Every finding on record at Divine Rehabilitation and Nursing at Toledo

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure fall interventions were in place as care planned. This affected one (#7) of two residents reviewed for falls. The facility census was 58. Findings include:Review of the medical record revealed Resident #7 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting the left non-dominant side, vascular dementia, hypertensive heart and chronic kidney disease with heart failure, and chronic kidney disease.Review of the Minimum Data Set (MDS) assessment, dated 06/22/26, revealed Resident #7 was moderately cognitively impaired and had no recent falls. Review of the care plan, dated 09/07/23, revealed Resident #7 was at risk for falls with an intervention to have the bed in the lowest position. Observation on 08/10/26 at 10:40 A.M. revealed Resident #7 in bed and the bed was observed to be in a high position, approximately three feet off the ground.Interview on 08/10/26 at 10:45 A.M. with Certified Nurse Aide (CNA) #492 verified Resident #7's bed was not in the lowest position. Review of facility policy titled, Fall Prevention Program, dated 2024, revealed residents with risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness and the plan of care will be revised as needed.

Based on review of the medical record, review of beneficiary notification, and staff interview, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice of Non-Coverage (ABN) notices were accurately completed and provided in a timely manner. This affected one (#6) of two residents reviewed for beneficiary notices. The facility census was 58. Findings include:Review of the medical record revealed Resident #6 was admitted on [DATE]. Diagnoses included type two diabetes mellitus with ketoacidosis, acute chronic systolic heart failure, essential hypertension, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 06/07/26, revealed Resident #6 was moderately cognitively impaired. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review revealed Resident #6's Medicare part A skilled services episode start date began on 02/27/26 and the last covered day of part A service was 03/31/26.Review of the Notice of Medicare Non-Coverage (NOMNC) revealed Resident #6's Medicare coverage of the current skilled service was to end on 03/31/26. The notice was dated on 03/30/26 and signed by Social Services #461 and Business Office Manager #447. No further notations were provided. Review of Resident #6's Advanced Beneficiary Notice of Non-Coverage (ABN), dated 03/31/26, revealed a notice was provided that Medicare does not pay for everything and the resident may have to pay for daily skilled nursing care with an estimated cost of $335.00 per day. The options selected was option two which read, I want the item, test, service or care listed above, but don't bill Medicare. You can ask to be paid now and I'm responsible to pay. I understand I can't appeal, since Medicare isn't billed. The notice was signed by Social Services #461 and Business Office Manager #447. No further notations were provided.Interview on 08/12/26 at 3:37 P.M. with Social Services #461 revealed Resident #6's NOMNC and ABN were not signed timely. Social Services #461 stated Resident #6 and the resident's representative were verbally informed. Social Services #461 verified there was no notation the resident or the resident's representative was informed and verified the signatures on both forms were signed by Social Services #461 and Business Office Manager #447. Additionally, Social Services #461 verified she likely checked the wrong box of option two stating the resident wanted the skilled services and would be responsible to pay.

Based on observation, medical record review, resident representative interview, staff interview, and review of facility policies, the facility failed to ensure residents were treated in a dignified manner. This affected three (#25, #34, and #37) of nine residents reviewed for dignity with care. The facility census was 58.Findings include:1. Review of the medical record revealed Resident #25 was admitted on [DATE]. Diagnoses included multiple sclerosis, hyperlipidemia, major depressive disorder, vascular dementia, and chronic obstructive pulmonary disease.Review of the Minimum Data Set (MDS) assessment, dated 07/25/26, revealed Resident #25 was moderately cognitively impaired and required set-up/clean-up assistance with eating.Review of the care plan, revised on 03/30/23, revealed Resident #25 required set up assist by one staff to eat.Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included chronic respiratory failure with hypoxia, epilepsy, and hemiplegia and hemiparesis following infarction affecting the right dominant side.Review of the MDS assessment, dated 05/23/26, revealed Resident #34 was severely cognitively impaired and required supervision/touching assistance. Review of the care plan, revised on 01/29/26, revealed Resident #34 required staff assistance and oversight with meals. Observation on 08/10/26 at 12:13 P.M. revealed Activities Assistant (AA) #426 assisting Resident #25 with the lunch meal. AA #426 was standing over Resident #25 throughout the entirety of the meal. Resident #25 was the only resident at the table and a chair was available. Subsequent observation revealed the Director of Nursing (DON) assisted Resident #34 with the lunch meal. The DON was observed to be standing over Resident #34 throughout the meal while assisting the resident. Interview on 08/10/26 at 12:27 P.M. with AA #426 revealed Resident #25 liked to have assistance with eating the lunch meal and verified not sitting while providing assistance. Interview on 08/10/26 at 12:34 P.M. with the DON verified standing above Resident #34 while assisting him with the lunch meal.2. Review of the medical record revealed Resident #37 was admitted on [DATE]. Diagnoses included metabolic encephalopathy, vascular dementia, and hypoglycemia.Review of the MDS assessment, dated 05/15/26, revealed Resident #37 was severely cognitively impaired and was dependent for eating, oral hygiene, showering/bathing, upper and lower body dressing, assistance for applying footwear, and personal hygiene.Review of the activities of daily living (ADL) care plan, revised on 07/14/26, revealed Resident #37 required one staff assistance personal hygiene. Observation on 08/10/26 at 10:20 A.M. revealed Resident #37 had a thick amount of white facial hair approximately one-quarter inch long throughout the chin and upper lip. The white facial hair was all the same length.Interview on 08/10/26 at 4:10 P.M. with Resident #37's representative revealed Resident #37 had always taken pride in her appearance and never had facial hair. Observation on 08/11/26 at 1:35 P.M. revealed Resident #37 continued to have thick white facial hair on the chin and upper lip. Interview on 08/11/26 at 1:40 P.M. with Licensed Practical Nurse (LPN) #431 verified Resident #37 had a thick amount of facial hair around the chin and upper lip. Observation on 08/12/26 at 10:12 A.M. of Resident #37 revealed the resident continued to have thick white facial hair on the chin and upper lip. Review of the facility resident rights policy, dated 2025, revealed residents have the right to a dignified existence and self-determination.Review of the facility activities of daily living policy, dated 2024, revealed residents who are unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure air mattresses were properly monitored for inflation and failed to ensure resident blood glucose levels were monitored. This affected one (#12) of one residents reviewed for blood glucose monitoring and functionality of air mattresses. The facility census was 58.Findings include:Review of the medical record revealed Resident #12 was admitted on [DATE]. Diagnoses included cervical disc disorder myelopathy, type two diabetes mellitus without complications, chronic pulmonary disease, low back pain, muscle wasting and atrophy, and bipolar disorder.Review of the Minimum Data Set (MDS) assessment, dated 08/04/26, revealed Resident #12 was cognitively intact and was identified to be at risk for pressure ulcers receiving a pressure reducing device for the bed. Review of the care plan, updated 07/29/26, revealed Resident #12 had an actual area of skin impairment due to a right great toe scab (resolved 08/03/26), a right second toe scab (resolved 08/03/26), a right knee scab (resolved 07/31/26), scrotum rash, and moisture associated skin damage (MASD) to the coccyx.Review of Resident #12's physician orders revealed a discontinued order dated 07/28/26 for Novolog flex pen subcutaneous solution pen-injector 100 units per milliliter (ml) with instructions to inject per sliding scale three times a day for diabetes mellitus type two. Review of Resident #12's physician orders revealed a discontinued order dated 07/28/26 for Trulicity subcutaneous solution auto-injector 0.75 milligrams (mg) per 0.5 ml with instructions to inject 0.5 ml subcutaneously one time a day every Sunday for diabetes. Review of Resident #12's physician orders revealed a discontinued order dated 07/30/25 for Liraglutide subcutaneous solution pen-injector with instructions to inject 1.2 mg subcutaneously one time a day for diabetic agent. Review of Resident #12's physician orders revealed a discontinued order dated 08/04/26 for a FreeStyle Libre reader device (continuous glucose system receiver). Review of Resident #12's physician orders revealed a discontinued order dated 08/04/26 for a FreeStyle libre plus sensor miscellaneous (continuous glucose system sensor). Review of a physician order dated 08/04/26 revealed Resident #12 had chronic obstructive pulmonary disease (COPD) and to avoid laying flat due to shortness of breath. The head of the bed should be elevated to prevent shortness of breath. Review of a nurse practitioner progress note dated 08/10/26 revealed Resident #12 was seen that day for nurse request for having low blood glucose levels and the resident's diabetes mellitus type two was historically well controlled. The resident's most recent blood glucose levels were between the low 80 milligrams per deciliter (mg/dl) and 120 mg/dl on average. Orders were given to nursing to discontinue Novolog and Liraglutide subcutaneous solutions pen-injector and to get a Hemoglobin A1C (blood test that measures your average blood sugar levels) for the next laboratory day and keep fasting blood glucose checks daily. Interview on 08/10/26 at 2:00 P.M. with Resident #12 revealed his air mattress was not working properly. Resident #12 reported when he was initially admitted he had a different bed for a few days and then was provided the air mattress. Initially the air mattress appeared to be okay, but within a couple of days of having it the mattress would deflate. Resident #12 stated he reported this to an unknown staff member who instructed him to stand up, lay the bed flat, allow the bed to inflate, and lay back down. Resident #12 stated he did as instructed but within 10 to 15 minutes the bed would deflate again, especially where his bottom sat. Resident #12 stated he informed an unknown staff member of this. Additionally, Resident #12 reported the facility took his blood sugar sensor off and he did not receive blood sugar checks. Observation and interview on 08/12/26 at 8:39 A.M. revealed Resident #12 in bed in a propped position. Subsequent interview with Resident #12 revealed his air mattress was deflated. Registered Nurse (RN) #416 encouraged Resident #12 to stand and transfer to a wheelchair. Continued observation of the air mattress revealed the mattress did not reinflate. The mattress had minimal to no air where the resident's weight was positioned in the middle of the bed. Interview on 08/12/26 at 8:46 A.M. with RN #416 verified Resident #12's air mattress was completely flat in the middle. Interview on 08/12/26 at 3:30 P.M. with the Director of Nursing (DON) revealed there should be an order for an air mattress to be monitored daily or every shift.Interview on 08/13/26 at 9:05 A.M. with the Administrator verified there was no order to monitor Resident #12's air mattress. Interview on 08/13/26 at 11:12 A.M. with Nurse Practitioner (NP) #634 verified effective 08/10/26, an order should have been in place to monitor Resident #12's fasting blood sugar every morning. NP #634 stated he provided a verbal order to the nurse on 08/10/26. Interview on 08/13/26 at approximately 11:30 A.M. with the DON verified Resident #12's blood glucose levels have not been monitored since the removal of the glucose system receiver/sensor was removed.

Based on medical record review, observation, and staff interview, the facility failed to ensure a dependent resident received assistance with eating. This affected one (#01) of three residents reviewed for mealtime assistance. The facility census was 61. Findings include:Review of the medical record revealed Resident #01 admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, moderate protein calorie malnutrition, hypertension, pain, osteoarthritis, mixed incontinence, and cerebral ischemia. On 10/18/24 Resident #01 was admitted to hospice services with the diagnosis cerebral atherosclerosis. Review of the nursing plan of care implemented on 10/23/24 addressed Resident #01's activity of daily living performance deficit related to Alzheimer's, confusion, impaired balance, diagnosis of Cerebral Atherosclerosis with life expectancy of six (6) months or less if the disease followed the natural course. Interventions included: Assist with feeding. Required documentation. The resident was totally dependent on two (2) staff for bed mobility. The resident was totally dependent on one (1) staff for personal hygiene and oral care. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was assessed with unclear speech, rarely/never understood, sometimes understands others, severe cognitive impairment, no recorded behaviors, dependent on staff for the provision of activities of daily living including eating, incontinent of bowel and bladder, weight of 62.0 pounds, on a physician prescribed weight gain regimen, received a mechanically altered therapeutic diet, and was at risk for pressure ulcer development with no skin breakdown. Review of the current physician orders revealed Resident #01 had the following orders; 06/02/25 a magic cup (a supplement) three times a day with lunch and dinner, 10/27/25 a regular diet, dysphasia advanced texture with thin liquid consistency, 01/30/26 monthly weights as tolerated. Review of the nutritional plan of care dated 09/12/25 and revised on 03/10/26 was implemented due to Resident #01's nutritional problem or potential nutritional problem related to underweight for age. Interventions included: provide and serve supplements as ordered, provide and serve diet as ordered, monitor intake and record every meal, and weigh as tolerated by the resident. Review of Resident #01's monthly weight record noted the following; on 03/04/26 the resident weighed 62.4 pounds, on 02/05/26 the resident weighed 62.4 pounds, on 01/19/26 the resident weighed 59.1 pounds, and on 01/05/26 the resident weighed 58.8 pounds. Review of the Nutritional Risk assessment dated [DATE] revealed Resident #01 had a recorded weight of 62.4 pounds and Body Mass Index (BMI) of 11.8 noting under weight for height and age. Intakes remain variable to poor. Ordered magic cup three times daily in addition to the house supplement eight (8) ounces three times daily. These were offered for comfort as opposed to aggressive nutrition interventions. No additional recommendations. Resident #01 had no weight or intake goals due to on hospice. As a hospice resident comfort should be maintained. Weigh resident as tolerated by resident. Offer supplements per her comfort/tolerance. Continue care plan as ordered; will continue to monitor and follow up as needed. Review of a functional abilities assessment dated [DATE] scored Resident #01 as dependent with activities of daily living including eating. During a continuous observation on 03/16/26 between 7:52 A.M. and 8:49 A.M., revealed at 7:52 A.M., the Certified Nursing Assistant (CNA) #200 took a breakfast tray into Resident #01's room, placed the tray on the overbed table, elevated the head of the bed, uncovered the plate and the bowl of hot cereal. CNA #200 proceeded to cut-up the food on the plate, set-up the meal in front of Resident #01 and opened a single use cardboard milk container. CNA #200 obtained a packet of sugar and placed the sugar on the hot cereal in the bowl and placed a spoon in the bowl. CNA #200 then left the room. Resident #01 was observed looking toward the television. At 7:57 A.M., Resident #01 had her eyes closed with no attempts to feed herself. At 8:05 A.M., Resident #01 remained in bed with no attempts to feed self, and food remained uncovered. At 8:10 A.M., Resident #01 was noted to obtain the carton of milk and attempted to drink. CNA #200 was observed seated at a computer in the 400 unit lounge. At 8:22 A.M. Resident #01 continued to attempt drinking from the milk carton with no attempts to eat the food. CNA #200 remained seated at the computer. At 8:31 A.M. Resident #01 continued with attempts to drink from the milk container. No attempts to take bites of food. At 8:36 A.M. Program Coordinator #300 went into the room and asked Resident #01 how breakfast was providing Resident #01 no assistance with the meal and left the room at 8:36 A.M. At 8:46 A.M. Resident #01 remained in bed holding the milk carton with no attempts to eat. At 8:49 A.M. CNA #200 went to the room and asked Resident #01 if she was finished. No verbal response was observed from Resident #01. CNA #200 placed the lid on the plate of untouched food and removed the tray from the room. During an interview on 03/16/26 at 8:52 A.M., CNA #200 verified Resident #01 had not eaten any of the breakfast meal. Observation on 03/16/26 at 12:09 P.M., CNA #200 took a meal tray to Resident #01's room and placed the tray in front of the resident on an overbed table. CNA #200 repositioned Resident #01 in bed and proceeded to uncover and set-up the lunch meal. CNA #200 sat next to Resident #01 and instructed Resident #01 to take a bite of each item before refusing the entire meal providing Resident #01 with bites of food from a spoon. At 12:17 P.M., the CNA #200 informed Registered Nurse (RN) #400 Resident #01 consumed a half portion of ice cream and a bite of beans while removing the tray from Resident #01's room. CNA #200 left the remaining portion of ice cream on the overbed table. However, no offer was provided to Resident #01 regarding meal alternatives. During a follow-up interview on 03/16/26 at 12:19 P.M., CNA #200 verified they had not offered to assist Resident #01 with breakfast. In addition, no attempts were initiated to offer alternative food choices following the lunch meal. During an interview on 03/16/26 at 12:28 P.M., RN #400 verified Resident #01 was dependent on staff for eating and was not provided with assistance during the breakfast meal. Additionally, Resident #01 was not offered alternative food choices when refusing the lunch meal. This deficiency represents non-compliance investigated under Complaint Number 2801593. This deficiency represents continued non-compliance from the biannual and complaint surveys completed on 03/05/26.

Based on observation, medical record review, staff interview, resident interview, review of a facility policy, and review of a glucometer manufacturer instructions, the facility failed to ensure glucometers were properly disinfected after use and failed to ensure bedpans were properly stored for residents with urinary infections. This affected three (#35, #49, and #54) of four residents observed for infection control practices with the potential to affected two additional residents (#22 and #42) who have their blood glucose level checked using the same glucometer as Resident #35 and #49. The facility census was 60. Findings include:1. Review of the medical record for Resident #49 revealed an admission date of 03/28/24. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, and type two diabetes mellitus.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had severe cognitive impairment. Review of the physician orders dated 09/28/24 revealed Resident #49 had an order for insulin glargine 14 units subcutaneously two times a day for diabetes mellitus. Further review of the physician orders revealed no orders for blood glucose monitoring. The resident had an order dated 01/12/26 for admission to hospice. Review of the medication administration record revealed the resident's glucose levels were monitored twice daily. Observations on 03/04/26 at 7:54 A.M. revealed Registered Nurse (RN) #500 used a glucometer to obtain Resident #49's glucose level. RN #500 returned to the medication cart and cleaned the glucometer with an alcohol swab. Interview on 03/04/26 at 7:56 A.M., with RN #500 verified an alcohol swab was used to clean the glucometer. RN #500 revealed she was an agency nurse and was not aware of the facility policy for glucometer cleaning. 2. Review of the medical record for Resident #35 revealed an admission date of 01/24/25. Diagnoses included vascular dementia and metabolic encephalopathy. Review of the quarterly MDS assessment dated [DATE] revealed Resident #35 had severe cognitive impairment. Observation on 03/04/26 at 8:00 A.M. revealed RN #500 used a glucometer to obtain Resident #35's blood glucose level. RN #500 used the same glucometer she had used to obtain Resident #49's blood glucose level. RN #500 returned to the medication cart and cleansed the glucometer with an alcohol swab. Observation and interview on 03/04/26 at 8:05 A.M., RN #500 verified if she had used an alcohol swab to clean the glucometer. RN #500 was asked if there were disinfectant wipes in the medication cart. RN #500 opened the bottom drawer of the medication cart and verified there were disinfectant wipes in the bottom drawer of the medication cart. Interview on 03/04/26 at 9:21 A.M., with the Director of Nursing (DON) verified staff should not be using alcohol swabs to clean and disinfect glucometers. The DON verified the four (#35, #49, #22, and #42) residents using the glucometer had no known blood borne pathogens. Review of the facility policy titled, Glucometer Disinfection, dated 2025, revealed the facility would ensure blood glucometers would be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. The glucometers would be disinfected with a wipe pre-saturated with an EPA (Environmental Protection Agency) registered healthcare disinfectant that is effective against Human Immunodeficiency Virus (HIV), Hepatitis C, and Hepatitis B virus. Review of the manufacturer's instruction manual for the blood glucose monitoring system revealed contact with blood presented a potential infection risk. The glucometer should be cleaned and disinfected between patient use. Option one for the cleaning and disinfecting should be completed by using a commercially available EPA-registered disinfect detergent or germicidal wipe. If blood was present on the meter, then two wipes must be used by using one wipe to clean and a second wipe to disinfect. Option two revealed to clean the glucometer with soapy water or isopropyl alcohol then disinfect with one milliliter of household bleach (five to six percent sodium hypochlorite solution) in nine milliliters of water to achieve a one to ten dilution (final concentration of 0.5 to 0.6 percent sodium hypochlorite). 3. Review of the medical record for Resident #54 revealed an admission date of 07/29/21 and a readmission date of 04/15/25. Diagnoses included schizophrenia, osteoarthritis, hypertension, and chronic pain. Review of the quarterly MDS assessment dated [DATE] revealed Resident #54 had impaired cognition. The resident was always incontinent of bowel and bladder and was dependent on staff for toileting hygiene. Review of a nurse's note dated 01/31/26 at 4:48 P.M. revealed Resident #54 had a multidrug resistant urinary tract infection and the resident was receiving antibiotic therapy. Observation on 03/02/26 at 10:34 A.M. revealed there were two soiled bedpans on Resident #54's bathroom sink and one soiled bedpan on the floor underneath the bathroom sink. The bedpans had not been placed inside a plastic barrier. Interview on 03/02/26 at 10:34 A.M. with Resident #54 revealed the staff had been using the bedpans to collect urine samples. Resident #54 revealed she had a urinary tract infection. Observation on 03/03/26 at 7:52 A.M. revealed the three uncovered bedpans remained in the same locations in Resident #54's bathroom. Interview on 03/03/26 at 7:52 A.M., with Licensed Practical Nurse (LPN) #421 verified there were two uncovered soiled bed pans on Resident #54's bathroom sink and one soiled uncovered bedpan on the floor underneath the bathroom sink. LPN #421 revealed the bedpans were used to collect urine specimens and the staff should have discarded the bedpans. Interview on 03/03/26 at 2:12 P.M., with the Administrator revealed staff should store urinary bed pans in a plastic bag.Review of the facility policy titled, Disinfection of Bedpans and Urinals, dated 2025, revealed bedpans and urinals would be handled in a manner to prevent the spread of infection through personal equipment. Staff were to place bedpans and urinals in the resident's bathroom after placing in a plastic bag.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure dependent residents received adequate oral care as ordered. This affected one (#23) of one residents reviewed for oral care. The facility census was 60. Findings include:Review of the medical record for Resident #23 revealed an admission date of 07/14/20 with diagnoses including epilepsy, dysphagia, type II diabetes mellitus, bipolar disorder, dementia, and gastrostomy status.Review of the quarterly Minimum Data Set assessment, dated 01/02/26, revealed Resident #23 had severely impaired cognition, had a feeding tube, and was dependent on staff for oral hygiene and personal hygiene.Review of the physician order dated 07/07/24 revealed Resident #23 should receive Chapstick (lip balm) to her lips every shift (twice daily).Review of the physician order dated 01/21/26 revealed Resident #23 should receive oral care twice daily because she was received no food or drink by mouth.Observation on 03/02/26 at 2:22 P.M. revealed Resident #23 lying in bed with her eyes closed. Resident #23's mouth was open and her lips appeared to be dry and peeling. Observation on 03/03/26 at 7:44 A.M. revealed Resident #23 lying in bed with her eyes open. Resident #23's mouth was open and her lips appeared to be dry and peeling. An attempted interview with Resident #23 at the time of the observation was unsuccessful.Observation on 03/03/26 at 4:06 P.M. revealed Resident #23 lying in bed with her eyes open. Her lips appeared moist and hydrated and no evidence of peeling was observed.Interview on 03/04/26 at 7:55 A.M. with Licensed Practical Nurse (LPN) #419 confirmed LPN #419 provided oral care to Resident #23 on 03/03/26. LPN #419 confirmed Resident #23 had a white substance on her lips but they were not peeling. LPN #419 stated the white substance easily wiped off with the application of lip balm. LPN #419 stated when LPN #419 returns to work after a day off, Resident #23's lips were often not well cared for. Interview on 03/04/26 at 9:08 A.M. with Certified Nurse Aide (CNA) #406 stated she worked on 03/03/26 during first shift and provided oral and lip care to Resident #23. CNA #406 confirmed Resident #23's lips were peeling on 03/03/26, and the excess skin wiped off without difficulty. CNA #406 stated the condition of Resident #23's lips on 03/03/26 would have taken more than one shift's lack of lip/oral care to become as dry and peeled as they were on 03/03/26.Review of the policy, Activities of Daily Living (ADLs), copyright 2024, revealed a resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure pressure ulcers were assessed thoroughly and accurately, failed to ensure wound care orders were implemented, and failed to ensure devices used to prevent pressure ulcer development were implemented as ordered. This affected two (#48 and #6) of three residents reviewed for pressure ulcers. The facility census was 60.Findings include:1. Review of the medical record for Resident #48 revealed an admission date of 09/16/25 with diagnoses including heart failure, acquired absence of the left leg above the knee, type II diabetes mellitus, heart disease, and peripheral vascular disease. Resident #48 was admitted with an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) to his right heel.Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/26, revealed Resident #48 had intact cognition and had one unstageable pressure ulcer.Review of the modified quarterly MDS assessment, dated 02/03/26, revealed Resident #48 had intact cognition and did not have a pressure ulcer.Review of the medical record for Resident #48 revealed the resident went to an offsite wound care clinic for treatment of the right heel pressure ulcer on 09/25/25, 10/09/25, 11/06/25, 12/18/25, 01/21/26, 01/28/26 and 02/25/26. Further review revealed the offsite wound care clinic completed a comprehensive assessment of Resident #48's right heel pressure ulcer on those dates.Review of Resident #48's weekly wound evaluations completed by facility staff, during concurrent interview with Registered Nurse Clinical Consultant (RNCC) #502 and Regional Registered Nurse (RRN) #501 on 03/04/26 at 10:50 A.M., revealed no evaluation was completed on Resident #48's right heel pressure ulcer between 10/09/25 and 10/23/25, between 10/23/25 and 11/06/25, and between 11/06/25 and 11/24/25. Further interview with RNCC #502 confirmed Resident #48's pressure ulcer should have been assessed weekly. Continued review of Resident #48's weekly skin assessment documentation revealed the facility used a skin observation tool on 11/24/25, 12/02/25, 12/11/25, and 12/18/25. Review of the skin observation tools for these dates, and continued interview with RNCC #502, revealed the documentation of Resident #48's right heel pressure ulcer included no measurements of the wound on 12/02/25, 12/11/25, and 12/28/25. Further review and interview confirmed all four skin observation tools provided no description of the wound bed, the surrounding tissue, odor, or drainage of Resident #48's right heel pressure ulcer.Continued interview with RNCC #502 revealed the facility changed from using the weekly wound evaluation form to using a skin grid pressure assessment form on 12/29/25. A skin grid pressure assessment was completed by staff on 12/29/25, 01/05/26, 01/12/26, 01/19/26, 01/26/26, 02/26/26, 02/09/26, 02/16/26, and 02/23/26. Further review of Resident #48's skin grid pressure assessments and continued interview with RNCC #502 confirmed the assessment provided no description of the wound bed and the surrounding tissue of Resident #48's right heel PU. Additionally, no indication of the stage of the wound was documented on the assessments.Interview on 03/05/26 at 2:25 P.M. with Registered Nurse Clinical Director of Reimbursement (RNCDR) #503 regarding Resident #48's modified quarterly MDS assessment dated [DATE] revealed Resident #48's quarterly MDS assessment dated [DATE] was originally completed to indicate Resident #48 had one unstageable pressure ulcer. RNCDR #503 stated upon review of the MDS assessment, and review of the facility's documentation of Resident #48's wound, RNCDR #503 could not find adequate evidence in the facility's documentation of Resident #48's wound to determine whether Resident #48 had a pressure ulcer and directed facility staff to modify the quarterly MDS assessment dated [DATE] to reflect Resident #48 did not have a pressure ulcer. RNCDR #503 stated the offsite wound clinic notes, documenting Resident #48's right heel PU, were unavailable to review at the time of the MDS assessment.Review of the facility's policy titled, Documentation of Wound Treatments, copyright 2025, revealed wound assessments were documented upon admission, weekly, and as needed. The following elements are documented as part of a complete wound assessment: (a) type of wound (pressure injury, surgical, etc.) and the anatomical location; (b) stage of the wound, if pressure injury, and (c) measurements. Additional documentation shall include, but is not limited to: description of wound characteristics: color of the wound bed, type of tissue in the wound bed, condition of the peri-wound skin, presence or absence of pain, date and time of wound management treatments, any treatment for pain, if present, and modifications of treatments or interventions.2. Review of Resident #48's offsite wound clinic treatment orders, dated 10/09/25, revealed treatment orders for his right heel pressure ulcer to be completed once daily and as needed.Review of the facility's physician order initiated 10/09/25 and discontinued 11/24/25, revealed directions to complete the treatment twice daily.Review of two facility treatment orders, initiated 11/30/25, revealed Resident #48 should receive right heel wound treatments once daily on day shift and once daily on night shift. Further review revealed the order for the day shift treatment was discontinued on 12/19/25 and the order for the night shift treatment was discontinued 12/31/25.Review of Resident #48's offsite wound clinic treatment order, dated 12/18/25, revealed twice daily treatment orders to Resident #48's right heel pressure ulcer. Interview on 03/05/26 at 11:19 A.M. with RNCC #502 confirmed Resident #48's treatment orders dated 10/09/25 were ordered twice daily versus once daily as ordered by the offsite wound clinic. Additionally, RNCC #502 confirmed Resident #48's night shift wound treatment, initiated 11/30/25, should have been discontinued on 12/19/25 when the new treatment orders from the offsite wound clinic were implemented. RNCC #502 further confirmed the two different wound treatments were documented as being provided concurrently.Review of Resident #48's offsite wound clinic treatment order, dated 02/25/26, revealed a section titled, Items to Follow Up On, with indication an x-ray of the right foot had been ordered and to complete as soon as possible.Interview on 03/05/26 at 3:19 P.M. with RNCC #502 confirmed the facility did not complete a right foot x-ray for Resident #48 after receiving the order on 02/25/26. RNCC #502 further stated Resident #48 began seeing the in-house wound care provider on 03/02/26. RNCC #502 stated she spoke with the in-house wound provider who stated after they assessed Resident #48's right heel pressure ulcer, they did not see any indication for an x-ray and did not feel an x-ray should be obtained.3. Review of the medical record for Resident #6 revealed an admission date of 07/08/21 with diagnoses of viral hepatitis B, chronic viral hepatitis C, nontraumatic intracranial hemorrhage, and hemiplegia.Review of the quarterly MDS assessment, dated 01/13/26, revealed Resident #6 had impaired cognition and was dependent on staff for lower body dressing. Further review revealed Resident #6 had no pressure ulcers.Review of the physician order dated 09/15/25 revealed Resident #6 was to wear offloading pressure boots to bilateral lower extremities at all times while resident in bed as tolerated. Further review revealed instructions to document all refusals.Observation on 03/02/26 at 9:59 A.M. revealed Resident #6 lying in bed. One offloading boot was on the floor near the head of the bed. Concurrent interview with Licensed Practical Nurse (LPN) #421 confirmed Resident #6 had an order to wear offloading boots as tolerated. LPN #421 confirmed Resident #6 was not wearing the offloading boot.Observation on 03/03/26 at 9:28 A.M. revealed Resident #6 lying in bed wearing an offloading boot on his left foot. Concurrent interview with LPN #419 confirmed Resident #6 was wearing only one boot and verified Resident #6's physician order indicated Resident #6 should wear offloading boots to both feet. LPN #419 looked through two closets before finding and applying, with Resident #6's consent, the right foot offloading boot.

Based on observation, medical record review, and resident and staff interview, the facility failed to ensure residents received diets as ordered. This affected one (#1) of three residents reviewed for diet. The facility census was 60.Findings include:Review of the medical record for Resident #1 revealed an admission date of 01/26/25 with diagnoses including congestive heart failure, bipolar disorder, parkinsonism, type II diabetes mellitus, and anxiety. Review of the annual Minimum Data Set assessment, dated 02/05/26, revealed Resident #1 had intact cognition and required setup for eating.Review of Resident #1's weight history from 11/02/25 through 03/05/26 revealed his weight was stable.Review of the physician order dated 12/24/25 revealed Resident #1 should receive double portions.Review of the nutrition assessment dated [DATE] revealed Resident #1 had weight loss due to a recent hospitalization. Further review revealed Resident #1 would benefit from re-implementing double portions. Interview on 03/02/26 at 10:22 A.M. with Resident #1 revealed he was not receiving double portions and felt he should be.Observation on 03/03/26 at 12:28 P.M. revealed [NAME] #525 plating Resident #1's noon meal. [NAME] #525 did not provide double portions. Concurrent interview with [NAME] #525 confirmed Resident #1's meal ticket did not indicate he received double portions.Interview on 03/04/26 at 4:00 P.M. with Dietary Manager (DM) #530 revealed the kitchen used a separate computer system than the electronic medical record system used by the clinical staff. DM #530 stated the two computer systems were linked and diet orders were imported into the kitchen computer system. Further interview with DM #530, and concurrent review of the physician order for Resident #1, revealed Resident #1 should be receiving double portions. Further interview with DM #530 and concurrent review of the kitchen computer system's diet order for Resident #1 revealed double portions were not indicated. DM #530 stated the kitchen's computer system was implemented approximately in early January 2026 and some diet orders prior to January 2026 may not have merged correctly.

Based on observation, medical record review, and staff interview the facility failed to ensure residents received tube feeding nutrition as ordered by the physician. This affected one (#23) of two residents reviewed for tube feeding. The facility census was 60. Findings include: Review of the medical record for Resident #23 revealed an admission date of 07/14/20 with diagnoses including epilepsy, dysphagia, type II diabetes mellitus, bipolar disorder, dementia, and gastrostomy status. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/02/26, revealed Resident #23 had significantly impaired cognition, had a feeding tube, and relied on tube feeding to receive 51 percent (%) or more of nutrition and fluid needs. Review of Resident #23's weights from September 2025 through March 2026 revealed the resident's weights were stable. Review of the physician order dated 01/24/26 revealed Resident #23 received Jevity 1.2 at 60 milliliters per hour (ml/hr) for 21 hours per day starting at 10:00 A.M. and discontinued at 6:00 A.M. Observation on 03/04/26 at 9:47 A.M., and concurrent interview with Licensed Practical Nurse (LPN) #419, revealed she hung Resident #23's one-liter (1000 ml) bottle of Jevity 1.2 and it was running at 60 ml/hour. Observation on 03/05/26 at 7:00 A.M. revealed Resident #23's tube feeding bottle was empty and the pump was off. Further observation revealed the bottle was dated 03/04/26. Concurrent interview with LPN #419 confirmed the tube feeding bottle was the same one LPN #419 hung the previous morning. LPN #419 confirmed Resident #23 received only one liter of tube feeding instead of the ordered 1260 ml. LPN #419 stated a second bottle of Jevity 1.2 should have been hung to provide the full amount of tube feeding as ordered by the physician.

Based on medical record review and staff interview, the facility failed to ensure laboratory tests were completed per physician orders. This affected one (#23) of five residents reviewed for laboratory tests. The facility census was 60.Findings include:Review of the medical record for Resident #23 revealed an admission date of 07/14/20 with diagnoses including epilepsy, dysphagia, type II diabetes mellitus, bipolar disorder, dementia, and gastrostomy status.Review of the quarterly Minimum Data Set assessment, dated 01/02/26, revealed Resident #23 had significantly impaired cognition, had a feeding tube, and relied on tube feeding to receive 51 percent (%) or more of nutrition and fluid needs. Review of the physician order dated 01/08/24 revealed Resident #23 received no food or water by mouth.Review of the physician order dated 10/03/24 and discontinued 02/26/26 revealed Resident #23 should have laboratory tests of a complete blood count (CBC) with differential, basic metabolic panel (BMP), and hemoglobin A1C every six months.Review of Resident #23's record revealed the most recent laboratory tests were completed on 06/02/25.Interview on 03/05/26 at 3:12 P.M. with the Administrator confirmed no laboratory tests were completed for Resident #23 since 06/02/25 and before the physician's order discontinued on 02/26/26.

Based on medical record review and staff interview, the facility failed to ensure skin assessments were completed accurately. This affected one (#48) of two people reviewed for skin assessments. The facility census was 60.Findings include:Review of the medical record for Resident #48 revealed an admission date of 09/16/25 with diagnoses including heart failure, acquired absence of the left leg above knee, type II diabetes mellitus, heart disease, and peripheral vascular disease. Resident #48 was admitted with an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) to his right heel.Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/26, revealed Resident #48 had intact cognition and had one unstageable pressure ulcer.Review of Resident #48's skin grid pressure assessments dated 12/29/25, 01/05/26, 01/12/26, 01/19/26, 01/26/26, 02/02/26, 02/09/26, and 02/16/26 revealed all the assessments were completed and signed by Wound Care Licensed Practical Nurse (LPN) #407 on 02/16/26. Interview on 03/03/26 at 3:37 P.M. with LPN #407 revealed she was new to the wound care role on 12/29/25. LPN #407 stated she was aware Resident #48 was seeing an outside wound clinic for his right heel unstageable pressure ulcer and was not aware Resident #48's right heel pressure ulcer needed to be assessed weekly at the facility. LPN #407 stated she was recently informed she needed to complete weekly wound assessments for Resident #48's right heel pressure ulcer even though he went to an offsite wound clinic. LPN #407 stated she used measurements from the wound clinic's assessment to complete the facility skin grid pressure assessments.Follow-up interview on 03/04/26 at 12:07 P.M. with LPN #407 confirmed she created Resident #48's skin grid pressure assessments dated 12/29/25, 01/05/26, 01/12/26, 01/19/26, 01/26/26, 02/02/26, and 02/09/26, on 02/16/26 using measurements from the offsite clinic's documentation. LPN #407 confirmed she did not complete a visual assessment of Resident #48's right heel on those dates. LPN #407 stated she measured Resident #48's heel wound on 02/16/26 and the measurements were consistent with the size she documented on all the previous assessments.

Based on observation, medical record review, and staff interview, the facility failed to ensure residents compression stockings were applied as ordered. This affected one (#6) of one residents reviewed for application of compression stockings. The facility census was 60.Findings include:Review of the medical record for Resident #6 revealed an admission date of 07/08/21 with diagnoses including viral hepatitis B, chronic viral hepatitis C, nontraumatic intracranial hemorrhage, and hemiplegia.Review of the quarterly Minimum Data Set assessment, dated 01/13/26, revealed Resident #6 had impaired cognition and was dependent on staff for lower body dressing.Review of a physician order dated 12/30/24 revealed Resident #6 was to wear compression stockings to bilateral lower extremities every morning.Observation on 03/02/26 at 9:59 A.M. revealed Resident #6 lying in bed without wearing compression stockings to his lower extremities. Concurrent interview with Licensed Practical Nurse (LPN) #421 confirmed Resident #6 was not wearing compression stockings. LPN #421 stated possibly Resident #6 had removed the compression stockings, then confirmed the stockings were not in Resident #6's bed and not on the floor.Interview on 03/05/26 at 2:57 P.M. with LPN #419, who worked routinely with Resident #6, revealed he was dependent on staff for lower body dressing, and could probably push down the compression stockings but would not be able to remove them.

Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed to safely store medications. This affected one (#43) out of five residents reviewed for medication storage. The facility census was 60. Findings include:Review of the medical record revealed Resident #43 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, arteriovenous malformation of the digestive system, paranoid schizophrenia, and disorganized schizophrenia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #43 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. Resident #43 was assessed with functional abilities to included supervision or touching assistance needed for showering/bathing, personal hygiene, upper and lower body dressing. Review of Resident #43's care plan last revised 02/27/26 revealed interventions allowing the resident to keep medications at bedside. Review of the current monthly physician orders revealed the resident had no orders to keep medications at the bedside and no orders to self-administer medications. Observation on 03/02/26 at 9:08 A.M revealed Resident #43 had blood coming from his nose. Licensed Practical Nurse (LPN) #421 entered the resident's room to assess the resident. Resident #43 stated he had medications in his dresser. LPN #421 opened the top drawer of Resident #43's dresser to reveal four unsecured medications including two nasal sprays and two respiratory inhalers. LPN #421 removed the unsecured medications. Interview on 03/02/26 at 9:37 A.M., with LPN #421 stated unsecured medications found in Resident #43's room included one bottle of over-the-counter saline nasal spray, one bottle of oxymetazoline hydrochloride 0.05 percent (%) 12-hour nasal spray, Asmanex inhaler, and Combivent inhaler 20 micrograms (mcg) per 100 mcg. Further interview revealed Oxymetazoline hydrochloride nasal spray, Asmanex inhaler, and Combivent inhaler had no patient name listed on the medications. LPN #421 furthermore confirmed Resident #43 had no order for saline nasal spray, Oxymetazoline hydrochloride 0.05% 12-hour nasal spray, or Asmanex nasal spray. Review of the facility policy titled, Medication Storage, dated 2025, revealed all drugs and biologicals will be stored in locked compartments.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure smoking materials were stored in a safe manner, failed to ensure resident smoking assessments were accurate, and failed to ensure fall interventions were in place as care planned. This affected two (#58 and #11) of three residents reviewed for accidents and hazards. The facility census was 60. Findings include:1. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus with chronic kidney disease, essential hypertension, unspecified intellectual disabilities, schizophrenia, anxiety disorder, bipolar disease, chronic obstructive pulmonary disease. Review of Resident #58's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMs) score of eight indicating moderate cognitive deficits. Further review revealed behaviors documented included rejection of care occurring one to three days a week during the seven day look back period, and functional abilities included partial/moderate assistance with toileting hygiene, shower/bathing, upper and lower body dressing, and personal hygiene. Review of the care plan for Resident #58, revised on 01/05/26, revealed interventions to instruct the resident on the risk of smoking, to instruct the resident on the facility policy for smoking, and for staff to observe clothing and skin for signs of cigarette burns. Also the resident could smoke unsupervised. There were no interventions allowing the resident to keep smoking material in his possession. Review of Resident #58's smoking safety screen assessment dated [DATE] revealed the resident had no cognitive loss, no dexterity problems, and the resident needed the facility to store lighter and cigarettes. Further review of the assessment revealed the resident was safe to smoke without supervision. Observation and interview on 03/02/26 at 8:52 A.M., Resident #58 revealed he was upset due to someone stealing his cigarettes. Certified Nurse Aide (CNA) #448 then came over to Resident #58 and stated Resident #58 sometimes had cigarettes on him. CNA #448 then reached into the front pocket of Resident #58's sweatshirt and removed a box of cigarettes, opened the box, and revealed two lighters inside the empty box of cigarettes. CNA #448 stated Resident #58 probably smoked all his cigarettes and the nurse would notify the resident's representative. CNA #448 then returned the box containing the two lighters back into Resident #58's sweatshirt pocket. Observation and interview on 03/02/26 at 9:24 A.M., the Administrator verified Resident #58 should not have lighters on his person. The Administrator then removed the box and two lighters from Resident #58's sweatshirt pocket. Further interview with the Administrator revealed the resident had cognitive impairment and it should have been noted on his smoking assessment. Interview on 03/02/26 at 9:27 A.M., with CNA #448 verified she removed a cigarette box containing two lighters from the pocket of Resident #58 and then returned both the box and two lighters back into Resident #58's pocket. CNA #448 stated she was not sure why she gave the lighters back to Resident #58 because he was not supposed to have them. Interview on 03/04/26 at 11:56 A.M., the Director of Nursing (DON) verified Resident #58 should not have cigarette lighters on his person due to his cognition. Review of policy titled, Smoking Policy/Consent, dated 01/29/26, revealed all smoking materials would be maintained by the facility staff and provided to the residents/patients on request for supervised/unsupervised smokers. Further review revealed smoking materials will be returned to the facility staff upon completion of smoking by supervised/unsupervised smokers. 2. Review of the medical record revealed Resident #11 admitted to the facility on [DATE] with diagnoses including dementia, repeated falls, injury of the left lower leg, hypertension, and anxiety disorder. Review of the most current MDS assessment dated [DATE] revealed Resident #11 had severely impaired cognition, behaviors directed at others, and rejection of care. Resident #11 required substantial to maximal assistance with activities of daily living including bed mobility and transfer, utilized a wheelchair for mobility propelled by staff, was incontinent of bowel and bladder, and sustained falls since admission. Review of a fall risk assessment dated [DATE] assessed Resident #11 at risk for falling as the resident sustained three or more falls over the last 90 days. Review of a nursing plan of care dated 12/11/25 revealed the care plan was revised to address Resident #11's high risk for falls related to confusion, gait/balance problems, incontinence, psychoactive drug use, and the resident being unaware of safety needs. Falls were listed on 03/07/24, 04/11/24, 05/25/24, 06/02/24, 06/13/24, 06/28/24, 11/27/24, 11/30/24, 12/10/24, 12/18/24, 12/30/24, 02/10/25, 02/25/25, 03/30/25, 05/20/25, 07/18/25, 07/25/25, 08/22/25, 09/6/25, and 12/11/25. An intervention included the placement of a mat to the bedside with no documentation included indicating which side of the bed the mat was to be placed. Observations on 03/02/26 at 10:32 A.M., and on 03/03/26 at 11:54 A.M. and 12:23 P.M., revealed Resident #11 in bed with a mat to the floor on the right side of the bed and no mat to the left side of bed. Further observation revealed exposed floor between bed and wall on the left side of then bed measuring approximately 24 inches. Observation on 03/04/26 at 5:40 A.M. revealed Resident #11 in bed with bilateral half grab rails applied to the bed frame and a defined parameter mattress was applied to the bed. Further observation revealed the fall mat was observed under the bed and not on the floor at the bedside. On 03/04/26 6:43 A.M. interview with Licensed Practical Nurse (LPN) #452 verified Resident #11's fall mat was not placed at the bedside as indicated. Continued observation on 03/04/26 at 8:02 A.M. and 9:58 A.M., and on 03/05/26 at 6:10 A.M., revealed Resident #11 in bed with a mat to floor at the right side of the bed and the left side of bed had no mat with exposed floor between the bed and wall measuring approximately 24 inches. On 03/05/26 at 8:45 A.M. interview with LPN #421 verified Resident #11 had a mat to floor on the right side of the bed and no mat to the floor on the left side of bed. LPN #421 confirmed the left side of the bed was noted with exposed floor between the bed and wall measuring approximately two feet. Review of facility fall prevention program policy, dated 2024, revealed the nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. The nurse will refer to the facility's high risk or low/moderate risk protocols when determining primary interventions. High risk protocols include, the resident will be placed on the facility's fall prevention program and will indicate fall risk on the care plan. The staff will implement interventions from low/moderate risk protocols and provide additional interventions as directed by the resident's assessment.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents prescribed psychotropic medications were monitored for behaviors and medication side effects. This affected three (#1, #48, and #66) of five residents reviewed for psychotropic medications. The facility census was 60.Findings include:1. Review of the medical record for Resident #1 revealed an admission date of 01/26/25 with diagnoses of congestive heart failure, bipolar disorder, parkinsonism, type II diabetes mellitus, and anxiety. Review of the annual comprehensive Minimum Data Set (MDS) assessment, dated 02/05/26, revealed Resident #1 had intact cognition and received an antianxiety medication.Review of the physician order, dated 12/30/25, revealed Resident #1 received clonazepam (an antianxiety medication) one (1) milligram (mg) one tablet by mouth twice daily for anxiety.Review of the care plan, initiated 01/02/26, revealed Resident #1 had a mood problem related to anxiety, depression, and bipolar disorder. Interventions included administering medications as ordered and monitor/document for side effects and effectiveness.2. Review of the medical record for Resident #48 revealed an admission date of 09/16/25 with diagnoses of depression, type II diabetes mellitus, heart disease, and peripheral vascular disease. Review of the quarterly MDS assessment, dated 02/03/26, revealed Resident #48 had intact cognition.Review of the physician order, dated 12/15/25, revealed Resident #48 received sertraline hydrochloride (Hcl) (an antidepressant) oral tablet 25 mg one tablet once daily for depression.3. Review of the medical record for Resident #66 revealed an admission date of 02/24/26 with diagnoses of pelvic fractures, cerebral infarction, dementia, bariatric surgery, and Raynaud's syndrome.Review of the nursing admission assessment, dated 02/24/26, revealed Resident #66 was alert and oriented to person, place, time, and situation.Review of Resident #66's baseline care plan, initiated 02/24/26, revealed Resident #66 should be monitored for medications and side effects.Review of the physician order dated 02/26/26 revealed Resident #66 received aripiprazole (an antipsychotic) oral tablet 10 mg once daily for depression.Review of the physician order date 02/24/26 revealed Resident #66 received Lexapro (an antidepressant) oral tablet 20 mg once daily for antidepressant.Interview on 03/05/26 at 11:19 A.M. and at approximately 11:45 A.M. with Registered Nurse Clinical Consultant (RNCC) #502, and concurrent review of the electronic medical records for Resident #1, Resident #48, and Resident #66, revealed no behavior monitoring was in place to monitor for efficacy and/or side effects of psychotropic medications received by Resident #1, Resident #48, and Resident #66.Review of the policy, Use of Psychotropic Medications, copyright 2025, revealed psychotropic medications were to be used only when a practitioner determined the medication(s) was appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).

Based on observation, medical record review, and staff interview, the facility failed to ensure a resident's urinary catheter bag was covered and placed in a manner to ensure dignity was maintained. This affected one (#5) of one residents reviewed with an indwelling catheter in place. The facility identified six current residents with indwelling urinary catheters in place in a facility census of 60. Findings include:Review of the medical record revealed Resident #5 admitted to the facility on [DATE] with diagnosis including, obstructive and reflux uropathy, obstructive hydrocephalus, vascular dementia, edema, chronic kidney disease, and abscess of prostate. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was assessed with severe cognitive impairment, was dependent on staff for the completion of activities of daily living, and had an indwelling urinary catheter in place. Review of a nursing plan of care revised on 01/22/25 addressed Resident #5's diagnosis of obstructive uropathy with a indwelling urinary catheter (Foley) in place. Interventions included to position the catheter bag and tubing below the level of the bladder and away from entrance room door. Review of a physician order dated 12/16/25 revealed to ensure the indwelling urinary (Foley) catheter was covered with a dignity bag and/or cover and was to be completed every shift. Observations on 03/03/26 at 9:20 A.M., 10:29 A.M., 11:52 A.M., and 12:25 P.M., and on 03/04/26 at 5:41 A.M., 8:04 A.M., and 10:45 A.M. revealed Resident #5 was in bed with an indwelling catheter drainage bag hanging from the bed frame draining yellow urine. There was no privacy bag in place and the drainage bag was visible from the common corridor. On 03/04/26 at 10:52 A.M. interview with Registered Nurse (RN) #500 verified Resident #5's indwelling catheter drainage bags are to be kept in a privacy bag or our of common sight to maintain dignity. On 03/04/26 at 10:54 AM interview with Certified Nurse Aide (CNA) #454 verified Resident #5's indwelling catheter drainage bag was exposed to the common corridor while he was in bed on 03/03/26 and 03/04/26. CNA #454 confirmed a privacy bag was installed on the resident's high back chair; however, no privacy bag was in place for the bag while the resident was in bed. On 03/04/26 at 11:21 A.M. interview with the Administrator verified the facility did not have a policy or procedure instructing placement of collection bags or associated personal drainage devices to ensure dignity.

Based on medical record review, review of hospital records, staff, pharmacist, and physician interview, and review of the facility policy, the facility failed to ensure residents were administered medications indicated for their medical diagnosis and free from unnecessary medications. This affected one (#39) of three residents reviewed for unnecessary medications. The facility census was 65.Findings include: Review of the medical record for Resident #39 revealed an admission date of 11/24/25 and a discharge date of 12/22/25. Admitting diagnosis included Type I diabetes mellitus (T1DM) (a form of diabetes known as juvenile diabetes where the pancreas does not function at all in the production of insulin to control blood sugar levels in the body).Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact and had a diagnosis of T1DM and required insulin injections.Review of the diagnosis list for Resident #39 revealed a diagnosis of Type I diabetes mellitus with other specified complications, Type I diabetes mellitus with diabetic autonomic (poly) neuropathy, chronic osteomyelitis, and acquired absence of right leg below the knee.Review of the hospital history and physical (H&P) (detailed history of the patient of past medical diagnosis and current problems during hospitalization) dated 11/13/25 revealed Resident #39 had a diagnosis of Type I diabetes mellitus.Review of the care plan, initiated 12/09/25, revealed Resident #39 had pain related to T1DM.Review of a written physician order dated 11/26/25 revealed Resident #39 was ordered Trulicity (a once weekly injectable medication used for Type II diabetes [T2DM]) 0.75 milligrams (mg) subcutaneously weekly. Further review of the physician orders located in the electronic medical record (EMR) revealed Resident #39 had an order dated 11/27/25 for Trulicity subcutaneous solution auto-injector 0.75 mg subcutaneously in the morning every Monday for diabetes, give 0.75 mg weekly. Additionally, Resident #39 was ordered Lantus SoloStar (long-acting insulin) subcutaneous solution pen-injector 100 unit/milliliter (u/ml), inject 32 units subcutaneously two times a day for diabetes and insulin lispro (rapid-acting insulin) subcutaneous solution pen-injector 100 u/ml, inject subcutaneously before meals and at bedtime for diabetes. Review of the Medication Administration Record (MAR) for December 2025 revealed Resident #39 was administered doses of Trulicity on 12/01/25, 12/08/25, and 12/15/25.Interview on 12/22/25 at 2:41 P.M. with Pharmacist #550 revealed Trulicity was not an approved medication for use in a patient with T1DM. Pharmacist #550 stated Trulicity was only approved for use in people who produced insulin as it triggered a hormone in the body to trigger insulin to work and do the job it was supposed to do. Pharmacist #550 further stated that anyone with a diagnosis of T1DM did not make insulin so Trulicity was useless for someone with T1DM and would be considered an ineffective treatment, and an unnecessary medication for that population of people.Interview on 12/22/25 at 3:00 P.M. with Nurse Practitioner (NP) #515 verified she prescribed Trulicity to Resident #39. NP #515 further stated she would use Trulicity to treat a resident with a diagnosis of T1DM and further stated she treated T1DM and T2DM the same. NP #515 verified she would give Trulicity to a resident with T1DM and stated, sure why not. NP #515 further stated she did not know Resident #39 very well as he was not in the facility for a long period of time.Interview on 12/22/25 at 4:41 P.M. with Physician #500 revealed Trulicity was not an appropriate medication for a resident diagnosed with T1DM and it was contraindicated. Physician #500 further stated when a medication list was reviewed and someone was on both long acting and short acting insulin, it was inferred that person had T1DM.Interview on 12/23/25 between 9:00 A.M. and 9:30 A.M. with Licensed Practical Nurse (LPN) #525 and Registered Nurse (RN) #520 verified Resident #39 had a diagnosis of T1DM and each denied knowledge that Trulicity was not approved for use in residents with a diagnosis of T1DM.Interview on 12/23/25 at 9:43 A.M. with Pharmacist #510 revealed Trulicity was not an approved medication for anyone diagnosed with T1DM due to the mechanism of how Trulicity worked, adding this would not be beneficial for anyone diagnosed with T1DM and would be an unnecessary treatment.Review of the facility policy titled, Unnecessary Drugs, undated, revealed it was the facility's policy that each resident's entire drug/medication regime was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs.This deficiency represents non-compliance investigated under Complaint Number 2686130.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEYBased on medical record review, staff interviews, review of the facility incident investigation, review of video surveillance, review of employee personnel files, review of the facility self-reported incident (SRI), and review of facility policy, the facility failed to ensure residents were free from abuse. Actual harm occurred on 11/15/25 at 8:42 P.M. when Resident #169 was subjected to excessive physical force by a facility staff member, after which Resident #169 verbalized a fear for his safety, and being depressed at times with positive thoughts of self-harm. This affected one (#169) of three residents reviewed for abuse. The facility census was 67.Review of the medical record for Resident #169 revealed an admission date of 07/22/25 and discharged date of 11/19/25. Diagnoses included alcohol dependence with withdrawal, anxiety, depression, difficulty walking, tobacco use, type two diabetes mellitus, chronic obstructive pulmonary disease, and noncompliance with other medical treatment.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #169 revealed he was identified as moderately cognitively impaired. Resident #169 was independently mobile with a manual wheelchair and required minimal assistance with bathing, lower body dressing, bed mobility, and transfers, had no aggressive behaviors toward self or others and no refusals of care.Review of a progress note dated 11/15/25 and timed at 8:58 P.M. written by Licensed Practical Nurse (LPN) #800 revealed Resident #169 was observed drinking alcohol in the designated smoking area. When Resident #169 was approached regarding the liquor and beer, the resident became agitated and started swinging at staff threatening them. Review of the physician orders for Resident #169 revealed he did not have an order to consume alcohol.Review of progress notes dated 11/16/25 revealed Resident #169 refused nursing care offered at 12:02 A.M., medications offered at 8:00 A.M., and a post-incident skin assessment attempted at 2:02 P.M.Review of a psychiatric physician note dated 11/17/25 revealed Resident #169 reported an altercation with LPN #800 to the physician. Resident #169 reported feeling depressed at times with positive thoughts of self-harm.Review of a progress note dated 11/17/25 and timed at 8:10 P.M. revealed Resident #169 was placed on a one-to-one observational status. Review on 11/25/25 at 10:45 A.M. and on 12/01/25 at 9:45 A.M. with the Administrator, of a two-minute surveillance video dated 11/15/25 and timestamped at 8:42 P.M. revealed Resident #169 was in the outdoor smoking area with a group of other residents. Resident #169 was observed sitting in his wheelchair wearing an unzipped coat and smoking a cigarette. Resident #169 was holding his cigarette with his right hand. Certified Nurse Assistant (CNA) #605 and CNA #712 were supervising the group of residents in the outdoor smoking area. LPN #800 entered the smoking area and walked toward Resident #169, approached the front of Resident #169, then circled around the resident from the right side, and stopped on the left side of the resident. LPN #800 then reached toward Resident #169 with her right hand, taking hold of the front left side of Resident #169's coat. LPN #800 proceeded to pull open the coat toward the left side of Resident #169's body and with her left hand reached between the coat and Resident #169's left side. Unidentifiable items were seen falling to the ground. Resident #169 pushed at LPN #800 with his left arm and LPN #800 let go of the coat. LPN #800 again reached for Resident #169's coat, this time while holding Resident #169's left arm down, LPN #800 pulled open the coat to the residents' left side and reached inside the coat toward Resident #169's left side. CNA #605 was seen walking toward the resident's right side while LPN #800 was reaching in and around Resident #169's coat and pulling on Resident #169's left arm. LPN #800 let go of Resident #169's left arm and backed away from the resident. Resident #169 was then observed shaking his left arm at LPN #800 while shuffling his feet to move the wheelchair closer to the nurse. LPN #800 took hold of Resident #169's left arm and pulled it away from his body while CNA #605 flicked the cigarette out of Resident #169's right hand onto the ground. LPN #800 moved to Resident #169's right side, took hold of the right side of the coat, pulled it open, reached into the coat toward Resident #169's right side and obtained an open can of an alcoholic beverage. LPN #800 handed the open beverage can to CNA #605 who poured the liquid out in the grassy area behind Resident #169. Resident #169 extended his right arm and index finger toward LPN #800's face. LPN #800 swung at Resident #169's right arm, making contact, knocking Resident #169's arm down. This occurred two additional times before LPN #800 walked away, leaving the outdoor smoking area.Review of the facility investigation interviews dated 11/16/25 with CNA #605 and CNA #712 revealed no deviation in the description of events between Resident #169 and LPN #800 as observed in the video surveillance. CNA #605's statement revealed concerns for safety as Resident #169 was threatening to burn the nurse with his cigarette. CNA #605 found it necessary to remove the cigarette from Resident #169's hand during the incident. Review of a statement provided by the Director of Nursing (DON) on 11/17/25 revealed Resident #169 indicated to her on 11/17/25 that he did not feel safe in the facility. The DON offered a continuous one-to-one and Resident #169 agreed.Review of the facility self-reported incident (SRI) #267611 filed on 11/16/25 at 12:25 P.M. revealed Resident #169 was abused by LPN #800 on 11/15/25 at 8:42 P.M. Continued review of the SRI revealed Resident #169 sustained mental anguish, fear, and a feeling of being unsafe.Interview on 11/25/25 at 10:45 A.M. with the Administrator revealed items that fell to the ground from Resident #169's coat during the altercation with LPN #800 on 11/15/25 were a small bottle of fireball whiskey, a pack of cigarettes, and a bottle of unidentified pills. Continued interview revealed Resident #169 was noted to frequently obtain alcohol and illicit drugs while off facility property. The Administrator shared Resident #169 was placed on a one-to-one observational status due to Resident #169 being non-compliant and voicing he felt unsafe in the facility.Additional interview on 11/25/25 at 2:18 P.M. with the Administrator revealed the facility did not have a policy regarding alcohol consumption and a physician order was required for residents to consume alcohol while on the premises. The Administrator revealed there were no residents currently with physician orders allowing the consumption of alcohol.Concurrent interviews on 11/25/25 at 3:15 P.M. with LPN #530 and LPN #542 revealed Resident #169 would often consume alcohol on the premises and did not have a physician order to do so. Review of the disciplinary action interview with LPN #800 dated 11/19/25 revealed LPN #800 contacted the on-call supervising nurse when she learned Resident #169 was consuming alcohol in the smoking area. LPN #800 was told by the on-call nurse, LPN #801, to confiscate the alcohol.Review of the personnel file for LPN #800 revealed she was hired on 02/27/25 and terminated on 11/19/25. LPN #800 was trained on abuse, per facility policy, on 02/27/25. Review of a disciplinary action dated 11/19/25 revealed LPN #800 was terminated as a direct result of the altercation on 11/15/25 with Resident #169.Review of a disciplinary action dated 11/19/25 for LPN #801 revealed she was also terminated for advising LPN #800 to confiscate the open container of alcohol from Resident #169 and for failing to timely report the incident to the Administrator.Review of the undated facility policy titled Abuse, Neglect, and Exploitation revealed abuse included punishment with the result of mental anguish, and mistreatment included inappropriate treatment of a resident. Further review of this policy revealed the facility would implement policies and procedures to prevent and prohibit abuse. The deficiency was corrected on 11/21/25 at 3:32 P.M. when the facility implemented the following corrective actions:- On 11/16/25, the incident between Resident #169 and LPN #800 was reported to the Administrator by Human Resources Director #606 immediately after Resident #145 reported the incident to the Human Resources Director. - On 11/16/25, the Administrator notified the Medical Director of the incident between LPN #800 and Resident #169.- On 11/16/25 at 12:25 P.M., the Administrator reported the incident to the state agency. (SRI #267611).- On 11/16/25, the DON assessed Resident #169 with no injuries noted.- On 11/16/25, the DON/designee conducted resident interviews for all interviewable residents to ensure they felt safe in the facility. Interviews revealed no other concerns about safety.- On 11/16/25, the DON/designee conducted skin assessments on all non-interviewable residents with no negative findings.- On 11/16/25, the Administrator reviewed the two-minute video footage of the incident dated 11/15/25 and timed at 8:22 P.M.- On 11/16/25, the Administrator interviewed Residents #138 and #145 who were sitting near Resident #169 in the video.- On 11/16/25, the Administrator completed staff interviews with CNA #605, CNA #712, LPN #572, LPN #800, and LPN #801.- On 11/16/25, the Administrator suspended LPN #800 and LPN #801.- On 11/17/25, Resident #169 was evaluated by psychiatry.- On 11/17/25, the DON touched base with Resident #169 and the resident indicated he did not feel safe in the facility. The DON offered a continuous one-to-one with an aide and Resident #169 agreed. An aide was placed to directly observe Resident #169.- On 11/17/25, Resident #169 was assessed by Social Services #554 with no additional concerns identified. Resident #169 was notified of the level of care paperwork being finalized for the transfer to another facility. Resident #169 had been accepted at another facility prior to the incident.- On 11/17/25, all staff were educated by Staff Development Coordinator #507 on abuse, neglect, exploitation, and timely reporting abuse.- On 11/17/25, the MDS Coordinator reviewed and updated Resident #169's care plan to reflect the trauma related to physical abuse.- On 11/17/25, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the incident and the action plan.- On 11/18/25, a police report was filed by the Administrator.- On 11/18/25, Resident #169 remained on direct observation.- On 11/18/25, Resident #169 was accepted to be admitted to another facility. Social Services #554 notified Resident #169 and made transportation arrangements. - On 11/19/25, all staff were educated on resident rights and smoking regulations by Staff Development Coordinator #507.- On 11/19/25, the Administrator terminated LPN #801 and LPN #800 for violation of company policy.- On 11/19/25, Resident #169 remained on direct observation.- On 11/19/25 at 1:30 P.M., Resident #169 was discharged from the facility. Resident #169 was in his electronic wheelchair and had all personal items.- On 11/20/25, a monthly QAPI meeting was held with a review of the incident and actions taken presented.- On 11/21/25 at 3:32 P.M., the Administrator closed the SRI. This deficiency represents non-compliance investigated under Complaint Numbers 2660931 and 2670000.

Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure staff honored the rights of residents. This resulted in actual harm on 11/12/25 at 2:50 P.M. when Resident #145 expressed fear of a nurse and a concern for her health status after a nurse unexpectedly approached her and administered a second dose of the influenza vaccination in error, despite Resident #145 declining the shot and informing the nurse that she had already received the 2025 influenza vaccination. This affected one resident (#145) of three residents reviewed for resident rights. The facility census was 67.Review of Resident #145's medical record revealed an admission date of 10/14/25. Diagnoses included cellulitis of the chest wall, type II diabetes mellitus, chronic pulmonary edema, obesity, and post-traumatic stress disorder. Review of Resident #145's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required the use of a wheelchair for mobility. Review of Resident #145's care plan revealed a past history of abuse where the resident was forced to do things against her will. Interventions included to keep the resident informed about changes in care, to provide a quiet non-threatening environment, to decrease stimulation, to reapproach the resident if care is resisted, and staff are not to attempt to force care. Review of the immunization record consent and information sheet revealed Resident #145 declined to receive both the influenza and pneumococcal vaccinations on 10/14/25. The declination was witnessed by Licensed Practical Nurse (LPN) #728. Review of Resident #145's physician orders revealed an order dated 10/14/25 and timed at 2:24 P.M. to administer the annual influenza vaccine unless contraindicated. Review of Resident #145's Medication Administration Record (MAR) for October 2025 revealed the influenza vaccination was administered intramuscularly on 10/15/25 at 4:19 P.M. into Resident #145's right deltoid. Further review of Resident #145's physician orders revealed an order dated 11/12/25 and timed at 10:53 A.M. for the pneumococcal vaccination to be administered intramuscularly one time only for two days. Review of Resident #145's MAR for November 2025 revealed that the pneumococcal immunization was administered on 11/12/25 at 2:50 P.M. into the resident's right deltoid by Registered Nurse (RN) #590. Review of a Medication Error Report written 11/13/25 at 9:50 A.M. revealed a medication error occurred on 11/12/25 at 2:51 P.M. when RN #590 administered an influenza vaccination to Resident #145 on 11/12/25 at 2:50 P.M. instead of the ordered pneumococcal vaccination. Review of the facility investigation completed by Infection Control Preventionist (ICP) LPN #801 of the medication error revealed she had placed the order for the pneumococcal vaccination on 11/12/25 and specifically put the timeline for two days to allow time for the vaccine to arrive from the pharmacy as the pneumococcal vaccination was not available in the facility. Per the investigation, Resident #145 was interviewed and revealed she informed RN #590 that she had previously received the influenza vaccine. Resident #145 stated she refused the vaccination when RN #590 came in the room and offered it to her. Resident #145 stated RN #590 informed her that she nor her husband, who was on the phone per video at the time of the incident, knew what they were talking about, at which time RN #590 came up behind Resident #145 and poked the resident in the right arm with the vaccination. Interview with the Administrator on 11/24/25 at 12:22 P.M. verified RN #590 administered the influenza vaccination to Resident #145 against her will and also verified the medication error occurred when RN #590 administered the influenza vaccination, instead of the pneumococcal vaccination. The Administrator confirmed Resident #145 received two influenza immunizations this season and should not have. Interview with Resident #145 on 12/01/25 at 11:50 P.M. revealed she decided to receive the influenza vaccination in October 2025, and it was administered. Resident #145 voiced concern that the influenza vaccination was administered again and against her will in November 2025. Resident #145 stated on 11/12/25 RN #590 entered her room and informed her she was to receive an influenza vaccination. Resident #145 stated she verbally refused the immunization and informed RN #590 that she previously received the vaccination. RN #590 told Resident #145 that she did not know what she was talking about at which time RN #590 came up behind Resident #145 and injected the immunization into her right arm. Resident #145 said she reported the nurse to administration. Resident #145 stated she is now afraid of RN #590, while the nurse no longer provides her care she is still in the building and provides care to other residents. Resident #145 also voiced concerns for her health due to receiving two influenza vaccinations a month apart. Interview with Certified Nurse Practitioner (CNP) #600 on 12/01/25 at 12:02 P.M. revealed she was aware Resident #145 received two influenza vaccinations. CNP #600 did see Resident #145 after being made aware of the administration of a second influenza vaccination and had no health concerns. Review of the undated facility policy titled General Immunization/Vaccination revealed residents, staff members, and volunteer workers retain the right to refuse immunizations. Review of the undated facility policy titled Medication Administration stated medications are to be administered as ordered by the physician and in accordance with professional standards of practice. Review of the undated facility policy titled Abuse, Neglect, and Exploitation revealed abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercation. This deficiency represents non-compliance investigated under Complaint Numbers 2676384 and 2670000.

Based on medical record review, personnel file review, family interview, staff interview, and policy review, the facility failed to ensure a resident who was dependent on tube feeding and ordered nothing by mouth (NPO) was not served food to eat by a staff member. This resulted in actual harm when Resident #34 who was found choking on food after being served a dish of watermelon at the bedside and left alone to consume the watermelon. Subsequently, Resident #34 was sent to the hospital for invasive procedure to dislodge the food from the esophagus. Resident #34 was admitted to the hospital with aspiration pneumonia from choking and aspirating (breathing food into the lungs) on food. This affected one (Resident #34) of three residents reviewed for altered needs for dietary. The facility census was 78. Findings include:Review of the medical record for Resident #34 revealed the resident was admitted to the facility on [DATE]. Diagnoses included sepsis, heart failure, dysphagia, sepsis due to enterococcus, gastritis with a gastric ulcer, and encounter for palliative care. Review of Resident #34's comprehensive Minimum Data Set (MDS) assessment, dated 08/06/25, revealed the resident had impaired cognition and was receiving parental nutrition via a feeding tube. Review of Resident #34's physician ordered diet revealed as of 04/29/25 the resident was ordered to receive nothing by mouth (NPO). The physician order dated 06/03/25 documented the resident was to receive a bolus of Jevity 1.5, via the feeding tube with 75 milliliters (ml) flush before and after bolus five times a day for feeding. Review of Resident #34's care plans, dated 08/18/25, revealed a focus for oral/swallowing risk. Interventions include serving diet per order and consult speech therapy for swallowing issues. Resident #34 required a feeding tube related to weight loss and increased needs. Goals were to be free from aspiration and maintain adequate nutritional status. Interventions for the focus include monitor and report as needed signs of aspiration, infections, and tube dysfunction. Review of Resident #34's progress notes, dated 08/11/25 at 4:18 P.M., revealed Resident #34 was having a choking episode and was transferred to the hospital for treatment. The resident was coughing and yelling while choking. Her vital signs were within normal limits. The resident's family and physician were notified. The medical record documented on 08/11/25, Resident #34 had been admitted to the hospital for a primary diagnosis of a foreign body in esophagus. Review of the hospital records documented on 08/12/25, Resident #34 underwent an esophagogastroduodenoscopy (EGD) procedure to remove the food bolus accumulating in her esophagus. The resident was ordered to remain NPO and continue to receive nutrition via the feeding tube. Resident #34 was discharged back to the facility on [DATE] with a diagnosis of aspiration pneumonia. Review of Resident #34's Computed Tomography (CT) scan, dated 08/11/25 at 8:35 P.M., revealed a finding of a food bolus seen within the distal esophagus, lower in position though more distal compared to prior exam but smaller in size. There was improved aeration (oxygen exchange) in the distal airways involving the lower left lobe, however, cannot rule out aspiration. During an interview on 08/18/25 at 10:21 A.M., Resident #34's family representative stated on 08/11/25, the family was contacted by the facility and was told a staff member in the activities department had given Resident #34 some watermelon. The family stated the nurse informed them the activities aide was not educated on Resident #34's dietary order. The facility nurse stated they called 911 and Resident #34 was transported to the hospital to receive emergency treatment. The family representative stated the hospital informed the family Resident #34 required an upper endoscopy to remove two pieces watermelon lodged in her esophagus and one piece of watermelon was moving into her lungs. While admitted to the hospital, Resident #34 was diagnosed with aspiration pneumonia from choking on the watermelon. During an interview on 08/18/25 at 11:03 A.M., Registered Nurse (RN) #216 stated on 08/11/25 a new aide from activities, Recreation Assistant (RA) #125 was passing out food to residents and RA #125 heard the resident coughing and yelling for help. RA #125 got the nurse, who assessed Resident #34 and found her coughing and drooling, with pieces of watermelon on her shirt. RN #216 stated she took the resident's vitals and called for emergency services to transport the resident to the hospital for treatment. During an interview on 08/18/25 at 11:17 A.M, RA #250 stated she was not the aide who passed the watermelon to Resident #34; however, she was working the day of the incident. The recreation aides are not educated on the resident's dietary restrictions. During an interview on 08/18/25 at 11:25 A.M., Director of Recreation (DOR) #123 stated on 08/11/25, RA #125 was newly hired to the facility and on 08/11/25, RA #125 was passing watermelon during activities. DOR #123 uses the dietary restriction sheet provided to know the resident's diet orders and restrictions. DOR #123 stated she instructed RA #125 to pass snacks on the 100 and 200 halls. DOR #123 stated RA #125's mother was working on the 100 hall on 08/11/25. DOR #123 stated she assumed RA #125's mother would instruct her on how to pass snacks to the residents on the hall she was working. DOR #123 stated she instructed RA #125 to pass snacks and then go back to the kitchen after she was done on 100 and 200 halls. DOR #123 stated RA #125 did not return to the kitchen after she was done passing the watermelon to the 100 and 200 halls and had left over watermelon. RA #125 continued to pass the watermelon to the residents in the 400-hall, including Resident #34. DOR #123 stated RA #125 received education after the incident. During an interview on 08/18/25 at 11:54 A.M. and on 08/19/25 at 10:00 A.M., the Administrator verified Resident #34 was served watermelon by RA #125 even though her diet order was NPO. All activity staff have been educated to review all residents dietary restrictions prior to providing any food the residents. Attempts to contact RA #125 on 08/18/25 and 08/19/25 were unsuccessful. Review of RA #125's personnel file revealed she was hired on 08/10/25. There was no evidence RA #125 had been educated on resident dietary restrictions to ensure safety when eating. Review of the policy titled, Therapeutic Diet Order , undated, revealed the facility will provide all resident with food the appropriate consistency in accordance with physician orders and plans of care. This deficiency represents non-compliance investigated under Complaint Number 2589259.

Based on record review, resident and staff interviews, observations, review of the facility's investigation and incident reports, hospital record review, policy review, and review of an instruction manual, the facility failed to ensure a resident requiring transfers with a mechanical lift was transferred safely. This resulted in Actual Harm on 05/15/25 when Resident #01 fell from a Hoyer lift during a transfer sustaining a fractured lumbar vertebral compression fracture. In addition, the facility failed to ensure Resident #61 received adequate supervision and assistance with bathing to prevent the resident from falling and failed to investigate Resident #61's falls which placed the resident at potential risk for more than minimal harm that was not Actual Harm. This affected two (#01 and #61) of three residents reviewed for falls. The facility census was 73. Findings include: 1. Review of the medical record for Resident #01 revealed an admission date of 09/18/20 with diagnoses of morbid obesity, heart disease, and osteoporosis. Review of the care plan updated 10/09/23 revealed Resident #01 had an activity of daily living (ADL) self-care performance deficit and was dependent on two staff for transfers and a mechanical lift. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/31/25, revealed Resident #01 had intact cognition and was dependent on staff for bed mobility and bed to chair transfers. Review of a nursing progress note dated 05/15/25 revealed a loud noise was heard coming from Resident #01's room. Resident #01 was on the ground lying on her back next to her bed in a towel with the mechanical lift above her with a ripped sling pad. Two Certified Nursing Assistants (CNAs) were next to the resident and the mechanical lift. Resident #01 complained of pain in her lower back and shoulder. The CNAs stated they were transferring Resident #01 from the shower bed to Resident #01's bed and the sling pad broke. Emergency rescue services were called, and Resident #01 was taken to the hospital. Review of the hospital records dated 05/15/25 revealed Resident #01 received a computed tomography (CT) scan of the lumbar spine without intravenous contrast and Resident #01 was found to have a second lumbar (L2) vertebrae fracture (likely hyperextension injury in the setting of rigid spine), without significant height loss and no evidence of retropulsed fragment (a piece of bone or disc material that has been displaced backward), favored acute. There was no plan to surgically repair the fracture. Review of the facility's investigation, initiated 05/15/25, revealed undated witness statements from the two CNAs (#202 and #230) who were present during Resident #01's fall on 05/15/25. Review of the statement from CNA #202 revealed she was assisting CNA #230, who was Resident #01's assigned CNA, in using a mechanical lift to transfer Resident #01 from her bed to a shower bed. CNA #202 stated she would not use the straps on the sling pad to transfer Resident #01 because she could see evidence the straps had been in the dryer. CNA #202 stated CNA #230 could not find another pad and used the one in the room to transfer Resident #01 to the shower bed. CNA #202 stated she put her hands under Resident #01 while transferring her to the shower bed. CNA #202 then assisted CNA #230 when transferring Resident #01 from the shower bed back to her bed after the shower. CNA #202 stated she could not keep her hands under Resident #01 during the transfer because she had to move the shower bed and that was when CNA #202 heard Resident #01 scream and CNA #202 saw three of the straps dangling from the mechanical lift and Resident #01 on the ground. Review of the undated witness statement from CNA #230 revealed when staff were moving Resident #01 back to bed, two of the sling pad straps snapped and Resident #01 slid out to the floor. CNA #230 stated it was the two straps by her legs that snapped. Review of the nursing progress note dated 05/16/25 (created on 05/18/25 and marked as late entry) revealed the interdisciplinary team met to discuss Resident #01's fall on 05/15/25 wherein the sling pad tore during a transfer causing Resident #01 to fall to the floor. The facility-initiated staff education on equipment usage for mechanical lifts and sling pads were checked for wear. The nursing progress note dated 05/16/25 at 8:30 P.M. revealed the facility was notified with an update on Resident #01 from the hospital indicating Resident #01 had an L2 compression fracture and it was non-operable. The nursing progress note dated 05/16/25 at 11:13 P.M. revealed Resident #01 returned to the facility from the hospital. Interview on 06/30/25 at 9:22 A.M. with Resident #01 stated staff were putting her to bed when the green straps broke on the sling pad and she fell to the floor. Resident #01 stated she was sent to the hospital and found to have a crack in her vertebrae and was told it would heal on its own. Resident #01 stated the pain was improving but it continued. Resident #01 also stated after the fall, her whole left side was black and blue, and it was very painful. Resident #01 stated she had noticed straps on the sling pads were broken for several days before the fall and Resident #01 stated she had told several staff but could not remember who she told. Interview on 06/30/25 at 2:20 P.M. with the Administrator, along with a review of CNA #202's statement, confirmed sling pads should not be dried in the dryer. Telephone interview on 06/30/25 at 3:10 P.M. with CNA #202 confirmed she was present during Resident #01's fall from the mechanical lift due to broken sling straps. CNA #202 stated she saw distressed straps, saw little hairs sticking out from the loops on the sling pad used to transfer Resident #01. CNA #202 stated she advised CNA #230 to get another sling and CNA #230 stated she could not find another one. CNA #202 stated when she assisted in transferring Resident #01 from the bed to the shower bed, CNA #202 placed her hands on Resident #01's bottom and assisted in supporting her weight. However, when she and CNA #230 were transferring Resident #01 back to her bed after the shower, CNA #230 raised Resident #01 with the mechanical lift from the shower bed and CNA #202 had to move the shower bed out from under Resident #01. CNA #202 stated she was unable to help support Resident #01's weight and that was when Resident #01 fell from the mechanical lift. Telephone interview on 06/30/25 at 3:40 P.M. with CNA #230 confirmed she was present during Resident #01's fall from the mechanical lift due to broken sling straps. CNA #230 stated she did not observe any concerns with the sling before using it to transfer Resident #01 on 05/15/25. CNA #230 stated she assumed Resident #01's weight and the wetness from the shower caused the straps to snap. Interview and observation on 07/01/25 at 8:34 A.M. with Central Supply (CS) #400 revealed she was given the task of inspecting the facility's sling pads on 05/15/25 for defects after Resident #01's fall. CS #400 stated she found slings with fraying near the loops and on the stitching, and some pads with loose, floppy loops without structural integrity. CS #400 confirmed the loops were used when attaching the sling pad to the mechanical lift and the loops should be stiff and intact. CS #400 stated she also found some sling pads with cut loops. CS #400 stated she could tell the loops were cut because of the clean cut across the fabric. CS #400 stated she did not determine why staff were cutting loops on the sling pads. CS #400 stated she observed the sling pad used to transfer Resident #01 on 05/15/25 and she could see where the loops were frayed after they ripped. CS #400 stated the straps were worn all the way through. CS #400 confirmed the facility determined laundry staff were putting sling pads in the commercial dryer with other linens. CS #400 stated the sling pads should not be put in the dryer because they wore out the material. Observation of a sling pad revealed evidence of the pad being dried in the dryer included white lint debris on the loops, and shrinkage of the sewn-in label. CS #400 confirmed the shrinkage of the label indicated the pad had been dried in the dryer. CS #400 recalled she had not ordered sling pads since the current Administrator began working at the facility in November 2024. CS #400 could not recall when she had previously ordered sling pads. Interview on 07/01/25 at 9:06 A.M. with Laundry Aide (LA) #401 revealed he worked in the facility for over a year and always washed and dried sling pads with linens until he was recently educated to hang dry all sling pads. A follow-up telephone interview on 07/01/25 at 1:49 P.M. with CNA #230 revealed she could not recall CNA #202 advising her not to use the sling pad for Resident #01's transfer on 05/15/25. Review of the email correspondence received on 07/01/25 at 3:02 P.M. from the Administrator revealed she could provide no evidence of historical sling pad purchases prior to the sling pads ordered after Resident #01's fall on 05/15/25. During an interview on 07/01/25 at approximately 3:15 P.M. with the Administrator she revealed she became aware sling pads should only be used for six months before replacement on 07/01/25, after reviewing the Instruction Manual. Review of the label affixed to the sling pad revealed a warning: Inspect patient slings for wear prior to each use. If signs of tearing, fraying or wear are found, discard the sling immediately; worn-out slings are not safe for use and may result in injury or death. Review of the undated Full Body Sling Instruction Manual revealed slings should be washed in warm or cold water and air dried, or tumble dried at cool or very low temperature. The useful life of the product was six months from the date of purchase under normal use; however, heavy use or excessive washing may reduce the useful life of the product. 2. Review of the medical record for Resident #61 revealed an admission date of 01/26/25 with diagnoses of bipolar disorder, spinal stenosis, and Parkinsonism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had intact cognition and required substantial/maximal assistance for bed mobility and was dependent on staff for bathing. Review of the Fall Risk Evaluation, dated 01/27/25, revealed Resident #61 was at risk for falls. Review of the care plan initiated 03/05/25 revealed Resident #61 had an activity of daily living (ADL) self-care performance deficit and required staff assistance for bed mobility and bathing/showering. Review of a nurse's progress note dated 05/13/25 revealed CNA #241 came to the writer stating Resident #61 was on the floor. Resident #61 was observed in the room lying on the left side next to the bed close to the wall. CNA #241 told the writer that she was cleaning up Resident #61 and stepped away to wet a towel in the bathroom and Resident #61 fell out of bed. CNA #241 stated she forgot to lock the bed. Resident #61 stated he was trying to get his arm comfortable and next thing you know he was on the floor. Resident #61 complained of hip pain and was sent to the hospital for evaluation. Review of the hospital records dated 05/13/25 revealed Resident #61 did not have any acute fractures. Review of the facility's incident report, dated 05/13/25, revealed Resident #61 was on his side with the bed high in the air and the bed wheels were not locked before the fall. Licensed Practical Nurse (LPN) #300 educated CNA #241 on the importance of locking the bed for safety reasons. Telephone interview on 06/30/25 at 3:01 P.M. with CNA #241 confirmed she was the CNA who was providing care to Resident #61 at the time of his fall on 05/13/25. CNA #241 confirmed she unlocked the wheels on Resident #61's bed while she was providing a bed bath. CNA #241 further confirmed Resident #61 was lying on his right side, facing the wall, when CNA #241 stepped away from him to wet a towel in the bathroom. CNA #241 stated Resident #61 fell between the bed and the wall while she was in the bathroom. CNA #241 confirmed she should have locked the bed wheels before leaving Resident #61 unattended. An interview on 07/01/25 at 10:16 A.M. with Resident #61 stated he recalled falling from the bed between the wall and the bed; however, Resident #61 could not recall whether he was aware the bed wheels were unlocked. Interview on 07/01/25 at 11:00 A.M. with the Administrator confirmed bed wheels should always be locked. Upon review of the fall on 05/13/25, the Administrator could not provide evidence CNA #241 was interviewed, provided a witness statement or received formal education, beyond that documented by LPN #300 at the time of the incident. Review of the care plan initiated 03/05/25, and most recently updated 06/17/25, revealed Resident #61 was at moderate risk for falls due to gait/balance problems. Interventions included keeping the call light in reach and encouraging the resident to use it, a perimeter mattress, keeping frequently used items within reach (added 04/16/25), providing a reacher [an assistive device designed to help people reach and grasp objects that are difficult to access] (added 05/06/25), staff education (added 05/14/25), and labs and medical work up (added 06/17/25). There were no interventions for a low bed or fall mat. Review of the facility's incident logs, dated 03/30/25 through 06/30/25, revealed Resident #61 fell on [DATE], 05/04/25, 05/13/25, 06/16/25, and 06/17/25. Review of the facility's incident report for the fall on 04/16/25 at 3:33 A.M. revealed Resident #61 had an unwitnessed fall and was found on the floor in his room. Resident #61 stated he was trying to get a phone that fell on the floor. The medical record did not indicate where Resident #61 was prior to the fall, whether in bed or a chair, if the call light was within reach and if it was used, and if the perimeter mattress was in place. Review of the facility's incident report for the fall on 05/04/25 at 10:40 P.M. revealed Resident #61 had an unwitnessed fall and was found on the floor in his room. Resident #61 stated he was trying to get a cord off the floor. The medical record did not state where Resident #61 was prior to the fall, whether in bed or a chair, if the call light was within reach and if it was used, and if the perimeter mattress was in place. Review of the facility's incident report for the fall on 05/13/25 at 9:40 A.M. revealed Resident #61 fell from the bed while being left unattended in an unlocked bed by the CNA while being cleaned. Resident #61 stated he was lying on his side and tried to get more comfortable and before he knew it, he was on the floor. The bed was high up, Resident #61 was on his side and the bed was not locked. Review of the facility's incident report for the fall on 06/16/25 at 11:25 A.M. revealed Resident #61 had an unwitnessed fall in his room and was on the floor wearing an adult brief only. Resident #61 stated he was getting up to go to the bathroom. Some confusion was noted as Resident #61 did not normally walk. Resident #61 was educated on the importance of using a call light for help. The medical record did not state where Resident #61 was prior to the fall, whether in bed or a chair and if the perimeter mattress was in place. Review of the facility incident report for the fall on 06/17/25 at 10:30 P.M. revealed Resident #61 had an unwitnessed fall in his room and was found on the floor in front of his bed. Resident #61 stated he was trying to walk. The contributing factors were confusion and a current urinary tract infection. The medical record did not state where Resident #61 was prior to the fall, whether in bed or a chair, if the call light was within reach and if it was used, and if the perimeter mattress was in place. Observation on 06/30/25 at 8:40 A.M. revealed Resident #61 lying on a perimeter mattress with a fall mat on the floor beside his bed. Interview on 06/30/25 at 3:21 P.M. with the Administrator confirmed the facility reviewed falls with an interdisciplinary team and would further investigate to gather additional information if all the information was not complete in the incident report. The Administrator stated the additional information would be documented, usually as a progress note, by the nurse who created the incident report. The Administrator further confirmed a thorough investigation was important to determine an appropriate intervention for each resident to prevent similar types of falls. Interview on 07/01/25 at approximately 10:30 A.M. with LPN #300 and concurrent observation of Resident #61 confirmed a floor mat was next to Resident #61's bed. LPN #300 said the fall mat had been there for a while and she assumed it was an intervention because of Resident #61's history of falls. Interview on 07/01/25 at 11:00 A.M. with the Administrator revealed Resident #61's fall mat was a fall intervention and should be included in his care plan. Further interview and concurrent review of Resident #61's falls revealed the previous Director of Nursing (DON) was tasked with completing fall investigations. The Administrator stated she could provide no evidence Resident #61's falls were investigated beyond the creation of an incident report. Upon review of the falls on 04/16/25, 05/04/25, 06/16/25 and 06/17/25 the Administrator could not determine where Resident #61 was prior to the fall, whether in bed or a chair, whether the fall mat was in place, and whether Resident #61 used a call light prior to the falls on 04/16/25, 05/04/25, and 06/17/25. Review of the Fall Prevention Program policy, copyright 2024, revealed the facility would, after each fall, complete a post-fall assessment, complete an incident report, and document all assessments and actions. Fall interventions should be implemented to address unique risk factors for each resident. The policy provided no specific guidance regarding a thorough investigation after a fall. This deficiency represents non-compliance investigated under Complaint Number OH00166353. This deficiency is an example of continued non-compliance from the survey dated 05/22/25.

Based on closed medical record review, family interview, staff interview, review of staff statements and review of the facility policy, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) assistance for Resident #100, who was found unresponsive, absent of breaths, without a pulse/heartbeat and was identified to have advance directives reflecting the resident was a Full Code (full life-saving measures to be taken in the event of cardiac/respiratory arrest) status. This resulted in Immediate Jeopardy and serious life-threatening harm/death on [DATE] when Licensed Practical Nurse (LPN) #300 responded to Resident #100's room and assessed the resident to be unresponsive and absent of vital signs. LPN #300 called for former LPN #501 to verify Resident #100 was absent of all vital signs and neither nurse initiated CPR nor called 911 for EMS assistance. Resident #100 subsequently passed away in the facility, without life-saving measures being implemented, without 911 being called, and LPN #300 and LPN #501 called the resident's time of death without the direction of a physician or other qualified health professional (for example, a Nurse Practitioner [NP]). This affected one (#100) of three residents reviewed for death in the facility. The facility census was 79. On [DATE] at 12:07 P.M., the Administrator, Director of Nursing (DON), and Regional Executive Director (RED) #502 were notified Immediate Jeopardy began on [DATE] at 1:11 A.M. when LPN #300 was informed by Certified Nursing Assistant (CNA) #339 that Resident #100, who had an advanced directive for a Full Code status, appeared to not be breathing. LPN #300 responded to Resident #100's room and assessed the resident and called for another nurse, LPN #501. LPN #300 and LPN #501 found the resident was not breathing and was absent of vital signs, including a pulse/heartbeat and blood pressure. Without initiating CPR, calling 911, or seeking direction from a physician, LPN #300 and LPN #501 called Resident #100's time of death at 1:11 A.M., stating the family at bedside refused life-saving measures. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 1:11 A.M., LPN #300 and LPN #501 assessed Resident #100 and found he was absent of vital signs. LPN #300 and LPN #501 called the resident's time of death in the facility at 1:11 A.M. • On [DATE] at 2:02 A.M., LPN #300 notified the DON, who was the on-call nurse, of Resident #100's passing. • On [DATE] at 2:02 A.M., LPN #300 notified the on-call physician of Resident #100's passing in the facility. • On [DATE] at 5:12 A.M., the Administrator educated all licensed nurses on the facility CPR protocol; to initiate any time a resident was a Full Code status. • On [DATE] at 7:49 A.M., the Administrator educated all licensed nurses on Ohio Law and Administrative Code regarding who can pronounce a time of death. • On [DATE] at 6:11 A.M., the DON provided individual educational consultation to LPN #300 and LPN #501 that the pronouncement of death by two LPNs on a Full Code resident was out of their scope of practice and the implementation of the facility CPR protocol and policy for all residents with a Full Code status. Additionally, LPN #300 and LPN #501 were educated that family refusal of CPR for a resident with a Full Code status still required the initiation of CPR. • On [DATE] at 9:00 A.M., the DON audited all residents to ensure accurate code status. Any identified concerns were addressed immediately. • On [DATE] at 9:00 A.M., LPN #503 audited all resident care plans to ensure code statuses were accurate. Any identified concerns were immediately addressed. • On [DATE] at 9:30 A.M., Human Resources Director (HRD) #314 audited all licensed nurses to ensure CPR certifications were up to date, with no concerns identified. • On [DATE], an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss CPR and code status for all residents. The facility policies and procedures related to the initiation of CPR and code status were reviewed, with no needed changes identified. The meeting also addressed the root cause of LPN #300 and LPN #501 not initiating CPR. In attendance at the meeting were the Administrator, DON, Unit Manager (UM) #302, UM #304, Wound Nurse (WN) #396, Business Office Manager (BOM) #336, Social Service Director (SSD) #373, HRD #314, LPN #503, and Activities Director (AD) #504. • By [DATE] at 5:30 A.M., the DON completed a code blue (indicating a medical emergency, typically cardiac or respiratory arrest) drill on all three shifts to ensure appropriate staff responses, with no concerns identified. • On [DATE] at 12:00 P.M., a QAPI meeting was held, and CPR was discussed as an area of performance improvement. Those in attendance were the Administrator, DON, Dietary Manager (DM) #505, HRD #314, BOM #336, Staffing Coordinator (SC) #328, WN #396, Director of Maintenance (DOM) #369, Therapy Director (TD) #506, and Medical Director (MD) #520. • On [DATE] at 9:38 A.M., the Administrator reported LPN #300 and LPN #501 to the Ohio Board of Nursing for not initiating CPR per physician ordered code status and for working outside of their scope of practice for calling Resident #100's time of death without physician direction. • On [DATE], the Administrator completed a post emergency code blue audit for [DATE] and [DATE] to ensure appropriate staff response. No additional emergency codes occurred in [DATE] or [DATE]. The Administrator will continue to audit all code blue situations for the next six months to ensure on-going compliance. Any areas of concern will be addressed with QAPI to ensure appropriate follow-up. • Review of two (#11 and #27) additional residents, reviewed for appropriate implementation of code status, revealed no additional concerns. • Interviews from [DATE] through [DATE] with Registered Nurse (RN) #304, LPN #300, LPN #302, LPN #406 and LPN #503 verified education was provided on initiating CPR on all residents with a Full Code status and qualified personnel to pronounce a resident's time of death. Additionally, each staff member confirmed mock emergency code drills were completed. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring for effectiveness and on-going compliance. Findings include: Review of the closed medical record for Resident #100 revealed an admission date of [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), dementia, prostate cancer, hypertension (high blood pressure), congestive heart failure, and orthostatic hypotension. Resident #100 passed away in the facility on [DATE]. Review of the Power of Attorney (POA) documents, dated [DATE], revealed Resident #100's daughter was his POA. Review of the annual Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #100 was moderately cognitively impaired. Review of a plan of care, initiated on [DATE], revealed Resident #100 had Full Code advanced directives. Interventions included call 911 for transportation to the local hospital, initiating CPR in the absence of a pulse, notify family and physician of changes in condition, and provide privacy during code situation. Review of a physician order dated [DATE] revealed Resident #100 had an order for Full Code status. Review of a nursing progress note dated [DATE] at 2:02 A.M. and written by LPN #300, revealed she was notified by CNA #339 that Resident #100 was not breathing. LPN #300 assessed the resident and called for another nurse to verify. Family was present at bedside and refused Full Code procedures. Resident #100 was pronounced (deceased ) at 1:11 A.M. The on-call nurse and physician were notified. Review of LPN #300's written statement, dated [DATE], revealed she was called to Resident #100's room by CNA #339 to check on the resident as he appeared to not be breathing. LPN #300 called another nurse to verify Resident #100's death. Family was in the room and did not want CPR to start, so CPR was not initiated. Resident #100's daughter was called to get the body moved. LPN #300 notified the on-call nurse by way of text and phoned the on-call physician at 1:24 A.M. Review of LPN #501's written statement, dated [DATE], revealed she was called to Resident #100's room to verify signs of life. No heartbeat or pulse were noted. Per family, CPR was not started. Review of the DON's statement, dated [DATE], revealed she inquired with Resident #100's daughter if she was present the previous night due to the nurse notification indicating the granddaughter was present. According to the statement, Resident #100's daughter indicated she was present, as well as her niece (Resident #100's granddaughter), the night of the resident's passing. The statement further stated Resident #100's daughter was at the facility and made arrangements for her father to be transferred to the funeral home of his choice. A telephone interview on [DATE] at 11:22 A.M. with Resident #100's daughter verified she was the resident's POA. Further interview with Resident #100's daughter revealed she was contacted by the facility on [DATE] to discuss possible hospice care for the resident. Resident #100's daughter stated she went to the facility but the staff member who called her was already gone for the day. Resident #100's daughter stated she did not discuss hospice care or a change in code status with anyone at the facility. Additionally, Resident #100's daughter verified she was not present at the time the resident was found unresponsive and without vital signs and did not give direction to facility staff to withhold CPR. Resident #100's daughter stated her niece, the resident's granddaughter, was at bedside at the time of the resident's death. Resident #100's daughter denied her niece would have directed facility staff to withhold CPR. A telephone interview on [DATE] at 1:19 P.M. with Resident #100's granddaughter verified she was at bedside with the resident when he passed away. She denied any other family being present at the facility. Resident #100's granddaughter stated she traveled from another state to visit Resident #100 and arrived at the facility on [DATE] at approximately 12:00 A.M. Resident #100's granddaughter stated she read to the resident from the bible and then laid her head down to try to get a small nap before she had to get back on the road. She reported the nurses came in and told her he was gone (deceased ). Resident #100's granddaughter confirmed nursing did not attempt to perform CPR and she did not direct any staff to not perform CPR. Resident #100's granddaughter confirmed the resident's daughter was not present at the time of his death and she did not arrive until after he had passed away. A telephone interview on [DATE] at 12:23 P.M. with LPN #300 revealed she began her shift on [DATE] with duties to collect a urine sample and to get laboratory (lab) draws done for Resident #100. LPN #300 stated she obtained the urine sample and called the lab to let them know it was ready to pick up and to get the blood draws completed. LPN #300 further stated that at an unknown time, a family member arrived and prayed over Resident #100. LPN #300 stated she was alerted by CNA #339 that Resident #100 did not appear to be breathing, so she went and got another nurse and they both verified Resident #100 was not breathing and did not have a heartbeat. LPN #300 stated she informed the family member she needed to perform CPR, and the family member directed her not to. LPN #300 further stated the family member at bedside called the POA (Resident #100's daughter), who stated, that's ok (to not perform CPR). LPN #300 stated she then called Resident #100's daughter and notified her of his passing. LPN #300 confirmed Resident #100's daughter was not at bedside when he passed away and did not arrive at the facility until after she notified her of his passing. LPN #300 stated Resident #100's daughter came to the facility to make arrangements because the resident's funeral home of choice was out of state. LPN #300 stated this incident taught her that when a resident was a Full Code status, even if family says not to do CPR, she must initiate CPR to comply with the advanced directive. An interview on [DATE] at 8:00 A.M. with the Administrator revealed she learned of the code situation while reading the 24-hour report in the early morning hours on [DATE]. After reading the information, the Administrator stated she immediately sent out education to all licensed nurses regarding Full Code status and the requirement to initiate CPR. The Administrator verified the education on performing CPR and code status was sent on [DATE] at 5:12 A.M. and an additional education was sent to all licensed nurses related to the personnel qualified to pronounce a time of death on [DATE] at 7:49 A.M. The Administrator verified LPN #300 and LPN #501 did not initiate CPR and called the resident's time of death, which was outside of the scope of practice for an LPN. A follow-up telephone interview on [DATE] at 8:35 A.M. with Resident #100's daughter revealed the only phone call she received on the night her father passed away was from the nurse who called to inform her he had passed away. Resident #100's daughter denied being on the phone with the resident's granddaughter and authorizing the withholding of CPR. Resident #100's daughter stated she went to the facility after she received the call to see him and make the funeral arrangements. Resident #100's daughter stated she never changed the resident's code status because she wanted the extra time with him. Review of the facility policy titled, Cardiopulmonary Resuscitation, undated, revealed it was the policy of the facility to adhere to residents' rights to formulate advanced directives. In accordance with these rights, this facility would implement guidelines regarding CPR. If a resident experienced cardiac arrest, facility staff would provide basic life support, including CPR, prior to the arrival of emergency medical services in accordance with the residents advanced directives. This deficiency represents non-compliance investigated under Complaint Number OH00165258.

Based on medical record review, staff interview, Carryout Attendant (CA) interview, review of facility video surveillance, and review of the facility policy, the facility failed to provide adequate supervision to ensure Resident #53, who had a diagnosis of schizoaffective disorder (a severe mental illness characterized by symptoms of schizophrenia, such as hallucinations and delusions, and a mood disorder), was assessed to be at risk for elopement, had a history of numerous elopement attempts, had a WanderGuard (wearable bracelet that triggers alarms at the doors to alert when a resident attempts to exit) applied to her wheelchair, and who was on 15-minute staff supervision checks, did not elope from the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious harm, injury and/or death when a visitor used a code to enter the locked front door of the facility, and Resident #53 was able to exit through the front door before the door was securely closed. The facility staff were unaware Resident #53 was missing until Certified Nursing Assistant (CNA) #301, who was on a lunch break, happened to enter a local carryout and found the resident sitting on the floor, approximately 35 minutes after the resident had eloped. This affected one (#53) of two (#53 and #08) residents reviewed for elopement. The facility identified two residents (#53 and #08) to be at risk for elopement. Additionally, the facility failed to complete admission and quarterly smoking assessments for two residents (#48 and #58), that placed the residents at risk for the potential for more than minimal harm that was not Immediate Jeopardy, to ensure they were safe to smoke unsupervised or if safe smoking measures were needed, in accordance with facility policy. This affected two (#48 and #58) of three residents reviewed for smoking. The facility identified 16 (#08, #12, #14, #22, #24, #26, #33, #34, #48, #58, #65, #66, #67, #68, #72, and #77) residents who smoked cigarettes. The facility census was 79. On 05/06/25 at 12:05 P.M., the Administrator, the Director of Nursing (DON), and Regional Executive Director (RED) #502 were notified Immediate Jeopardy began on 04/21/25 at 6:56 P.M. when a visitor entered the code to the locked front door, entered the facility, and Resident #53 was able to exit out of the front door without staff knowledge. Resident #53 ambulated through the open door, leaving her wheelchair with the attached WangerGuard inside the lobby area. Resident #53 walked approximately 0.2 miles from the facility to a carryout. The route traveled included a sidewalk with broken concrete and rocks along a five-lane road with posted speed limits of 45 miles per hour (MPH). Staff were unaware the resident had eloped from the facility until approximately 7:31 P.M., when CNA #301 incidentally discovered the resident sitting on the floor of the carryout. At the time, Resident #53 was actively hallucinating and stating the facility kidnapped her. CNA #301 notified the DON, who sent UM #302 and LPN #300 to assist with returning the resident to the facility at 7:59 P.M. The Immediate Jeopardy was removed on 05/06/25, when the facility implemented the following corrective actions: • On 04/21/25, UM #302 and LPN #300 assisted with returning Resident #53 to the facility. • On 04/22/25, LPN #305 ensured CNAs completed every 15-minute supervision checks for Resident #53 to ensure safety. • On 04/28/25, Registered Nurse (RN) #317 completed a skin observation for Resident #53, with no concerns identified. • By 05/05/25, the Administrator or designee educated all facility staff members on elopement prevention and missing resident policy. • On 05/05/25, an Ad Hoc Quality Assessment and Performance Improvement (QAPI) meeting was held to review the incident and identify corrective action. In attendance were the Administrator, the DON, Director of Maintenance (DOM) #369, Medical Records (MR) #333, Human Resource Director (HRD) #314, Social Services Designee (SSD) #373, LPN #503, UM #304, Director of Therapy (DOT) #522, and Wound Care Nurse (WCN) #396. • On 05/05/25, the DON reassessed Resident #53 for elopement risk to ensure accuracy. Additionally, Resident #08, the only identified like resident, was reassessed by the DON for elopement risk. Both residents remained at risk for elopement. • On 05/05/25, the Administrator reviewed and revised the elopement book to include information for residents who were identified to be at risk for elopement. • On 05/05/25, the DON reviewed all residents' elopement risk care plans to ensure accuracy. Any areas of concern were addressed immediately. • On 05/05/25, the DON completed a pain evaluation for Resident #53, with no concerns identified. • On 05/05/25, the Administrator and/or SSD #373 continued to seek a more appropriate alternative placement for Resident #53's safety and well-being. • On 05/06/25, the Administrator or designee educated all staff on how to complete fifteen-minute supervision checks and how to document the checks. • On 05/06/25, the Administrator conducted an elopement drill on each shift to ensure staff knowledge and comprehension of the elopement and missing resident policy and procedure. • On 05/06/25, the Administrator completed a Root Cause Analysis and determined Resident #53 eloped without staff knowledge due to the CNAs providing care for other residents, leaving Resident #53 without supervision. • On 05/06/25, the DON, UM #302 and UM #304 reassessed all facility residents for elopement risk, with no new residents identified to be at risk. • On 05/06/25, RN #523 and LPN #503 reviewed Resident #53's care plan to ensure accuracy. • On 05/06/25, the Administrator and DON reviewed elopement policies and procedures and determined no changes were needed. • On 05/06/25, Resident #53 was placed on an on-going one-on-one staff supervision to ensure safety. The Administrator, or designee will be responsible for ensuring sufficient staff coverage to provide the supervision. This will continue until a more appropriate, alternative placement is found for the resident. • On 05/06/25, the Administrator or designee moved Resident #53's room to a less stimulating, more visible area of the building. • On 05/06/25, the Administrator placed signage on the front entry door to remind visitors to ensure no residents exited the facility upon entrance and the door closed securely behind them. • Beginning on 05/06/25, the DON or designee will complete a headcount on every resident, three times a week for four weeks then weekly for two months, then as determined by the Quality Assessment and Assurance (QAA) committee to ensure no missing residents. • Beginning on 05/06/25, the Administrator or designee will conduct random elopement drills on each shift weekly for four weeks to ensure staff knowledge and comprehension of elopement and missing resident policy and procedure, then as determined by the QAA committee. • The results of audits will be reviewed by the QAPI committee to ensure on-going compliance. • Review of one additional resident (#08), identified as the only other resident assessed to be at risk for elopement, revealed no concerns. Although the Immediate Jeopardy was removed on 05/06/25, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the medical record revealed Resident #53 was admitted on [DATE]. Diagnoses included angina pectoris, depression, schizoaffective disorder, anxiety disorder, unspecified osteoarthritis, iron deficiency anemia secondary to blood loss, and unspecified hearing loss. Review of the Minimum Data Set (MDS) assessment, dated 04/09/25, revealed the resident was cognitively intact. Review of the elopement risk assessment, dated 02/01/25, revealed Resident #53 was at risk for elopement and a WanderGuard was placed to the right leg. Review of the care plan, dated 02/05/25, revealed Resident #53 was at risk for elopement. Interventions included to assess for fall risk, check device (WanderGuard) for function and location every shift, distract resident from wandering by offering pleasant diversions (structured activities, food, conversation, television, and books), monitor for fatigue and weight loss, provide structured activities (toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes), and wander alert (WanderGuard). Review of a nursing progress note, dated 02/17/25, revealed Resident #53 was outside without a coat, stating she wanted to see the police so they could take her to NorthStar (unknown what this is). Resident #53 stated she was attempting to go to NorthStar because that was where the voice told her she needed to go to be in the morgue. Resident #53 stated the voice told her to remove the WanderGuard. Review of a nursing progress note, dated 02/21/25, revealed Resident #53 had followed another resident out the front door. The WanderGuard alarmed; however, the doors did not lock due to another resident going out at the same time. Review of a nursing progress note, dated 02/25/25, revealed Resident #53 went outside and sat in a chair out front with her wheelchair next to her. The WanderGuard had alarmed, and Resident #53 had two bags of clothes packed and stated she was waiting for her son. Review of a physician order dated 03/03/25 revealed an order for Resident #53 to have every fifteen-minute safety checks, every day and night shift for monitoring. Review of a nursing progress note, dated 03/05/25, revealed Resident #53 was in a cab and would not exit. Resident #53 was upset about wanting to go to the bank. Resident #53 stated President [NAME] gave her authorization to go to the bank. Resident #53 admitted to having auditory hallucinations of voices telling her to leave and go to New York and had visual hallucinations of Italian females telling her it was ok to go. Review of an additional nursing progress note dated 03/05/25 revealed Resident #53 was noted to have elopement behaviors and required extensive monitoring. Resident #53 was on every 15-minute checks 24-hours a day, seven days a week. Review of an Interdisciplinary Team (IDT) progress note, dated 03/06/25, revealed Resident #53 had a history of schizoaffective disorder. Resident #53 had a WanderGuard applied to her wheelchair due to cutting it off from her ankle on previous occasions. Intervention in place to maintain fifteen-minute safety checks until further notice. Review of the elopement risk assessment, dated 03/25/25, revealed Resident #53 was at risk for elopement and every 15-minute supervision checks were implemented. Review of a behavior note, dated 04/07/25, revealed Resident #53 was outside of the facility doors. Review of a nursing progress note, dated 04/08/25, revealed Resident #53 was observed standing from her wheelchair, pressing the handicapped access button to open the front doors. Resident #53 was convinced to sit back down and not go outside due to the cold weather. The WanderGuard remained intact on the resident ' s wheelchair due to the resident cutting the WanderGuard off her leg numerous times. Review of a behavior note, dated 04/08/25, revealed Resident #53 was sitting out front this morning when staff arrived at work. Resident #53 was redirected back into the building. Review of a nursing progress note, dated 04/21/25, revealed Resident #53 exited the building around 5:30 P.M. and went to the carryout store. Resident #53 sat on the floor and refused to get up and stated she was being kidnapped. Extensive effort required as the resident refused until the store clerk told her she had to leave. Emergency services (911) were called to help. Resident #53 was delusional and stated she wanted to take a cab to [NAME] Road (a heavily traveled four-lane road). Resident #53 was encouraged to talk to her doctor that helped her with her voices and behaviors, who would assist her if she returned to the facility. Resident #53 finally got into the car with staff and returned to the facility. Emergency services were canceled due to prolonged wait. Facility management was aware; the physician was notified and attempted to call family three times with no answer. Psychiatric Nurse Practitioner (PNP) #500 to visit with resident this week. Review of the Resident Location Visual Check logs from 03/03/25 to 05/05/25 revealed visual checks were only documented as completed on 03/18/25, 03/19/25, 03/26/25, 03/27/25, 03/28/25, 03/30/25, 03/31/25, 04/01/25, and 04/02/25. There was no evidence 15-minute supervision checks were completed on 04/21/25, the date Resident #53 eloped from the facility. Review of the facility video surveillance from 04/21/25 revealed at 6:55 P.M., Resident #53 was seated in her wheelchair in the front lobby. At 6:56 P.M., an unknown visitor entered the door code from outside of the facility, unlocking the door, and entered the building. The visitor passed Resident #53, who abruptly stood up and walked out the front doors, leaving her wheelchair and attached WanderGuard in the lobby. No staff were seen on the video at the time of the elopement. Further review revealed Resident #53 returned to the facility at 7:59 P.M. with UM #302 and LPN #300. Review of CNA #301 ' s written statement revealed he took his lunch break at 7:31 P.M. (on 04/21/25). He went to the carryout to get something to drink and, upon entrance, saw Resident #53 sitting on the floor of the carryout. CNA #301 notified the DON, and two nurses arrived to assist with the resident. Review of CNA #319 ' s written statement, dated 05/06/25, revealed on 04/21/25, following dinner and after trays were picked up, she began rounds (checking on residents). After providing care to a resident, LPN #300 notified her that Resident #53 had left the building, went to the carryout and sat on the floor. One of the facility staff walked into the carryout to get something to drink and called the facility to inform them Resident #53 was at the carryout. An interview on 05/05/25 at 8:58 A.M. with LPN #305 confirmed Resident #53 had a WanderGuard placed on her wheelchair instead of her person due to the resident removing it from her body. An interview on 05/05/25 at 10:48 A.M. with UM #302 revealed Resident #53 was on 15-minute supervision checks for at least a month or more prior to the elopement on 04/21/25. UM #302 stated Resident #53 was not safe to leave the facility by herself and had been fixated on going outside. UM #302 stated Resident #53 walked well independently and had previously cut the WanderGuard off of her ankle. UM #302 confirmed that on 04/21/25, Resident #53 walked from the facility to the carryout. UM #302 was uncertain if CNA #301 had followed the resident to the carryout or if he found her there. UM #302 stated she responded to the carryout and found Resident #53 sitting on the floor. UM #302 stated it took extensive effort to get the resident into a car and back to the facility. A telephone interview 05/05/25 at 11:05 A.M. with CNA #301 revealed on 04/21/25 he was on his break and went to a pizza shop then to the carryout, located in the same plaza, to get something to drink. Upon entering the carryout, he saw Resident #53 sitting on the floor. CNA #301 reported the resident was stating the facility had kidnapped her. CNA #301 stated he called the DON, who had two facility nursing staff come to the carryout to assist with returning the resident to the facility. CNA #301 confirmed he was not with the resident when she left the facility. An interview on 05/05/25 at 11:17 A.M. with the DON revealed Resident #53 found ways to cut the WanderGuard from her person but would not remove it from the wheelchair, so the facility decided to place the WanderGuard on the wheelchair. The DON stated the WanderGuard had been replaced at least five times after the resident had found ways to remove it from her wrists and ankles. Upon approaching the doors, the DON stated the WanderGuard should lock the doors to prevent exit. The DON reported Resident #53 had schizophrenia and the voices would tell her to leave. The DON verified Resident #53 left the faciity on [DATE] and went to the carryout, but her understanding was that a staff member (CNA #301) was right behind her. An interview on 05/05/25 at 4:30 P.M. with CA #521 revealed on 04/21/25, a woman (Resident #53) had come into the carryout, stated she was waiting for a ride, and sat on the floor. CA #521 verified the resident was alone and no one was with her. CA #521 reported a short time later, a male entered the carryout and appeared surprised to see her. Shortly after, two women came in and finally convinced her to return to the facility. An interview on 05/06/25 at 8:07 A.M. with MR #333 verified no 15-minute supervision checks had been documented as completed on 04/21/25. MR #333 verified the copies of the visual checks provided (03/18/25, 03/19/25, 03/26/25, 03/27/25, 03/28/25, 03/30/25, 03/31/25, 04/01/25, and 04/02/25) were all that she had. An interview on 05/06/25 at 8:09 A.M. with the DON revealed she was unaware Resident #53 eloped from the facility on 04/21/25 until 05/05/25, as she thought CNA #301 had been with the resident. The DON verified the facility had no evidence that 15-minute supervision checks were completed for Resident #53 on 04/21/25. An interview on 05/07/25 at 3:05 P.M. with CNA #319 verified she was assigned to Resident #53 ' s hall on 04/21/25 when the resident eloped. CNA #319 stated she did not know they were still doing 15-minute checks on Resident #53 at that time and was unaware the resident had eloped until she was informed by LPN #300, after the resident returned to the facility. Review of the facility policy titled, Elopements and Wandering Residents, dated 2024, revealed the facility ensured residents who exhibit wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents, and received care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. In addition, adequate supervision would be provided to help prevent accidents or elopements. Charge nurses and unit managers would monitor the implementation of interventions, response of interventions, and document accordingly. The effectiveness of interventions would be evaluated, and changes would be made as needed. Any changes or new interventions would be communicated to relevant staff. 2) Review of the medical record for Resident #48 revealed an admission date of 06/06/24 with a diagnosis of nicotine dependence. Review of the quarterly MDS assessment, dated 04/05/25, revealed Resident #48 was cognitively intact. Review of the care plan, initiated 08/11/24, revealed Resident #48 was care planned for smoking. Interventions included instruct resident on facility smoking policy for smoking location, time, and safety. Further review of the medical record revealed no evidence of a Smoking Safety Screen (assessment to determine supervision and safety needs while smoking) was completed until 03/25/25, approximately eight months after admission, when the resident was assessed to require no supervision. An interview on 05/13/25 at 12:03 P.M. with the Administrator verified Resident #48 was not assessed for smoking safety upon admission or quarterly thereafter. 3) Review of the medical record for Resident #58 revealed an admission date of 12/19/24. Diagnoses included hemiplegia and hemiparesis affecting the right side, assault by a sharp object, burns on head, face, neck, and trunk, and history of cocaine abuse. Resident #58 discharged from the facility on 05/05/25. Review of the quarterly MDS assessment dated [DATE] for Resident #58 revealed he was cognitively intact. Review of the care plan, initiated 12/19/24, revealed Resident #58 was care planned for smoking and to conduct a Smoking Safety Evaluation upon admission and as needed. Further review of the medical record revealed no evidence that a Smoking Safety Screen was completed upon admission. On 03/25/25, approximately three months after admission, Resident #58 was assessed to be able to smoke without supervision. An interview on 05/13/25 at 12:03 P.M. with the Administrator verified Resident #58 was not assessed for smoking safety upon admission. Review of the facility policy titled, Resident Smoking, undated, revealed all residents would be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. Residents who smoked would be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision was required for smoking, or if a resident was safe to smoke at all, and all safe smoking measures would be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who would be responsible for supervising residents while smoking. This deficiency represents non-compliance investigated under Master Complaint Number OH00165791 and Complaint Numbers OH00165258 and OH00164697.

Based on medical record review, staff interview, review of radiology results, radiology vendor interview, review of electronic mail (e-mail) correspondence, review of hospital records and review of the facility policy, the facility failed to ensure X-ray results were received timely to prevent a delay in treatment. This resulted in Actual Harm to Resident #49 on 05/05/25 at approximately 9:58 A.M. when the radiology vendor faxed stat (immediate) X-ray results to the facility, showing the resident had a right hip fracture, the facility did not receive the results, and then failed to follow up with the radiology vendor to verify the outcome until 05/06/25. Consequently, Resident #49 experienced a pain level of 10 on a scale of zero to 10 (with 10 being the worst pain) and was not transferred to the hospital for evaluation and treatment for approximately 24 hours after the X-ray results were initially faxed to the facility. Resident #49 was subsequently admitted to the hospital, where he received surgical repair for the fractured right hip. This affected one (#49) of three residents reviewed for falls. Additionally, the facility failed to ensure weekly wound monitoring and assessments were completed for one resident (#19), that placed the resident at risk for the potential for more than minimal harm that was not actual harm. This affected one (#19) of three residents reviewed for wound care. The facility identified 10 residents (#1, #19, #20, #29, #44, #51, #65, #67, #71, and #72) who required wound care at the facility. The facility census was 79. Findings include: 1) Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included acute on chronic systolic (congestive) heart failure, malignant neoplasm of the prostate, cocaine use, major depressive disorder, and nonrheumatic aortic stenosis. Review of the Minimum Data Set (MDS) assessment, dated 02/08/25, revealed Resident #49 was moderately cognitively impaired and required supervision assistance with toileting, shower/baths, upper and lower body dressing, applying footwear, and personal hygiene. Review of a nursing progress note, dated 05/04/25 at 9:56 P.M., revealed Resident #49 was found lying on his right side on the floor of his bedroom. The resident was assessed, including range of motion (ROM), vital signs and pain, and assisted into bed. Resident #49 denied hitting his head, was provided the call light and necessities in reach. The physician and the on-call manager, Registered Nurse (RN) #304, were notified. Resident #49 complained of pain to the right knee and an order was given for a stat X-ray of the right knee. Review of a nursing progress note dated 05/05/25 revealed Resident #49 complained of right hip pain when he moved. Resident #49 rated the pain as a 10 on a zero to 10 pain scale. The physician was notified, and a new order was received for an X-ray of the right hip. The X-ray was completed. Review of the radiology report results on 05/05/25 at 9:55 A.M., revealed Resident #49 was diagnosed with an acute non-displaced right femoral neck (hip) fracture. Review of a nursing progress note, dated 05/06/25 at 9:15 A.M., revealed X-ray results were received, the physician was notified, and an order was received to transport Resident #49 to the emergency room (ER) for evaluation. Transportation was arranged at 8:50 A.M. and Resident #49 was transported at 9:15 A.M. Review of an Interdisciplinary Team (IDT) progress note, dated 05/07/25 at 2:40 P.M., revealed the IDT met to discuss the resident ' s fall on 05/04/25. Resident #49 was observed on the floor in his room, lying on the right side. Resident #49 complained of right knee pain to the nurse at the time of the fall. An X-ray of the right knee was ordered and the following morning the resident complained of hip pain and stated the knee pain had resolved. A hip X-ray was ordered, and the results revealed the resident had a non-displaced fracture of the right femur neck. Resident #49 was transported to the ER for evaluation and was admitted to the hospital. Review of the hospital records, dated 05/06/25 at 9:47 A.M., revealed Resident #49 presented to the ER with an X-ray obtained on 05/05/25 that was positive for a femoral fracture. Further review of an orthopedic surgery note, dated 05/08/25, revealed Resident #49 ' s femoral fracture was surgically repaired on 05/06/25 with the insertion of an intramedullary (a metal rod inserted into the hollow center of a long bone to stabilize and support fractures to promote healing) rod. Review of e-mail correspondence from the Administrator, received on 05/08/25 at 12:28 P.M., verified a stat X-ray of Resident #49 ' s right hip was ordered on 05/05/25 at 9:09 A.M. The X-ray technician arrived on 05/05/25 at 9:33 A.M., the X-ray was completed on 05/05/25 at 9:34 A.M., the X-ray was verified on 05/05/25 at 9:36 A.M., and the final report was completed on 05/05/25 at 9:55 A.M. An interview on 05/07/25 at 11:25 A.M. with the Director of Nursing (DON) verified Resident #49 had a stat X-ray of the right hip on the morning of 05/05/25 and the results were not received by the facility until the morning of 05/06/25. A follow-up interview on 05/07/25 at 2:27 P.M. with the DON revealed on 05/06/25, she reviewed the facility ' s 24-hour report and saw that the X-ray results for the right hip X-ray completed on 05/05/25 had not been received. The DON stated she accessed the radiology vendor ' s system and reviewed the results, which showed Resident #49 had a right hip fracture. The DON stated the results should have been faxed to the nurses ' station and to the primary fax in the copy room. The DON verified the nurse on shift would have been expected to follow-up with the radiology vendor if the results had not been received within four to six hours after the X-ray was taken. The DON confirmed there was no evidence the facility followed up on the results of Resident #49 ' s X-ray until 05/06/25, approximately 24 hours after the X-ray was completed. An interview on 05/12/25 at 9:10 A.M. with Registered Nurse (RN) #317 revealed she cared for Resident #49 during the day shift on 05/05/25. RN #317 stated she was informed during report that the resident had complained of knee pain; however, upon assessing the resident, he reported the knee pain had resolved but he had significant pain in the right hip. Around the same time, the X-ray technician was there to complete the order for the right knee X-ray. RN #317 stated she contacted the physician to change the order to an X-ray of the right hip, which was completed at that time. RN #317 confirmed she did not receive the results of the X-ray during her shift and reported to the oncoming shift nurse that the results were pending. RN #317 stated she knew it was a hip fracture and had been curious about the results all day. RN #317 stated she checked the radiology tab in the facility ' s medical record system throughout the day and did not see a report. RN #317 stated she did not know where else to look for the X-ray results. Interview on 05/12/25 at 9:29 A.M. with Customer Support (CS) #524 with the radiology vendor verified Resident #49 ' s hip X-ray was completed on 05/05/25 at 9:35 A.M. and the results were faxed to the facility on [DATE] at 9:58 A.M. 2) Review of the medical record for Resident #19 revealed an admission date of 03/25/21 with diagnoses of diabetes mellitus and peripheral vascular disease (PVD). Review of the annual Minimum Data Set (MDS) assessment, dated 04/06/25, revealed Resident #19 was cognitively impaired and had one venous ulcer (these types of ulcers are considered chronic and they tend to heal and re-open frequently, the result of PVD). Review of the physician orders for May 2025 revealed Resident #19 had an order to cleanse the right ankle wound with normal saline, pat dry and apply collagen alginate, cover with an abdominal (ABD) pad, and apply an Unna boot (boot for reduction of venous fluid to help with vascular circulation) from the toes to two fingers below the knee. Change the dressing three times per week on Monday, Wednesday, and Friday and as needed. Review of the wound assessment dated [DATE] revealed the area on Resident #19's right ankle was previously healed and re-opened on this date. The assessment indicated the area measured 4 centimeters (cm) by (x) 3.6 cm x 0.1 cm and was a venous ulcer. Further review of the medical record from 04/09/25 through 05/13/25 revealed no evidence weekly wound assessments or monitoring was completed for Resident #19 ' s venous ulcer. Interview on 05/13/25 at 10:24 A.M. with Licensed Practical Nurse (LPN) #396 revealed she had all of the wound measurements for Resident #19 ' s venous ulcer and would obtain them, adding she had not uploaded all of the information into the electronic medical record (EMR) yet. Further interview with LPN #396 revealed the facility policy was to complete weekly monitoring and measurements of wounds. LPN #396 further stated that Resident #19 was followed by an outside wound care provider, and on the weeks he had an appointment there (generally every two weeks), she utilized the measurements from the appointment and entered them into the resident's EMR for continued monitoring of the wound. A follow-up interview on 05/13/25 at 11:03 A.M. with LPN #396 verified there was no evidence that wound monitoring and/or assessments had been completed for Resident #19 ' s venous ulcer since 04/09/25, including any assessments from the outside wound care provider. LPN #396 stated she had been on vacation for approximately one month and she was unable to locate any documentation related to the resident's wound assessments. Review of the facility policy titled, Documentation of Wound Treatments, undated, revealed the facility completed accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Wound assessments were documented upon admission, weekly, and as needed if the resident or wound condition deteriorated. The following elements were documented as part of a complete wound assessment: type of wound, stage of the wound, measurements to include height, width, depth, undermining and tunneling, and wound characteristics. Additionally, documentation should include weekly progress towards healing and effectiveness of the current intervention. This deficiency represents non-compliance investigated under Complaint Number OH00165492 and Complaint Number OH00165258.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observation, medical record review, resident interview, staff interview, review of facility self-reported incident, and review of the facility investigation report, the facility failed to ensure the safety and psychosocial health of a dependent resident. This resulted in actual harm when Resident #46 experienced sexual abuse while receiving a shower from facility staff. This deficient practice affected one (#46) of three residents reviewed for physical abuse. The facility census was 73. Findings include: Review of Resident #46's medical record revealed an admitted [DATE]. Diagnoses included morbid obesity, congestive heart failure, asthma, and diabetes mellitus. Review of Resident #46's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Resident #46 was dependent on staff for bathing/showers, toileting, lower body dressing and personal hygiene. Review of Resident #46's shower/bath record revealed he received showers on 12/14/24 and 12/21/24. Review of the nurse progress note dated 12/26/24 revealed a Certified Nursing Assistant (CNA) informed the Director of Nursing (DON) and Administrator of a resident's (#46) concern. An investigation was immediately started and an interview of Resident #46 was conducted by the Administrator. Resident #46 was tearful, distraught, and upset throughout the interview. Review of a facility self-reported incident, dated 12/26/24, revealed sexual abuse by a facility staff member was reported from the victim, Resident #46. On 12/26/24 at 2:15 P.M. it was reported to the Administrator by CNA #200 that Resident #46 stated CNA #100 had allegedly been sexually inappropriate with him while providing personal care. Review of the facility investigation notes revealed a witness statement from CNA #200 dated 12/26/24. On 12/23/24, CNA #200 noticed Resident #46 had a shower on 12/21/24 and inquired about the shower on 12/21/24 as CNA #200 worked all week and usually gave Resident #46 a shower or bed bath each morning. CNA#100 overheard CNA #200 ask about Resident #46's shower and replied, I worked on 12/21/24 and scrubbed Resident #46 hard; he should be fine. On 12/26/24, CNA #200 began Resident #46's bath and Resident #46 informed CNA #200 she was being a bit rough; CNA #200 apologized and told the resident she was just trying to do a good job at getting him clean. During care CNA #200 noticed Resident #46 was nervous and in talking with the resident, Resident #46 informed CNA #200 that CNA #100 had violated him by inserting her gloved fingers into his anus. Resident #46 showed CNA #200 with his hands how he was violated four or five times in the month of December 2024. Resident #46 told CNA #200 that he thought it was an accident at first, but it continued to occur. CNA #200 immediately reported the conversation to the Administrator and Director of Nursing. Further review of the medical record for Resident #46 revealed a physician progress note dated 12/27/24 which stated Resident #46 was a [AGE] year-old male in long term care with a previous medical history of heart failure, morbid obesity, diabetes mellitus type 2, and arthritis who was being seen after the resident reported being assaulted while receiving personal care. The resident reported feelings of anxiety and anger following the episode. A skin assessment was performed with the Unit Manager and no bruising or breaks in the skin were noted. The patient initially requested to be transferred to a local hospital for assessment; however, after the Unit Manager contacted the hospital and learned a sexual assault exam must be completed within 72 hours of the assault, Resident #46 declined transfer. Review of Resident #46's care plan updated on 12/27/24 revealed the resident had the potential risk for trauma related to physical and sexual violence. Review of Resident #46's shower/bath record revealed he received showers on 12/14/24 and 12/21/24. Interview with Resident #46 on 01/07/25 at 9:20 A.M. revealed when given a shower the resident laid on the shower bed on his side so the staff could clean his backside. Resident #46 stated he informed CNA #200 that CNA #100 was rough with him four or five times in the month of December, and he did not like the treatment. Resident #46 stated during care CNA #100 would thrust hard on his bottom and would put her gloved finger into his rectum. Resident #46 confirmed CNA #200 asked him on 12/26/24 if something happened to him and he informed her of the incidents involving CNA #100 and that was when he learned from CNA #200 that CNA #100 had bragged to other staff members that she fisted him. Resident #46 stated all the staff were talking about him and third shift staff have refused to provide care due to being afraid he would report them for sexual abuse. Observation of Resident #46 during the interview revealed the resident was tearful and anxious. Interview on 01/07/25 at 10:03 A.M. with CNA #200 revealed a month prior to 12/26/24 she had overheard CNA #100 state she had placed her fist into Resident #46's rectum, and he enjoyed the act. CNA #200 thought it was a rumor, and no one believed CNA #100, so nothing was reported. CNA #200 verified on 12/26/24 when providing a bed bath to Resident #46, the resident began to give her hints that CNA #100 was rough and hurt him during care. CNA #200 stated when she asked Resident #46 about her concerns, he informed her that every time CNA #100 touched his bottom she slipped a gloved finger into his anus, adding this occurred five to six times. CNA #200 stated she informed the resident she was going to report the incidents to the Administrator, and the resident was in agreement. Interview with the Administrator on 01/07/25 at 11:10 A.M. revealed CNA #100 was terminated for insubordination after getting into a verbal argument with a Unit Manager in front of a resident earlier in the day on 12/26/24, prior to knowledge of the sexual abuse allegation. The Administrator stated the DON attempted to contact CNA #100, but the phone was out of service. The Administrator added the police were contacted immediately and they have started an investigation. Review of the local law enforcement information revealed on 12/26/24 a police report was filed, and an investigation is ongoing. Review of facility policy titled Abuse, Neglect, and Exploitation undated, revealed abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse. Sexual abuse is non-consensual sexual contact of any type with a resident. The deficient practice was corrected on 12/28/24 when the facility implemented the following corrective actions: On 12/26/24, The Administrator filed a Self-Reported Incident for sexual abuse to the State of Ohio. On 12/26/24, resident interviews for abuse concerns were conducted by the Unit Manager on all residents with a Brief Interview for Mental Status (BIMS) score of 10 or higher. On 12/26/24, skin assessments were completed by the Unit Manager for residents with a BIMS score of less than 10. On 12/26/24, the Medical Director was notified of the abuse incident. On 12/26/24, staff interviews were completed by the DON. On 12/27/24, staff education on abuse completed by the Administrator. On 12/27/24, head to toe assessments were completed on all residents with a BIMS of less than 10 by the Unit Manager and the Nurse Practitioner. On 12/27/24, 12/30/24 and 12/31/24, psychosocial interviews with Resident #46 were completed by the Social Worker. On 12/27/24, an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Medical Director, DON, Unit Manager and Administrator to review the incident and the corrective action plan. On 12/28/24, ongoing monitoring was implemented with the Unit Manager or designee to complete weekly audits for six weeks on five residents with BIMS score of 10 and above to ensure residents are free from abuse. These results will be reported to the QAPI committee. Observations of Resident care and staff to resident interaction on 01/07/25 and 01/08/25 throughout the survey revealed residents were treated with dignity and respect. Interviews on 01/07/25 and 01/08/25 with Register Nurses (RN) #110 and #156, Licensed Practical Nurse (LPN) #150 Certified Nursing Assistants (CNA's) #112, #131, #153, #162 and #173 and Laundry Aide #200 were able to identify types of abuse and procedures for escalating behaviors and abuse allegations. They reported they received training on abuse policies and procedures, and reporting allegations of abuse. On 01/08/25, two (#71 and #75) additional residents were sampled and reviewed for abuse. No concerns were identified. On 01/08/25, review of the facilities self-reported incidents revealed there were no further concerns identified regarding abuse. Interviews on 01/07/25 and 01/08/25 with Residents (#23, #33, #48, #71 and #75), revealed no concerns related to abuse. Residents reported feeling safe at the facility. This violation represents non-compliance investigated under Master Complaint Number OH00161152 and OH00160931.

Based on medical record review, staff and family interview, review of the hospital documentation, and policy review, the facility failed to ensure care was provided to prevent an avoidable fall with injury and was thoroughly investigated to determine the root cause analysis to identify potential hazards to reduce and/or eliminate falls with major injury. This resulted in Actual Harm when State tested Nursing Assistant (STNA) #245 rolled Resident #70 away from her during care and the resident held onto the nightstand next to the bed. Subsequently, the night stand moved and Resident #70 shifted, fell on to the floor, and had complaints of hip and back pain. Resident #70 was sent to the hospital four days later after having continued pain with a left femoral neck fracture and a Thoracic (T)12 compression fracture which required surgical intervention. This affected one (#70) out of three residents reviewed for falls. The facility census was 65. Findings include: Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] and discharged on [DATE]. Diagnoses included muscle wasting and atrophy, hemiplegia and hemiparesis following cerebrovascular disease, muscle weakness, fracture of part of the neck of the left femur, fracture of the thoracic (T)11 and T12 vertebra, fracture of the lower end of the left femur, cerebral infarction, and wedge compression fracture of the thoracic vertebra. Review of the minimum data set (MDS) assessment dated [DATE], prior to the fall with injury, revealed Resident #70 had moderate impaired cognition, required two-person extensive assistance for bed mobility and transfers. The resident required one-person extensive assistance for personal hygiene, toilet use, and dressing. Review of the plan of care dated 08/23/22 revealed Resident #70 had a plan in place for falls due to deconditioning and gait/balance problems. Interventions included grab bars to both sides of the bed, updated 11/22/22, educate resident to be careful when assisting with activities of daily living, anticipate and meet the resident needs, follow the facility protocol, evaluate, and treat the resident needs. A plan dated 09/14/22 revealed Resident #70 was totally dependent on one staff for repositioning and turning in bed, set up assistance for personal hygiene, and totally dependent on one staff for dressing. Review of the physician orders dated from November 2022 through discharge date [DATE] revealed Resident #70 had a low air loss mattress and there were no orders documented for assist/grab bars for both sides of the bed. Review of the fall documentation dated 11/22/22 revealed State tested Nursing Assistant (STNA) stated Resident #70 was turned onto the right side as she was changing the bed sheets on the other side, the resident stated she was going to fall and the STNA helped the resident to the floor as she started to fall slowly out of the bed. Licensed Practical Nurse (LPN) #219 was at the nurse's station at the time of the incident. A head-to-toe assessment was initiated, and no bruising, bleeding, or abrasions were noted at the time. Only a small superficial tear to the right knee was noted. Resident #70 rated pain a 10 out of 10 with 10 being the worst pain and Tylenol was due again in one hour. Resident #70 had vital signs assessed, the physician and the resident representative were notified and were to monitor the resident. The Interdisciplinary team (IDT) met regarding Resident #70's fall with injury. The root cause analysis was completed showing compliance with care. An intervention of bilateral side rails during patient care was implemented. Intervention in place would prevent the resident from pushing off furniture and allowing resident to participate in positioning with care. Resident #70 was a part of the intervention decision. Review of the pain evaluation dated 11/22/22 at 1:30 P.M. revealed Resident #70 complained of pain rated at a 10 to the right hip and the right knee. Review of the hospital documentation dated 11/26/22 revealed Resident #70 presented to the emergency room (ER) from the nursing facility with complaint of hip and back pain after a fall in the facility two days ago. Resident #70 reported limited short-term memory and does not recall the initial time of the injury. The nursing facility reported radiological exams obtained at their facility due to complaints of pain with findings of a left femoral neck fracture and a T12 compression fracture. Imaging has been completed at the hospital with confirmation of an impacted left femoral neck fracture on the computerized tomography (CT) scan of the left hip and a T12 wedging and compression fracture as well as a small retro pulsed fragment into the spinal canal superiorly at T12 but without canal stenosis or evidence of cord compression visualized on the thoracic spine CT. Interview on 01/30/23 at 2:43 P.M. with STNA #245 verified she was familiar with Resident #70 and had regularly provided care for the resident. STNA #245 verified she had provided care for the resident the date she had a fall with injury. STNA #245 reported she was the only aide in the room and was providing incontinence care to Resident #70. STNA #245 stated the resident was rolled to the right side with the left leg hanging over the right leg. The nightstand was against the bed and Resident #70 used her hands on the nightstand to support herself. STNA #245 stated the resident appeared stable and not at risk of falling. The aide left the side of the bed to bag the brief and believes the resident then shifted applying pressure to the nightstand causing it to move and Resident #70 fell out of the bed. STNA #245 stated she was in the room when it occurred but could not reach the resident in time. STNA #245 called for help and an additional aide and nurse came to assist and they used a mechanical lift to transfer Resident #70 from the floor back to the bed. Telephone interview on 01/31/23 at 9:18 A.M. with Resident #70's family representative revealed she believed the facility dropped the resident in November 2022 although the facility reported to her, Resident #70 had inched out of the bed on her own. During an interview on 02/14/23 at 10:37 A.M. with the Director of Nursing (DON) she stated STNA #245 was not doing anything improper during care for Resident #70 at the time of her fall. The DON stated no corrective action was taken and education was provided to STNA #245. The DON stated she had STNA #245 show her in the resident's room after the resident went to hospital what happened during the fall. Follow up interview on 02/14/23 at 11:12 A.M. with the DON, after requesting the root cause analysis, she stated she had not kept her root cause analysis; therefore, it could not be provided. Follow up interview on 02/14/23 at 11:16 A.M. with STNA #245 revealed Resident #70's bed was mid-way in the air up to her waist and she had an air mattress. She rolled the resident away from her and onto her right side with her left leg over her right. STNA #245 said the nightstand slowed her fall; however, the resident was heavy set, so the resident hit the ground with some force. STNA #245 said Resident #70 had used the nightstand before to hold onto and the resident did not have a side rail on the right side at the time of the incident. STNA #245 said the trash bag was on the end of the bed and she just turned to place the linens in the bag when the fall occurred. After the nurse came in and assessed the resident she had complained of pain in her hip and back. During a follow up interview on 02/14/23 at 1:55 P.M. the DON said the Quality Assurance and Performance Improvement (QAPI) will discuss falls/falls with injury in the February QAPI. The DON stated she used her incident logs as auditing tools for falls. She verified nursing should turn residents towards them, not away from them while providing care. The DON stated she verbally educated STNA #245 after the fall and was unable to produce any written education for the staff regarding falls. No specific information related to Resident #70's fall after it had been requested was provided. Review of the policy titled Fall Risk Assessment, undated revealed it is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This deficiency represents noncompliance in Complaint Number OH00139660.

Based on medical record review, observation, staff interview, resident interview, and review of information from the National Pressure Injury Advisory Panel (NPIAP) the facility failed to timely implement interventions and treatments to prevent and promote pressure ulcer healing. This resulted in Actual Harm when Resident #283 was admitted to the facility with an open area observed to the left and right buttock, assessed as a partial thickness wound, and preventative treatment was not initiated as ordered. The wound declined and was assessed as an unstageable pressure ulcer five days later and developed a new deep tissue injury to the right heel. In addition, the facility failed to give nutritional supplements to aid in wound healing as ordered for Resident #37 and Resident #49 and had not provided ordered pressure ulcer treatments for Resident #49. This affected three residents (#283, #37, and #49) of three residents reviewed for pressure ulcers. The facility identified six residents in the facility with pressure ulcers. The facility census was 83. Findings include: Review of the medical record for Resident #283 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nursing assessment for skin dated 10/02/21 revealed the Resident #238 had a right buttock partial thickness wound which measured 4.2 centimeter (cm) by 3.8 cm by less than 0.1 cm. The left buttock had a partial thickness wound which measured 2.4 cm by 1.4 cm by less than 0.1 cm. Review of the immediate needs care plan dated 10/02/21 revealed Resident #283 had nutritional problem or potential nutritional problem related to [CONDITION(S)], Urinary Tract Infection ([CONDITION(S)]), urinary retention, anxiety, gastro-[CONDITION(S)] reflux disease, chronic kidney disease, [CONDITION(S)], diarrhea, and major depressive disorder. Interventions included: Administer medications as ordered. The registered dietician would evaluate and make diet change recommendations as needed (PRN). There was no immediate needs care plan related to pressure ulcer care. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 10/06/21 revealed to apply skin prep to bilateral heels every shift and apply a Prafo (an orthotic to reduce pressure) boot to the right foot. An order dated 10/07/21 revealed an alternating low air loss mattress should be placed on the bed. An order dated 10/19/21 was initiated for Prostat (a protein supplement) two times a day to promote healing after the dietician recommendation dated 10/05/21 was brought to the facilities attention through surveyor intervention. Review of the Treatment Administration Record (TAR) dated October 2021 revealed Resident #283 had no documented treatment to the bilateral buttock's wounds on 10/02/21 and 10/03/21 as ordered. Review of the Medication Administration Record (MAR) dated October 2021 revealed Resident #283 had no protein supplements administered or recorded on the MAR. Review of the nutritional risk assessment dated [DATE] revealed Resident #283 had a moderate decrease in food intake over the past three months due to loss of appetite, digestive problems, chewing or swallowing difficulties. Resident #283 had pressure sores stage one and stage two. Recommended Prostat (a protein supplement) 30 milliliters (ml) twice daily to provide increased protein needs related to wound healing. Review of the weekly wound assessment notes dated 10/05/21 by the wound nurse Licensed Practical Nurse (LPN) #449 and the Nurse Practitioner (NP) #530 revealed the bilateral buttocks wound was acquired 10/01/21, unstageable at original and unstageable currently with epithelial tissue, granulation tissue, and slough tissue present. Deep Tissue Injury (DTI) of the surrounding tissue with 80 percent of necrosis and/or slough was in the wound bed. A moderate amount of serosanguinous drainage with no odor, measured 7.2 cm by 21.2 cm by 0.2 cm and no tunneling. The peri-wound DTI was Moisture Associated Skin Damage (MASD) with irregular wound edges. A new treatment order was put in place to cleanse with NS, pat dry, apply calcium alginate (a [MEDICATION(S)] treatment) to the wound bed, cover with foam dressing, change daily and PRN. There was also a new wound to the right posterior heel assessed as a DTI, a scabbed area to the left dorsal foot, and an abrasion to the right great toe. Observations on 10/18/21 at 3:00 P.M. and 10/19/21 at 2:30 P.M. revealed Resident #283 was lying on her back in bed and had the Prafo boots on both feet and the right Prafo boot was on sideways allowing the right heel to rest on the mattress. Interview on 10/18/21 at 3:00 P.M., the Resident #283 revealed she was admitted to the facility with a wound on her coccyx and a wound to one of her heels and she had acquired a couple more pressure sores since she has been here. Resident #283 stated the staff had not helped her off of her bottom and they had not obtained the air mattress until after she was at the facility for a week. Resident #283 stated she had not received any nutritional supplements to aid in wound healing and was unsure if all her dressings were being changed as ordered. Interview on 10/18/21 at 3:15 P.M. with LPN #529 verified Resident #283 the Prafo boot applied to the right foot was on sideways and the right heel was resting on the mattress. The LPN #529 removed the boot and propped the right leg up on a pillow to float the heel. Interview on 10/19/21 at 3:15 P.M. with Registered Nurse (RN) #405 revealed Resident #283 had multiple pressure ulcers, one on her coccyx, one on the right heel, the fifth toe on the left foot, one on the left ischium and had a wound on her right posterior calf. RN #405 verified she had not administered any type of protein supplement to Resident #283. Interview on 10/20/21 at 10:59 A.M. with LPN #449, who was also the wound nurse, revealed Resident #283 was admitted to the facility with a stage two pressure ulcer to the coccyx and sacrum. Interview on 10/21/21 at 2:09 P.M. with the Director of Nursing (DON) verified she was unsure why an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident #283 had no documentation of wound care for the bilateral buttocks on 10/02/21 and 10/03/21. The DON also verified that a baseline care plan was not initiated for Resident #283 for pressure ulcers and the plan was not initiated until 10/06/21 for skin breakdown. Review of the National Pressure Injury Advisory Panel Stages revealed a Stage 2 Pressure Injury was described as: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). An Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. A Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. 2. Review of the medical record for Resident #49 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set assessment dated [DATE] revealed the resident had no cognitive issues, abnormal behaviors or rejection of care. Extensive assistance was required for bed mobility, locomotion, dressing, toileting and personal hygiene and the resident was totally dependent for transfers, walking and bathing. the assessment further revealed the resident was frequently incontinent of both bowel and bladder. There was no terminal prognosis or issues with chewing, but the resident was on a mechanically altered and therapeutic diet. An in house acquired stage II pressure ulcer was present and three venous ulcers which were present on admission. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It further revealed the left lateral and left medial foot were to have skin prep applied each shift. The left lateral heel and ankle wounds were to be cleansed with 0.125 percent Dakins, patted dry and have silver alginate to the wound bed, and covered with a foam dressing. The dressing was to be changed daily and as needed. the coccyx and sacral wound was to he cleansed with 0.9 Normal Saline and patted dry, with house barrier cream, covered with a foam dressing and changed three times weekly and as needed. The orders further revealed the resident was admitted to Hospice on 09/30/21. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nutritional risk assessment dated [DATE] revealed the dietician recommended Glucerna eight ounces by mouth three times daily to supplement intake related to wound healing. Review of Treatment Administration Records dated 09/2021 revealed the left ankle treatment to cleanse with 0.9 Normal Saline, pat dry, apply [MEDICATION(S)] 0.1 percent to wound bed, apply silver alginate, cover with ABD and secure with Kling wrap was not documented on 09/15/21 and 09/29/21. The left lateral third toe treatment to cleanse with 0.9 Normal Saline, pat dry, apply small pieces of silver alginate to the wound bed between the third and fourth toes, covered with gauze was not provided on 09/15/21 and 09/29/21. Review of Treatment Administration Records dated 10/2021 revealed the left lateral third toe was area was to be cleansed with 0.9 Normal Saline, patted dry, apply silver alginate to the wound bed between the third and fourth toes, cover with gauze and kling wrap was not documented on 10/05/21. [MEDICATION(S)] Plus cream 2.5 percent-10 percent was to be applied to legs topically twice daily. This was not documented on 10/01/21, 10/03/21, 10/04/21 and 10/05/21. The left lateral and left medial foot were to have skin prep applied every shift. This was not documented on 10/14/21. Review of the Medication Administration Record dated 10/2021 revealed the Glucerna supplement was marked as not available at 6:00 A.M. on 10/06/21, 10/07/21, 10/13/21 and 10/14/21 at 6:00 A.M., at 2:00 P.M. on 10/03/21 nor 10:00 P.M. on 10/05/21, 10/12/21, 10/13/21, 10/14/21 and 10/17/21. Observation of Resident #49 on 10/21/21 at 9:00 A.M. revealed the resident's left foot was covered with Kerlix wrap, which was removed by Registered Nurse #514. The old dressing to the left ankle was removed and had a large amount of serosanguinous (watery, with blood in it) drainage. The treatment was provided as ordered and the dressing was replaced, but not covered with a wrap. The dressing to the coccyx area was removed and showed a healed area where the one open area had been. RN #514 applied house barrier cream to the area and covered it with a protective foam dressing. Interview on 10/19/21 at 9:30 A.M., Resident #49 revealed the staff had not always changed her dressing on her bottom and she had not received her Glucerna like she should. Interview on 10/20/21 at 5:00 P.M., Unit Manager #468 revealed the family did bring in most of the Glucerna and they did not always have it. Interview with Licensed Practical Nurse (LPN) #401 on 10/20/21 at 5:40 P.M. revealed the family did supply the Glucerna but she could also obtain it from the kitchen. She stated the resident usually got it on her shift, but she had seen there were times of the other shifts the resident had not received the supplement. Interview with Licensed Practical Nurse #449 on 10/21/21 at 9:35 A.M. verified the left foot was not to be wrapped with kerlix at this time and should not have had the kerlix on it when they walked into the room. Interview with Director of Nursing (DON) on 10/20/21 at 1:30 P.M. revealed the Glucerna was not always available. She stated the resident's family brought it in and they sometimes had issues getting it. A follow-up interview with the DON on 10/25/21 at 10:30 A.M. verified there was no documentation on the dressings that were not documented on the Treatment Administration Record nor of the Glucerna being provided. 3. Review of the medical record for Resident #37 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a five-day Minimum Data Set 2.0 assessment dated [DATE] revealed the resident had no cognitive deficits. It further revealed the resident required extensive assistance with bed mobility, locomotion, dressing, toileting, personal hygiene and was totally dependent with transfers and bathing. An indwelling catheter was present as was a stage IV pressure ulcer (deep, open area that extends to the muscle and bone) and four unstageable ulcers. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Braden skin risk assessment dated [DATE] revealed the resident was at risk for skin breakdown. Review of a skin observation tool dated 10/14/21 revealed the resident had a stage II ( partial skin thickness ulcer) pressure ulcer to the coccyx. Review of Medication Administration Records dated 09/2021 revealed the resident had not received the magic cup at 9:00 A.M. on 09/09/21, 09/10/21 or 09/13/21, or at 9:00 P.M. on 09/08/20, 09/20/20. Review of the MAR dated 10/2021 revealed the resident additionally had not received the magic cup on 10/05/21, 10/08/21, 10/14/21, 10/18/21. Review of a Dietary Communication form dated 08/12/21 revealed the resident was to receive the supplement Boost supplement between meals. No further forms were available for review. Review of a nutritional note dated 08/13/21 revealed the dietician recommended magic cups twice daily to supplement protein and calorie intake. Review of Nutritional status update dated 10/14/21 revealed the resident received magic cups twice daily to supplement his intake. Review of progress notes dated 09/09/21 revealed the magic cup was not available. Dietary was notified of the need for it to be ordered. Review of progress notes dated 09/10/21 revealed the magic cup was not in the nourishment refrigerator. Dietary was notified of the need to have it stocked in the nourishment refrigerator. Interview with Licensed Practical Nurse (LPN) #401 on 10/19/21 at 10:50 A.M. revealed the resident did not get his magic cup that day but she did mark it as given on the MAR. She stated she did not know how often the resident actually received the supplement because she thought it came on the meal tray. Interview with Dietary Aide #430 and Cook #501 on 10/19/21 between 10:55 A.M. and 11:00 A.M. revealed the magic cup was not listed on the meal ticket for Resident #37 so they had not been providing it. Interview with Director of Dietary #415 on 10/19/21 at 11:00 A.M. revealed he was not aware of the order for a magic cup for Resident #37 so it had not been provided. Interview with Resident #37 on 10/19/21 at 10:50 A.M. revealed he had not received his magic cup supplement today. He further added he was lucky if he received it once a week, and that was only if he begged for it. Observation of the breakfast tray on 10/19/21 at 9:00 A.M. revealed no magic cup was provided on the meal tray. Review of facility policy Snacks (Between Meal and Bedtime), Serving dated 09/2010 revealed the snack was to be provided and documented in the medical record after it was served.

THIS DEFICIENCY REPRESENTS AN EXAMPLE OF PAST NON-COMPLIANCE Based on medical record review, review of inservice reports, review of incident/accident reports, surveyor observation and staff interview, it was determined the facility failed to ensure one resident was transferred properly to prevent an avoidable fracture. This resulted in actual harm for Resident #67 who sustained a fractured right tibia during the improper transfer. This affected one (#67) of two sampled residents reviewed for fractures of a total of two residents in the facility with fractures. The facility census was 84. Findings include: Review of Resident #67's medical record revealed the resident had a most recent admission to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident required extensive assistance with two person physical assistance for transfer. Review of the plan of care for Activities of Daily Living, developed on 01/08/11 and last updated on 08/31/11, noted an intervention for her immobility was to utilize a Hoyer (mechanical) lift and two staff members for transfers. Review of facility documentation entitled "Incident Report" dated 08/13/11 revealed Resident #67 reported that upon return to the facility from a dialysis appointment a state tested nurse aide (STNA) lifted her from the stretcher to her chair. The resident indicated that during the transfer, her foot touched the floor. The report noted the resident had no pain at the time. However, immediate interventions listed on the "Incident Report" included the aide was counseled, an investigation was done, the resident was sent to the emergency department, staff education and the resident's transfer method was re-evaluated. Review of Emergency Medical Technician (EMT) #1's undated written statement revealed she was present at the time of Resident #67's transfer on 08/13/11 that resulted in a right tibia fracture. EMT #1 indicated she and her partner returned Resident #67 from her dialysis appointment. Upon return, the resident did not want them to transfer her from the stretcher to her bed. The resident requested to be put in her wheelchair. EMT #1 noted a male STNA (STNA #1) entered the resident's room and asked them (the EMT's) to take her back out into the hallway so he could transfer her from the stretcher to her wheelchair. EMT #1 stated they asked STNA #1 if he was going to use a Hoyer lift but the STNA said they were not allowed to use the lifts in the hallway. The EMT's then offered their assistance with the transfer; however, STNA #1 refused help and positioned the resident on the side of the stretcher. EMT #1 documented she again offered assistance but STNA #1 declined help. He then asked Resident #67 to give him a "bear hug" and hold on tight and he proceeded to lift her into a standing position and pivoted her towards her wheelchair. Upon doing so, the resident started to yell and scream because her leg was twisted underneath the chair. At that time, another aide came to assist and helped straighten out the resident's leg. EMT #1 indicated Resident #67 had tears running down her face and told the other aide that her leg hurt a lot. EMT #1 documented she immediately reported the incident to the charge nurse then left the building. Review of EMT #2's written incident report from 08/13/11 at approximately 2:30 P.M., when Resident #67 was improperly transferred by STNA #1, revealed the same sequence of events as EMT #1's written statement. Review of x-ray reports from 08/13/11 revealed Resident #67 sustained a fracture to the right fibula. An additional x-ray obtained on 09/06/11 also indicated the resident had a right tibia fracture. During interview with the Director of Nursing (DON) on 10/04/11 at 10:00 A.M. verified STNA #1 improperly transferred Resident #67 which resulted in the resident receiving a fractured right tibia. The DON indicated STNA #1 was terminated and all staff was inserviced by 08/18/11 regarding proper transfer techniques, including Hoyer lift transfers. The inservice instructed staff to check each resident's care card for the appropriate transfer method prior to transfers. In addition, staff are to check with the nurse or contact therapy to evaluate the resident if at any time there is a concern with the mode of transfer. On 10/04/11 at 3:15 P.M., Resident #67 was observed being transferred from her wheelchair to the bed. Two staff members were present for the transfer and utilized the Hoyer lift appropriately. There were no concerns identified with the transfer. Review of the facility's incident and accident logs from 08/13/11 through 10/04/11 revealed there have been no further incidents involving improper resident transfers that resulted in injury. "This deficiency substantiated Complaint Number OH 459."