees and a raised bump on his head. Basic first aid was provided. The note indicated the resident was alert to self per usual and denied complaints of pain during the assessment. Emergency personnel/911 was called and the resident was transported to the local hospital for further evaluation. The resident did not return to the facility following this incident. Review of the local Emergency Medical Services (EMS) run report, dated 08/04/19 revealed a call for assistance was received at 4:26 P.M. EMS arrived at the facility at 4:30 P.M. and found a [AGE] year-old male lying in the recovery position. The resident presented with neck and back pain. The EMS narrative documentation revealed EMS was dispatched to the facility for a male who fell out of his wheelchair after rolling down a hill. He had neck and back pain reported by nursing staff. The EMS documentation revealed the resident rolled about 150 yards down a hill where his wheelchair tipped, and he fell in the gravel. The nursing staff also stated that he was down for 15 minutes, but his fall was unwitnessed. The resident was on the anti-coagulant medication, [MEDICATION NAME] and he had a long history of dementia per the nursing staff. He had minor abrasions and a hematoma to the parietal area of the skull. Both hands were reported to have abrasions on them, but the wounds were covered with bandages prior to the EMS arrival. Both knees were found to have minor abrasions to the top of the patella region. The on-scene nurses did not have any further information available to EMS, nor did they have any packet of information available to be handed off to the EMS. The resident was placed in a cervical collar as precautionary measures. EMS arrived to the emergency room (ER) at 4:41 P.M. and the resident was in the ER at 4:59. Review of Resident #75's hospital records revealed the resident had a history of [REDACTED]. The resident presented to the hospital as a trauma after wandering out of his nursing home and falling down a hill, from which he sustained a cervical (C) C1/C2 neck fracture. The resident's dementia was progressive and he was hard of hearing, so his daughter assisted with history. The daughter reported her mother had been in the hospital for rectal bleeding for several days and she could not care for her father at home, so she placed him at the nursing facility for five days until her mother could go home. The resident wandered out of the nursing facility and was found down a hill. He sustained multiple bruises and abrasions and the cervical spine fracture. The resident was evaluated and reported not to be a surgical candidate at this time due to age, poor functional status, and dementia. The resident would be admitted for monitoring, pain management, and placement to a different skilled facility. Review of the computerize tomography (CT) scan report from the hospital dated 08/04/19 revealed the resident had an unstable fracture pattern at C1 and C2. There was a displaced atypical Jefferson fracture. There was also a displaced fracture involving the odontoid (part of the cervical spin) which was displaced posteriorly by 6 mm. A rotatory subluxation was also present at C1 and C2. Review of the facility investigation of the incident revealed it contained written and typed statements from staff as follows: A statement, dated 08/04/19 from LPN #120 revealed upon arrival to the facility for her shift on 08/04/19 at 6:30 [NAME]M. Resident #75 was sitting in the A wing living area in his wheelchair. The statement revealed the resident needed persistent reminders to stay seated in his wheelchair due to the fear of him falling. LPN #120 attempted to have one-on-one staff with the resident the majority of the day. At approximately 3:40 P.M. HA #314 asked if the nurse would assist the resident onto the commode in his room. The nurse advised her to call for an STN[NAME] At approximately 4:00 P.M., she went to Resident #75's room and he was not there. The statement indicated she attempted to see if any staff knew where the resident was and after not finding the resident the facility elopement procedure was initiated. The resident was found down over the hill in front of the building and was injured. EMS was called and staff requested wound supplies for the resident's injuries. Review of a statement from Dietary Aide (DA) #204, dated 08/04/19 revealed on 08/04/19 at 3:00 P.M. Resident #75 had come to the back kitchen door and was pushing his wheelchair into it repeatedly, so she asked what was wrong. The resident reported he was looking for the church services. The DA told him it was on the 300 hall. The statement indicated they talked for about 15 minutes before he went to look for someone on 300 hall. Around 3:25 P.M., she saw the resident walking down the 200 hall unit. Review of a statement from STNA #808, dated 08/04/19 revealed she assisted Resident #75 off the commode and into his wheelchair on 08/04/19 at 4:00 P.M. She stated the resident had requested to watch the television in his room. When she exited his room, he was in his wheelchair watching the television. Review of a statement from LPN #312, dated 08/04/19 revealed Resident #75 had been in the common area on A hall, in the activity room, and was one-on-one with staff due to being a fall risk. The statement indicated on 08/04/19 at 3:38 P.M. Resident #75 was with STNA #118 and herself on the A hall (100 hall) with one-on-one supervision. Resident #75 stated he was trying to go to church. The LPN made him aware that church was over, and he went back into the common area. LPN #312's statement indicated on 08/04/19 at 4:10 P.M., she used her walkie talkie to call staff in the dining room to see if Resident #75 was there. Staff responded no he was not. LPN #120 then called over the walkie talkie asking if anyone had eyes on Resident #75 at that time. Everyone responded no and the elopement search begun. As staff were searching, STNA #403 yelled He's down the hill on the ground! The three staff ran down the hill and there was blood noted on the resident's head. 911 was called since staff could not determine if he had fallen down the entire hill at that time. Review of a statement from STNA #403, dated 08/04/19 at 4:00 P.M. revealed the STNA was on B hall (200 hall) when a page came over the walkie talkie about Resident #75. She went to the main entrance and walked over by the flagpole where she saw Resident #75 laying at the bottom of the hill. On 08/06/19 during a review of the facility investigation, there was no conclusion as to what door the resident exited or how Resident #75 was able to exit the facility unsupervised by staff. On 08/06/19 at 11:39 P.M. interview with the DON and Administrator revealed they were not able to determine how Resident #75 eloped from the building. The administrative staff revealed the doors on the 200 unit, 300 unit, the [MEDICAL TREATMENT] door at the end of 200 hall and the front doors were unlocked but had a wander guard system in place. However, Resident #75 did not have a wander guard device in place. During the interview, the DON revealed the admission elopement assessment, completed on 08/02/19 was inaccurately completed as the resident was physically capable of getting out of the facility on his own. The DON confirmed Resident #75 who was cognitively impaired had exited the facility without staff knowledge and was found at the bottom of a hill next to the facility and sustained cervical neck fractures On 08/06/19 at 12:23 P.M., telephone interview with Resident #75's daughter revealed prior to her fathers' five-day respite admission to the facility he required twenty-four-hour care seven days a week and was provided this care at home. He was walking at home with a walker prior to his admission to the facility. Resident #75's daughter revealed the resident was placed in the facility for an emergency respite care stay because she was also her mother's caretaker and she had been hospitalized . Hospice had recommended the five-day respite stay to her for her father. She stated she had concerns with the facility right away. Her concerns included that they had placed her demented father at the end of an isolated hallway. She reported dementia residents needed to be around people and not be isolated. Her second concern was that they placed her father in a wheelchair and he did not know how to use it and she had to show him. He was used to using a walker. She was also under the impression from facility staff that her father would have alarms and staff supervision due to his dementia diagnosis. She was told by other residents in the facility when she was visiting that they were concerned with her father's safety and they would keep an eye on him. She confirmed he was wandering around the building when she had visited. The daughter as well as her friend had visited her father the day of the incident on 08/04/19. The daughter stated on 08/04/19 her friend left around 3:45 P.M. to 3:50 P.M. The friend and herself had told staff when they were leaving so the staff were aware and could keep an eye on him. On 08/06/19 at 12:55 P.M. and 3:05 P.M. interview with LPN #120 revealed she worked day shift on Sunday 08/04/19. When she arrived for her shift the resident was attempting to stand up and was asking questions that did not make sense. She stated he did wander around the building that day, however he was not exit seeking. She stated when she notified the daughter of the elopement incident the daughter had questioned why he did not have a wander guard on because she was under the impression he was to have one. She reported the daughter had visited earlier that day and the daughter did report to her that she was leaving. LPN #120 did not recall seeing a visitor visiting Resident #75 at first, then reported there might have been someone visiting him in a purple shirt. When the daughter left, she had staff bring the resident to the common area so he could be visually observed. LPN #120 reported the hospitality aide provided one-on-one supervision when she was able to as the resident was attempting to stand without staff supervision. Staff were told to keep the resident in a common area. LPN #120 did not know why the STNA left Resident $75 in his room by himself except that he requested to watch television. LPN #120 verbalized her time frame of the incident and it correlated with her statement provided as part of the investigation on 08/04/19. LPN #120 reported you could see where the resident's feet had slid in the grass and see the tire tracks from the wheelchair down the hill until it reached the drop off. The drop off was about 25 feet and the resident was lying at the bottom of the drop off broadline to the driveway of the building at the bottom of hill. She thought the wheelchair was lying across the bottom of his legs but couldn't recall 100 percent. LPN #120 revealed following the incident education was provided on elopement drills, assessments, and the elopement binder. LPN #120 was able to verbalize the procedure to follow for an elopement. On 08/06/19 at 2:10 P.M. telephone interview with Resident #75's Hospice nurse (HN) #704 revealed Resident #75 was a current Hospice patient and she had provided services to the resident at home as well. The resident was sent to the facility for emergency respite care for five days while the resident's care giver (his daughter) was at the hospital with his wife. Hospice had not seen the resident at the facility, however when she gave report to LPN #309 he was a high fall risk and would benefit with the use of alarms. The resident had been more confused in the last few weeks. HN #704 reported the resident was never left alone at home. His wife or daughter was always at his side. She reported he had no desire to leave home because he had someone with him at all times. She reported any resident with dementia would be at risk for elopement especially with a change in environment. On 08/07/19 at 6:35 [NAME]M. interview with STNA #400 and STNA #210 revealed Resident #75 was wandering in the facility Saturday night (08/03/19) into Sunday (08/04/19) morning. Early Sunday morning the STNA staff indicated they saw the resident sitting in the main entrance lobby by himself looking out the door. The STNA brought the resident back to his unit because she didn't want him setting off the alarms. The resident would not stay in bed and staff tried to keep the resident in the common area or provided one-on-one if they were able. The STNA staff did identify Resident #75 used a wheelchair but was also observed walking in the hallway and would occasionally miss a step now and then. The STNA staff thought the resident liked looking out the windows and doors. On 08/07/19 at 7:14 [NAME]M., interview with LPN #312 revealed she had worked the previous Friday, Saturday and Sunday on A-back hall. On Friday 08/02/19 Resident #75 was confused and staff initiated one-on-one due to safety concerns over the resident falling. She stated although this was not documented as being completed staff were notified verbally. LPN #312 indicated on Saturday 08/03/19 Resident #75 was a little more active and got to know the building. He mostly stayed in the lounge until the end of her shift then he became more active and started attempting to walk around. On Sunday 08/04/19 he was wandering around the building looking for the church. He was trying to find the lady who said she would take him to church. It was noted he was in the kitchen looking for the church. He never verbalized he wanted to go home or exited, however he would sit in front of the door and look out the window. On Sunday 08/04/19 at 3:38 P.M. he told the LPN he was looking for the church. She told him church was over. After she was done with medication administration, she went to assist LPN #120. LPN #120 asked if she had seen Resident #75 because they had been trying to keep visual checks on him all weekend. The HA was helping staff watch him, but she had to go to the dining room to help with the dinner meal. The resident was not in the dining room, so they started looking through the rooms on 300 hall. The staff split up and went outside. STNA #403 found him at the bottom of the hill next to a building around 4:23 P.M. On 08/07/19 at 7:19 [NAME]M. interview with LPN #309 revealed she was Resident #75's admitting nurse on Friday 08/02/19. She had worked 6:30 [NAME]M. to 3:00 P.M. Friday and the resident arrived via stretcher. Resident #75 was confused but knew his name and knew he was in St. Clairsville. Upon talking to Hospice staff, the LPN was informed the resident had a history of [REDACTED]. On 08/07/19 at 10:00 [NAME]M., interview with the DON revealed that although the facility had video cameras in the hallways (except for on the 300 unit) the facility had not viewed the camera footage as part of the investigation as to how Resident #75 exited the facility unsupervised or what door he might have exited until today. The DON revealed video camera footage showed Resident #75 exiting the facility on 08/04/19 (time not provided) from the door that adjoins the [MEDICAL TREATMENT] center to the nursing home. This door was noted to be off the 200 unit. On 08/07/19 at 10:02 [NAME]M., observation of the video camera footage with Business office Manager (BOM) #503, the DON and Administrator revealed on 08/04/19 at 3:52 P.M., Resident #75 was observed exiting the [MEDICAL TREATMENT] door at the end of 200 hall unsupervised by staff. At 3:52:33 an unidentified person exited the secure unit next to the [MEDICAL TREATMENT] door and walked behind the nurse's station. Additional observation of the video camera footage on a larger screen revealed footage of the A-Hall nurse's station (corner of 100 and 300 unit) and B-Hall nurse's station (200 Hall) was available. Observation with BOM #503 revealed Resident #75 entered the camera view on A-hall on 08/04/19 at 3:50:41. At 3:50:41 STNA #808 exited behind the nurse's station and headed down the end of 100 hall (vent unit). At 3:51:43 P.M., two STNAs, STNA #808 and STNA #403 were at the corner of the nurse's station and the resident was near the other end of the nurse's station on the same side. There was no evidence any of the staff attempted to redirect the resident as he headed down the hallway past the therapy department towards 200 halls. There was no evidence the resident was being provided one-on-one supervision as recommended as a nursing intervention. The resident exited the A-Hall nurse's station camera footage at 3:51:57 and was heading down towards the 200 hall. At 3:51:45 P.M., the resident appeared on the camera footage on B hall nurses' station The resident exited the camera footage at 3:51:59. An unidentified staff member was noted at the front of B Hall at 3:52:06 P.M. and an unidentified staff exited the secure unit (near the [MEDICAL TREATMENT] door) and went behind the nurse's station at 3:52:33 P.M. BOM #503 verified the video camera footage at the time of the observation. On 08/07/19 at 10:12 [NAME]M. observation of the facility exit door off the 200 unit with MD #508 revealed it exited to a foyer. From the foyer you could either walk straight to enter the adjoining [MEDICAL TREATMENT] center or turn right to exit the facility to the outside parking lot through double automatic sliding doors. Although the exact route Resident #75 took after walking outside the door was not determined as part of the facility investigation, the following observations were made: After exiting the double automatic doors, the driveway was paved. To the left the paved road would bring you around the [MEDICAL TREATMENT] center and to the front of the nursing home building or straight down to the main highway. Walking to the right would take you around the building to another paved parking lot. The pavement ended almost to the back corner of the building then it turned into a grassy area. Around the corner of the building near the 300 unit where the resident resided there was an area of grass which turned into a concrete sidewalk that would bring you around to a parking lot in front of the 300 unit (which appeared to be an addition to the main building). That parking lot from the 300 unit leads to the front of the nursing home building. To the right of the parking lot there was a steep embankment. The embankment appeared to be greater than 45-degree downward angle. Measurements were obtained with MD #508 which noted the hill was 130 feet down from the corner of the parking lot and then there was a steep change in elevation near the bottom of the hill that measured an additional 30 feet to the location where the resident was found. LPN #312 confirmed where Resident #75 was found at the bottom of the hill. MD #508 verified he was provided education on the elopement policy and procedure following the incident and he also stated he ensured the flashlights in the elopement kit had new batteries and current supplies needed. On 08/07/19 at 11:18 [NAME]M., interview with the DON revealed she was not aware Resident #75 was having wandering behaviors over the weekend and indicated additional staff statements and audits were being initiated at this time. On 08/07/19 at 3:22 P.M. interview with the DON and Manager of Clinical Services RN #701 verified the two STNAs on the camera video footage seen prior to Resident #75 exiting the facility were STNA #808 and STNA #403. She confirmed there was no documented evidence in Resident #75's medical record that indicated the resident was attempting to stand or wandering from the time of his admission through 08/04/19. RN #701 verified the resident did not have an immediate needs plan of care for [MEDICAL CONDITION] or dementia and that no updated wandering or elopement assessment or interventions had been initiated by direct care staff following the observed incidents on 08/03/19 and 08/04/19 when staff initiated one-on-one supervision for the resident. Review of the facility policy titled Elopement and Wandering Residents, dated 04/25/18 revealed the facility would ensure that residents who exhibited wandering behavior and/or were are at risk for elopement received adequate supervision to prevent accidents and receive care in accordance with their person-centered pan of care addressing the unique factors contributing to wandering or elopement risk. Wandering was defined as random or repetitive locomotion that may be goal-directed (e.g.,) the person appears to be searching for something such as an exit) or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. This deficiency is an incidental finding to Complaint Number OH 860.

Based on observation, record review, and interview, the facility failed to ensure one resident's pain was timely and adequately addressed. Actual harm occurred when Resident #65 requested assistance into bed, and was not timely assisted resulting in increasing pain to the lower back described by the resident as excruciating, and subsequently affecting his daily activities. This affected one (Resident #65) of three residents reviewed for pain. Findings include: Review of Resident #65's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance of one staff member with dressing and personal hygiene; extensive assistance of two staff members with bed mobility and toilet use; and dependent of two staff members with transfers. Review of the pain assessment dated [DATE] revealed the resident had almost constant pain to his torso that limits day to day activities. Review of the Medication Administration Record [REDACTED].M. for pain rated a 6 of 10, on 1 to 10 pain scale. On 02/28/18 at 10:25 A.M. observation revealed Resident #65's call light was turned on. At 10:35 A.M., LPN #102 entered Resident #65's room, and asked the resident what he needed. The resident informed the nurse he was ready to go to bed. LPN #102 informed the resident she would get staff to assist him to bed. On 02/28/18 at 10:40 A.M. Resident #65 was observed seated in his wheelchair in his room. The resident was observed to frequently shift his weight while seated in his wheelchair. Interview with Resident #65 revealed he had been waiting to go to bed since he returned from [MEDICAL TREATMENT] at around 10:00 A.M. The resident stated, it's excruciating to have to sit in the wheelchair for long periods due to sciatic pain. On 02/28/18 at 11:00 A.M. Resident #65 was observed seated in his wheelchair. Interview with Resident #65 revealed he had burning to his lower back from sitting in the wheelchair, and rated the pain a 6 on a 1 to 10 pain scale. The resident stated he had been up since 5:00 A.M. for [MEDICAL TREATMENT]. On 02/28/18 at 12:40 P.M. Resident #65 was observed lying in his bed facing the door. The resident's lunch tray was sitting on his overbed table and the resident had not eaten. The meal tray contained meatloaf, corn, mashed potatoes and ice cream. Interview with Resident #65 revealed he was unable to eat his lunch due to his pain. Further interview revealed staff assisted him to bed at approximately 12:00 P.M. and sitting in the wheelchair makes his back pain worse. The resident shared his pain rating was a 7 when staff assisted him to bed. On 02/28/18 at 12:45 P.M. interview with STNA #108 verified Resident #65 returned from [MEDICAL TREATMENT] around 10:00 A.M. and was not assisted back to bed until 12:00 P.M. due to the amount of work needing completion prior to assisting the resident to bed. On 02/28/18 at 4:40 P.M. interview with STNA #107 verified Resident #65 did not eat his lunch. On 03/01/18 at 1:10 P.M. interview with LPN #102 revealed she administered [MEDICATION NAME] to Resident #65 upon his return from [MEDICAL TREATMENT] on 02/28/18. Further interview revealed sitting up in his wheelchair for long periods of time makes his sciatic pain worse. This deficiency substantiates allegations contained in Master Complaint Number OH 415, Complaint Number OH 313, and Complaint Number OH 271

Based on record review and interview, the facility failed to ensure treatments and interventions were implemented for residents with pressure ulcers. This affected two residents (Resident #11 and #128) of three residents reviewed for pressure ulcers. The facility identified nine residents with pressure ulcers. Harm occurred when Resident #128 was admitted to the facility on [DATE] with a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough) pressure ulcer to the right buttock that deteriorated to an unstageable pressure ulcer on 11/11/14 due to the lack of appropriate care and implementation of treatment. Findings include: 1. Review of Resident #128's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the pressure ulcer risk assessment, dated 11/06/14, revealed the resident was at high risk for pressure ulcers. Review of the skin assessment admit/re-admit assessment dated [DATE], revealed Resident #128 was admitted to the facility with a Stage II right buttock pressure ulcer measuring 1.0 centimeters (cm) in length by 2.4 cm in width with 0.1 cm depth. Review of the skin grid assessment dated [DATE], revealed Resident #128's right buttock pressure ulcer declined to an unstageable pressure ulcer that measured 1.0 cm in length by 1.2 cm width. The wound bed was assessed to be covered with 100% yellow slough (necrotic/avascular tissue). Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #128 was cognitively intact for daily decision making, had an unstageable pressure ulcer and required extensive assist with bed mobility. Review of the physician orders [REDACTED]. Review of the Laboratory Chemistry Profile result dated 11/06/14, revealed Resident #128's total protein was 6.0 (normal 6.3-8.2 G/dL) and [MEDICATION NAME] was 2.6 (normal 3.5-5.0 G/dL). Review of the medical record revealed no documented evidence of a pressure ulcer assessment between 11/05/14 and 11/11/14, and no evidence of a pressure ulcer care plan until 11/24/15. Review of the Skin-Pressure Ulcer policy revised November 2006, revealed the wound was to be evaluated daily. Review of the Skin Assessment and Documentation Guide policy dated November 2014, revealed skin was to be monitored daily. On 02/05/15 at 10:48 A.M., interview with Corporate Nurse #200 verified Resident #128 was admitted to the facility with a Stage II right buttock pressure ulcer, no treatment was initiated for the pressure ulcer until 11/08/14, and it deteriorated to an unstageable pressure ulcer on 11/11/14. 2. Record review revealed Resident #11 was admitted to the facility on [DATE], with readmissions on 12/01/14 and 01/28/15. The resident had [DIAGNOSES REDACTED]. Review of Resident #11's physician orders [REDACTED].#11's heels while in bed. Review of Resident #11's skin assessment dated [DATE], revealed a left buttock pressure ulcer was present, measuring one cm in length by one cm in width. On 02/03/15 at 2:45 P.M., Resident #11 was observed in bed laying on her left side with her left heel directly on the bed. Interview with State tested nursing assistant (STNA) #21, at the time of the observation, verified Resident #11's left heel was laying against the bed and was not floated off the bed per the physician order.