Every finding on record at Dublin Post Acute

Based on record review and staff interview, the facility failed to ensure Resident #86 was discharged appropriately. This affected one resident (Resident #86) of three residents reviewed for discharge. The census was 76. Findings include:Closed medical record review of Resident #86 revealed an admission date of 12/01/24 and diagnoses of unspecified sequelae of cerebral infarction, type two diabetes mellitus with hyperglycemia and epilepsy. Resident #86 was discharged on 07/22/26 to a hotel and was later transferred to the hospital. As of 07/30/26, Resident #86 remained at the hospital. Review of the care plan dated 06/14/25 revealed Resident's #86 plan was to discharge into the community once an appropriate setting had been found for him.Review of the progress notes from social service dated 05/26/26 revealed there continued to be no community discharge recommendation for Resident #86.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/04/26, revealed Resident #86 had a Brief Interview for Mental Status (BIMS) of 14 indicating intact cognition. The resident had functional limitation in range of motion on one side of body for upper and lower extremity. The resident utilized a wheelchair for a mobility device. The resident required a setup or clean-up assist with eating, oral hygiene, upper body dressing, personal hygiene, The resident required supervision or touching assist with toileting hygiene, showering, lower body dressing, putting on/taking off footwear, sit to stand, chair/bed-to-chair transfer, lying to sitting on side of bed, walking 10 feet and toilet transfers.Review of Resident #86's Medicaid Inpatient Notice of Days Approved, revealed on 07/05/26 the facility was notified the resident's insurance coverage was approved through 07/21/26. The resident did not meet criteria for long term care of skilled stay. The resident and facility would need to work on discharge plan and estimated discharge for next review. The resident had an income and is appropriate for a lower level of care.Review of progress notes from social services dated 07/07/26 revealed there was no update regarding safe discharge plan due to lack of family support and resident unwilling to pursue potential sources of income.Review of the Discharge summary dated [DATE] revealed Resident #86 was discharged to the community with his medications and upcoming appointment instructions. Review of the resident's upcoming appointments, only included a follow up eye appointment on 08/10/26. Resident #86 was educated on medication management and verbalized understanding. The discharge summary identified the resident required wound care and assistance with wheelchair transfers. The discharge summary did not include services in place to assist the resident with transfers, what type of wound care was needed, or if he could independently arrange transportation to appointments throughout the community.Interview on 07/28/26 at 11:22 A.M. with Administrator revealed the facility arranged for Resident #86 to be discharged to a handicapped hotel room and they paid bill from 07/22/26 through 07/31/26. Administrator paid transportation cost to hotel and provided the resident with a $100 gift card. Resident #86 received a check from his resident account in the amount of $4,881.27. Administrator denied the resident needing any assistance upon discharge and identified the resident to be independent with activities of daily living.Interview on 07/28/26 at 1:38 P.M. with Social Services Director (SSD) revealed she was off work when Resident #86 was discharged . SSD visited Resident #86 two to three times at the hotel he was discharged to as she had been working with Resident #86 to assist in group home placement. SSD revealed group home placement would assist the resident in transitioning into the community and the group home could provide oversight with medication and support services. SSD revealed the facility was waiting to hear back if the resident would be accepted into the group home. SSD revealed the resident qualified for PASSPORT services (services and supports to stay in their homes or other community settings, rather than enter nursing homes), but it was not set up at the time of discharge.Interview on 07/28/26 at 2:24 P.M. with Director of Nursing (DON) confirmed a physician order was not obtained prior to discharge of Resident #86. DON revealed they completed Resident #86's Discharge Summary and confirmed the summary was not fully completed and did not include resident signature.Interview on 07/30/26 at 8:57 A.M. with Administrator revealed the Ombudsman was not involved in Resident #86's discharge process.Interview on 07/30/26 at 10:00 A.M. with SSD revealed on 07/28/26 while visiting Resident #86 at the hotel he was discharged to, the resident fell while transferring self from the bed to wheelchair. Local emergency services were contacted and transferred Resident #86 to local hospital for evaluation. As of 07/30/26, Resident #86 was still at the hospital.A policy was requested related to resident discharges, and the facility did not have one to provide. This deficiency represents non-compliance investigated under Complaint Number 3117287.

Based on record review and staff interview the facility failed ensure Resident #86 was provided with timely notice of discharge and a discharge summary including all necessary components to assist in continuity of care. This affected one resident (# 86) of three residents reviewed for discharges. The census was 76.Findings include:Closed medical record review of Resident #86 revealed an admission date of 12/01/24 and diagnoses of unspecified sequelae of cerebral infarction, type two diabetes mellitus with hyperglycemia and epilepsy. Resident #86 was discharged on 07/22/26 to a hotel and was later transferred to the hospital. As of 07/30/26, Resident #86 remained at the hospital. Review of the care plan dated 06/14/25 revealed Resident's #86 plan was to discharge into the community once an appropriate setting had been found for him.Review of the progress notes from social service dated 05/26/26 revealed there continued to be no community discharge recommendation for Resident #86.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/04/26, revealed Resident #86 had a Brief Interview for Mental Status (BIMS) of 14 indicating intact cognition. The resident had functional limitation in range of motion on one side of body for upper and lower extremity. The resident utilized a wheelchair for a mobility device. The resident required a setup or clean-up assist with eating, oral hygiene, upper body dressing, personal hygiene, The resident required supervision or touching assist with toileting hygiene, showering, lower body dressing, putting on/taking off footwear, sit to stand, chair/bed-to-chair transfer, lying to sitting on side of bed, walking 10 feet and toilet transfers.Review of Resident #86's Medicaid Inpatient Notice of Days Approved, revealed on 07/05/26 the facility was notified the resident's insurance coverage was approved through 07/21/26. The resident did not meet criteria for long term care of skilled stay. The resident and facility would need to work on discharge plan and estimated discharge for next review. The resident had an income and is appropriate for a lower level of care.Review of progress notes from social services dated 07/07/26 revealed there was no update regarding safe discharge plan due to lack of family support and resident unwilling to pursue potential sources of income.Review of Resident #86's medical record revealed it was absent of a physician's discharge order with services needed upon discharge and was absent of a 30 day notice of discharge.Review of the Discharge summary dated [DATE] revealed Resident #86 was discharged to the community with his medications and upcoming appointment instructions. Review of the resident's upcoming appointments, only included a follow up eye appointment on 08/10/26. Resident #86 was educated on medication management and verbalized understanding. The discharge summary identified the resident required wound care and assistance with wheelchair transfers. The discharge summary did not include services in place to assist the resident with transfers, what type of wound care was needed, or if he could independently arrange transportation to appointments throughout the community.Interview on 07/28/26 at 11:22 A.M. with the Administrator confirmed Resident #86 was not issued a 30 day discharge notice. Resident #86 was informed insurance coverage was ending 07/21/26 and he was provided payment options including private pay or group home placement. Resident #86 refused to utilize funds to pay for his care at the facility due to concern he may become homeless and would need money for future housing or living expenses. Administrator revealed Resident #86 declined all options and said he would leave the facility, therefore they arranged for a hotel discharge. Administrator revealed the facility arranged for Resident #86 to be discharged to a handicapped hotel room and they paid bill from 07/22/26 through 07/31/26. Administrator paid transportation cost to hotel and provided the resident with a $100 gift card. Resident #86 received a check from his resident account in the amount of $4,881.27.Interview on 07/28/26 at 1:38 P.M. with Social Services Director (SSD) revealed she was off work when Resident #86 was discharged . SSD visited Resident #86 two to three times at the hotel he was discharged to as she had been working with Resident #86 to assist in group home placement. SSD revealed group home placement would assist the resident in transitioning into the community and the group home could provide oversight with medication and support services. SSD revealed the facility was waiting to hear back if the resident would be accepted into the group home. SSD revealed the resident qualified for PASSPORT services (services and supports to stay in their homes or other community settings, rather than enter nursing homes), but it was not set up at the time of discharge.Interview on 07/28/26 at 2:24 P.M. with Director of Nursing (DON) confirmed a physician order was not obtained prior to Resident #86's discharge. DON revealed they completed Resident #86's Discharge Summary and confirmed the summary was not fully completed and did not include resident signature.Interview on 07/30/26 at 8:57 A.M. with Administrator revealed the Ombudsman was not involved in Resident #86's discharge process.Interview on 07/30/26 at 10:00 A.M. with SSD revealed on 07/28/26 while visiting Resident #86 at the hotel he was discharged to, the resident fell while transferring self from the bed to wheelchair. Local emergency services were contacted and transferred Resident #86 to local hospital for evaluation. As of 07/30/26, Resident #86 remained at the hospital.A policy was requested related to resident discharges, and the facility did not have one to provide. This deficiency represents non-compliance investigated under Complaint Number 3117287.

Based on medical record review, staff, resident and family interviews, and policy review, the facility failed to ensure scheduled personal hygiene care was consistently provided. This affected two (Resident #32 and #45) out of three dependent residents reviewed for activities of daily living. The facility census was 69.Findings Included:1.Review of the medical record for Resident #32, revealed an admission date of 01/24/26 with re-entry on 03/01/26. Diagnoses included metabolic encephalopathy, unspecified asthma, aftercare following joint replacement surgery, and difficulty in walking not elsewhere classified.Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 11 indicating moderate cognitive impairment. The assessment indicated the resident required maximal assistance with showering and extensive assistance with other activities of daily living.Review of nursing documentation from 01/24/26 through 02/26/26 revealed Resident #32 had not received any showers during the first week of admission [DATE] - 01/31/26). Subsequent documentation indicated showers were provided on 02/06/26, 02/12/26, 02/19/26, and 02/22/26. All other scheduled showers were either missed or documented as No without notation of refusal, including 02/02/26, 02/08/26, 02/15/26, and 02/20/26. No follow-up interventions, attempts to reschedule, or communication with the family were documented for missed showers.Interview on 03/02/26 at 2:20 P.M., with the Resident #32's spouse revealed the resident had received two showers since admission to his knowledge. He stated on 01/30/26 at 11:00 A.M., he wrote a note indicating his spouse was supposed to be washed up the day before but the washrag was not used.On 03/02/26 at 3:10 P.M., interview with the Director of Nursing (DON) verified no separate shower logs were maintained for Resident #32 and that documentation was completed only in the task area of the electronic record.On 03/03/26 at 8:59 A.M., interview with the Licensed Practical Nurse (LPN) #213 verified Resident #32 was scheduled for showers on Monday and Thursday day shift. The LPN #213 reviewed the task documentation and verified the only documented showers were on 02/06/26, 02/12/26, 02/19/26, and 02/22/26. The LPN #213 verified no refusals were documented for the missed shower dates.2. Review of the medical record for Resident #45 revealed an admission date of 01/27/26. Diagnoses included other cerebral palsy, moderate persistent asthma uncomplicated, moderate protein-calorie malnutrition, and schizoaffective disorder unspecified.Review of the admission MDS assessment dated [DATE] revealed a Brief Interview for Mental Status score of 13 indicating no cognitive impairment. The assessment indicated the Resident #45 required dependent assistance with showering and toilet hygiene and maximal assistance with additional activities of daily living.Review of the shower task documentation revealed the resident was hospitalized from [DATE] through 02/17/26 and those dates were marked as not available. Documentation indicated the only bath provided from date of admission to 03/04/26 was a bed bath on 02/25/26. No refusals were documented in the progress notes.On 03/02/26 at 8:45 A.M., interview with Resident #45 revealed she stated she had not been bathed since admission. She stated her scheduled showers were Tuesday and Saturday on night shift. She stated that she only received a bed bath on 02/25/26.On 03/03/26 at 8:59 A.M., interview with the LPN #213 verified that if a resident refused a bath it should be documented as a refusal and not marked as no. LPN #213 verified the only documented bathing for Resident #45 was a bed bath on 02/25/26.Review of the facility policy titled Activities of Daily Living (ADL), Supporting, revised March 2018, revealed residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. The policy further stated residents who were unable to carry out ADLs independently would receive services necessary to maintain grooming and personal hygiene. The policy indicated appropriate care and services would be provided in accordance with the plan of care, including hygiene such as bathing, dressing, grooming, and oral care. The policy also stated a resident's ability to perform ADLs would be measured using clinical tools including the Minimum Data Set (MDS), and interventions would be monitored, evaluated, and revised as appropriate.This deficiency represents non-compliance investigated under Complaint Number 2736536 and 2790910

Based on medical record review, review of the hospital after visit summary, and staff interview, the failed to transcribe and implement hospital discharge orders. This affected one (Resident #21) of three residents reviewed. The facility census was 69.Findings include:Review of the medical record revealed Resident #21 was admitted on [DATE]. Diagnoses included necrotizing fasciitis, acute and chronic respiratory failure, type 2 diabetes, and obstructive and reflux uropathy. Resident #21 was discharged to the hospital on [DATE] and returned 02/27/26.Review of the hospital discharge after visit summary (AVS) for Resident #21 revealed an order dated 02/27/26 for Ciprofloxacin (an antibiotic) 500 milligrams (mg) every 12 hours for 13 doses and an order for vancomycin (an antibiotic) 125 mg four times a day for nine days. Additionally, the AVS revealed an order dated 02/27/26 to discontinue enoxaparin (an anticoagulant) 40 mg per 0.4 milliliters (ml) and hold Metformin (diabetes) 500 mg until 03/02/26.Review of the Medication Administration Record (MAR) for Resident #21 dated February 2026 revealed Ciprofloxacin and vancomycin were not administered. Further review of the MAR dated March 2026 revealed Ciprofloxacin and vancomycin were not administered. Additionally, review of the MAR dated March 2026 revealed enoxaparin was administered once on 03/01/26, 03/02/26, and 03/03/26. Further review revealed Metformin was administered twice on 03/01/26.Interview on 03/03/26 at 2:45 P.M. with Registered Nurse (RN) #178 verified Resident #21 was not taking prescribed antibiotics.Interview on 03/04/26 at 9:37 A.M. with the Director of Nursing (DON) verified Resident #21's orders were not transcribed upon his readmission to the facility on [DATE]. The DON further verified the discharge orders should have been implemented upon Resident #21's return.This deficiency represents non-compliance investigated under Complaint Number 2736536.

Based on medical record review, review of the hospital discharge summary, review of the self-reported incident (SRI), review of investigative documentation, review of documentation from the contracted company, review of the incident/accident log, and staff interview, the facility failed to ensure adequate supervision and monitoring following intravenous (IV) insertion by a contracted provider. This affected one (Resident #70) out of three residents reviewed for accidents. The facility census was 69.Findings include: Review of the medical record for Resident #70 revealed an admission date of 01/21/26 and a discharge date of 02/01/26. Diagnoses included syncope and collapse, muscle weakness generalized, cognitive communication deficit, expressive language disorder.Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had a Brief Interview for Mental Status score of 12, indicating she was cognitively intact. The assessment indicated the resident required maximal assistance with most activities of daily living and did not receive parenteral or intravenous feeding at that time.Review of the hospital Discharge summary dated [DATE] from OhioHealth revealed the plan included discontinuation of intravenous fluids and encouragement of oral intake. Nursing documentation dated 01/21/26 at 8:05 P.M. indicated a provider order for laboratory testing including complete blood count (CBC) and basic metabolic panel (BMP) due to dehydration concerns.On 01/24/26 at 1:04 P.M., documentation provided by Contract Company #01 indicated intravenous (IV) line placement was completed and signed off at 1:04 P.M. Review of the medical record revealed no documented nursing assessment immediately following the IV line placement to verify removal of the tourniquet or to evaluate the intravenous site.On 01/24/26 at 4:11 P.M., a late entry nursing note documented the resident's Power of Attorney (POA) expressed concern regarding hydration status and requested intravenous fluids. The Director of Nursing (DON) obtained an order for as needed fluids. Documentation indicated the intravenous team was contacted and an intravenous line was placed. The note indicated that the tourniquet was not removed prior to administering intravenous fluid. During a routine assessment, another nurse observed that the tourniquet remained in place on the resident's upper arm. The tourniquet was removed, the provider and family were notified, and a new order for as needed subcutaneous fluids were obtained.On 01/24/26 at 8:00 P.M., a nursing note documented that a peripheral intravenous line was placed in the left arm and intravenous fluids consisting of five percent dextrose in water at 100 milliliters per hour were initiated. The nurse documented that Resident #70's daughter requested assessment of the left arm. The arm was noted as swollen, and a tourniquet was observed on the upper arm. The tourniquet was removed, the arm was elevated, and a cold compress was applied. The daughter declined discontinuation of intravenous fluids at that time.Review of the facility's Self-Reported Incident (SRI) number 270405 related to the event indicated the tourniquet was left in place following intravenous placement. The Self-Reported Incident had not specified the exact time the intravenous line was placed, the time the swelling was identified, or the duration the tourniquet remained in place. The SRI noted the nurse removed the tourniquet once aware of the concern.Review of the facility's investigation revealed conflicting statements regarding the duration the tourniquet remained in place. On 03/02/26 at 12:49 P.M., interview with Registered Nurse (RN) #178 revealed that when the outside companies placed intravenous lines, it was expected that staff assessed the site after placement. He stated there was no defined expectation that the nurse must immediately enter the room after vendor completion.On 03/04/26 at 9:02 A.M., interview with the Administrator revealed that during the investigation for Resident #70's tourniquet being left on, she initially thought it was the floor nurse, RN #238, who left the tourniquet on, which was why the nurse was suspended and education was provided to the nurse. She stated that they later found out it was an outside company, Contract Company #01, but they had not confirmed which company provided the care until 03/03/26. She stated no education or information was provided to Contract Company #01 to prevent the same situation from happening again. The Administrator verified the facility could not determine the exact timeframe the tourniquet remained on Resident #70's arm and stated they had no sign off documentation indicating when post placement assessment occurred until surveyor intervention on 3/3/26. The Administrator stated that based on documentation review, it was believed the tourniquet was identified within approximately a two hour window, however, this timeframe could not be verified.On 03/04/26 at 9:26 A.M., interview with RN #238 revealed that Contract Company #01 arrived in the late afternoon on 01/24/26 to place the intravenous line. He stated he contacted Contract Company #01 to complete the intravenous placement and received verbal handoff upon completion of the procedure. He reported that after receiving report, he entered the resident's room and initially observed a tourniquet still in place on the resident's arm, which he removed. He stated that shortly thereafter, the resident's daughter alerted him to continued concerns regarding the resident's arm. Upon reentering the room, he observed a second tourniquet remaining on the resident's upper arm, which he then removed. He stated the resident's arm was slightly swollen and he did not observe discoloration. He applied a cold compress to reduce the swelling. He further stated that he had not immediately notify management of the swelling and that management was not aware of the condition of the resident's arm until his next scheduled shift on Tuesday, 01/27/26. He stated he passed the information to the oncoming night shift nurse but acknowledged that no supervisory staff were notified at the time of discovery. He reported that an in-service education was later conducted regarding the situation.Review of the facility documentation revealed no documented evidence of immediate post-procedure assessment following intravenous placement by Contract Company #01. The facility provided documentation of an agreement with Contract Company #01. The facility acknowledged responsibility for the care provided but was unable to produce documentation verifying timely monitoring of the resident after intravenous placement.Review of the incident/accident log verified the event was listed on 01/24/26 and investigated. Documentation indicated the floor nurse was initially suspended during the investigation due to uncertainty regarding responsibility for leaving the tourniquet in place.This deficiency represents non-compliance investigated under Complaint Number 2736536.

Based on medical record review and staff interview, the facility failed to ensure laboratory orders and wound cultures were completed timely. This affected one (Resident #71) of three residents reviewed for laboratory tests. The census was 69.Findings include:Review of the medical record for Resident #71 revealed an admission date of [DATE] with diagnoses including a fracture of the right humerus, wedge compression fracture of second lumbar vertebra, multiple fractures of ribs, thrombocytopenia, and hypertension. Resident #71 discharged from the facility on [DATE].Review of the physician orders revealed an order dated [DATE] for a complete blood count (CBC) and basic metabolic panel (BMP). Further review revealed no evidence the blood tests were completed as ordered. Review of the provider progress notes dated [DATE] revealed labs ordered on [DATE] were not completed. Further review of the physician orders revealed an order dated [DATE] for a CBC and BMP. Review of laboratory testing results revealed the labs were completed as ordered on [DATE].Review of the physician orders revealed an order dated [DATE] for a wound culture and sensitivity. Review of laboratory reports revealed a wound culture was collected on [DATE] and reported on [DATE]. The laboratory report indicated the test was not performed due to specimen integrity issues, noting that the facility had submitted an expired swab dated [DATE] and instructed the facility to recollect a new wound culture specimen. Further review of the medical record had no documentation that a repeat wound culture was obtained following the notification that the specimen was invalid. Further review revealed a physician order dated [DATE] for a wound culture and sensitivity. Review of laboratory testing results revealed the culture was collected [DATE].Interview on [DATE] at 1:07 P.M. with the Director of Nursing (DON) verified Resident #71's physician ordered laboratory tests from [DATE] were not completed as ordered. The DON further verified the specimen collection swab used to collect the wound culture on [DATE] was expired and was not recollected until [DATE].This deficiency represents non-compliance investigated under Complaint Number 2736536.

Based on observation, record review, interviews, and policy review, the facility failed to implement a comprehensive and individualized pressure ulcer program to timely identify, treat and/or prevent a decline of pressure ulcers. Actual Harm occurred to one resident (#23), who had been identified at risk for pressure ulcer development and required maximum staff assistance for bed mobility, on 12/10/25 when the facility failed to accurately assess, put a treatment and appropriate interventions in place in a timely manner, and complete treatments as ordered to a pressure ulcer wound to the resident's back that was first identified on 12/08/25 (two days after the resident was admitted to the facility). An outside wound company assessed the area on 12/10/25 and identified the area as a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough) pressure ulcer to the center midline upper back that measured two centimeters (cm) long, two cm wide, and 0.01 cm deep. The daily treatment ordered on 12/10/25 was completed on 12/12/25, 12/15/25, 12/16/25, 12/24/25, 12/26/25, 01/05/26, 01/07/26, and 01/12/26, reflecting only eight of 35 days that the treatment was completed. The outside wound company did not assess the area again until 12/31/25. At that time, the area was identified as an Unstageable (full-thickness tissue loss where the wound bed is obscured by dead tissue such as slough) pressure ulcer to upper spine which measured 2.5 cm long and 1 cm wide. Additionally, the facility failed to ensure low air loss mattresses used for pressure ulcer prevention were being used with the recommended pressure settings for two residents (#8 and #61) which placed the residents at risk for more than potential harm that was not actual harm. This affected three (#8, #23, and #61) of six residents reviewed for pressure ulcers. The facility census was 65. Findings include: 1) Review of the medical record revealed Resident #23 was admitted on [DATE] with diagnoses that included a fracture of the right humerus, wedge compression fracture of second lumbar vertebra, multiple fractures of ribs, thrombocytopenia and hypertension. The after-visit summary from the hospital dated 12/06/25 revealed Resident #23 had a displaced comminuted fracture of right humerus. Resident #23 also had Lumbar Kyphoplasty (minimally invasive procedure to fix spinal compression fractures) wound closed with Dermabond glue. The Admission/re-admission Summary note dated 12/07/25 revealed Resident #23 arrived by ambulance and was transferred to the bed with two-person assistance. A head-to-toe assessment was completed. There were bruises and edema (swelling) on both arms and a sling to the resident's right arm due to a fracture. Edema was noted to both legs and both heels were dry. There were no open areas to the heels. The resident had a Stage II open pressure wound with slough on the right upper thigh that measured five centimeters (cm) long and three cm wide. Review of the Baseline Care Plan dated 12/07/25 revealed there was nothing marked under skin integrity (prior and current concerns). The care plan also revealed Resident #23 required substantial/maximal assistance with sitting to lying and lying to sitting on the side of the bed. The Braden Scale Observation assessment dated [DATE] revealed Resident #23 scored a 16 which indicated the resident was at risk for the development of pressure ulcers. There was no documentation that a pressure ulcer plan of care with interventions was developed or implemented to decrease Resident #23's risk for developing pressure ulcers based on the resident's pressure ulcer risk assessment (Resident #23 was identified as at risk). Review of a physician progress note dated 12/08/25 revealed Resident #23 was seen at the hospital from [DATE] through 12/06/25 for a right humerus fracture. The hospital course was complicated by a lumbar compression fracture to L2. Resident #23 underwent kyphoplasty on 12/03/25. Wound documentation dated 12/08/25 by the facility wound nurse, Registered Nurse (RN) #254, revealed Resident #23 had a surgical wound to the spine that was present upon admission. The wound was measured at 15.9 cm long and 18 cm wide. The wound was to be cleansed with normal saline/generic wound cleanser and covered with foam dressing. Review of the outside Wound Company dated 12/10/25 by Nurse Practitioner (NP) #515 revealed Resident #23 presented with an acute pressure ulceration of the center midline upper back. The initial evaluation revealed Resident #23 had a Stage II pressure ulcer to the center midline upper back that measured two cm long, two cm wide, and 0.01 cm deep. There was a moderate amount of serosanguineous (thin, watery, pink or light red fluid) exudate. The wound was to be cleansed with normal saline, and medical grade honey (antibacterial, anti-inflammatory, and antioxidant properties) and calcium alginate (creates a moist healing environment and absorbs exudate) were to be applied and then covered with clean dry dressing every day and as needed. An addendum revealed the wound location was closer to the left upper back. Wound documentation dated 12/10/25 by RN #254 revealed Resident #23 had a Stage II pressure ulcer/injury to lower back. The wound measured 1.84 cm long and 1.59 cm wide. There was a moderate amount of serosanguineous exudate. Review of the plan of care dated 12/10/25 reveled Resident #23 was at risk for skin breakdown/pressure ulcers related to displaced comminuted fracture of shaft of humerus, right arm, and subsequent encounter for fractures with routine healing. Interventions included to administer medication and treatments as ordered, apply barrier cream as indicated, and encourage the resident to float heels, keep the resident's skin clean and notify the physician and/or responsible party of non-compliance with treatment. Further review of the plan of care revealed there were no interventions related to the resident's Stage II pressure ulcer to the upper back. Review of the Treatment Administration Record (TAR) revealed a treatment for Resident #23's upper mid back to be cleansed with normal saline or a wound cleanser, patted dry, medical grade honey, and calcium alginate applied, and covered with an abdominal (ABD) pad and gauze wrap bandage every day for wound care starting on 12/11/25. The treatment was documented as being completed five (12/12/25, 12/15/25, 12/16/25, 12/24/25, and 12/26/25) out of 21 days. There was no documentation of the treatment being completed as needed. The documentation for turning and repositioning revealed there were 11 shifts between 12/07/25 and 01/01/26 that Resident #23 was not turned and repositioned. Review of the 5-day Medicare Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact. The resident was dependent on another person for toileting, bathing, rolling left to right, sitting to lying, lying to sitting, and sitting to standing. Resident #23 was at risk for pressure ulcers and was admitted with a Stage II pressure ulcer (to the resident's right leg) that was present upon admission and a skin tear. Wound documentation dated 12/17/25 by NP #515, from an outside wound company, revealed an evaluation was only completed of Resident #23's right leg. Wound documentation dated 12/17/25 by RN #254 revealed Resident #23 had a Stage II pressure ulcer to lower back. The area was improving and measured 0.5 cm long and 0.5 cm wide. There was a moderate amount of serosanguineous exudate. Review of the Braden Scale Observation assessment dated [DATE] revealed Resident #23 scored 14 which indicated the resident was at moderate risk for the development of pressure ulcers; however, this pressure ulcer risk assessment was not accurate as the resident already had an identified pressure ulcer at this time. Wound documentation dated 12/24/25 by NP #515, from an outside wound company, revealed an evaluation was only completed of Resident #23's lower right leg. Wound documentation dated 12/24/25 by RN #254 revealed Resident #23 had a Stage II pressure ulcer to lower back that was improving and measured 5 cm long and 1.3 cm wide. The wound bed had 80% granulation (healthy, red, bumpy, new tissue) with a moderate amount of serosanguineous exudate. The Braden Scale Observation assessment dated [DATE] revealed Resident #23 scored a 15 which indicated the resident was at risk for the development of a pressure ulcer. Wound documentation dated 12/31/25 by NP #515, from an outside wound company, revealed Resident #23 had an Unstageable (full-thickness tissue loss where the wound bed is obscured by dead tissue such as slough) pressure ulcer to upper spine that measured 2.5 cm long and 1 cm wide. There was a moderate amount of serosanguinous exudate, and the peri wound was ecchymotic (skin discoloration blue/purple/black/brown/yellow). The wound was being evaluated for the first time, and a treatment plan would be established. Debridement was postponed due to high patient discomfort or pain concerns. The resident had mild transient pain during wound assessment. The resident's pain was addressed with rest period, repositioning, reassurance and distraction. The resident responded well to pain interventions and the assessment was completed. Wound documentation dated 12/31/25 by RN #254 revealed Resident #23 had a Stage II pressure ulcer to lower back that was deteriorating. The area measured 2.5 cm long and 1 cm wide with 100% slough. The TAR for January 2026 revealed Resident #23's upper mid back was to be cleansed with normal saline or a wound cleanser, patted dry, Medi honey, and calcium alginate to be applied, and covered with an abdominal (ABD) pad and a gauze wrap bandage every day for wound care. The treatment was documented as being completed three (01/05/26, 01/07/26, and 01/12/26) out of 14 days. There was no documentation of the treatment being completed as needed. The Braden Scale Observation assessment dated [DATE] revealed Resident #23 scored a 17 which indicated the resident was at risk for the development of pressure ulcers. Wound documentation dated 01/07/26 by NP #515, from an outside wound company, revealed Resident #23 was under hospice care (this is not accurate as the resident was not receiving hospice services). Resident #23 had an Unstageable pressure ulcer to upper spine that measured 3.5 cm long and 2.5 cm wide. There was 70% granulation and 30% slough with moderate serosanguinous exudate. The peri wound was ecchymotic and the wound had declined. The resident had declining medical condition, dementia/confusion, and poorly compliant with offloading that have contributed to the decline of the wound (there was no documentation of the resident being non-compliant with treatment including offloading, and the resident did not have a plan of care in place for non-compliance). An additional wound was evaluated and identified as Wound #3 that was present upon admission. The wound was a Stage III (involves full-thickness skin loss where fat tissue was visible, but bone, tendon, or muscle were not exposed) pressure ulcer to the upper spine. The Stage III pressure ulcer measured 1.5 cm long, 1 cm wide, and 0.1 cm deep. There was 90% granulation and 10% slough and a moderate amount of serosanguinous exudate. This was the initial evaluation of the Stage III pressure ulcer. Resident #23 had poor nutritional intake, dementia/confusion, incontinence, and overall poor medical condition making the presence of the wound unavoidable. A new order was given for the wound to be cleansed with normal saline, covered with calcium alginate and a bordered gauze dressing. The treatment was to be completed daily and as needed. Any medical grade honey may be used. The resident had mild transient pain during wound assessment. The resident's pain was addressed with rest period, repositioning, reassurance and distraction. The resident responded well to pain interventions and the assessment was completed. Wound documentation dated 01/07/26 by RN #254 revealed Resident #23 had an Unstageable pressure ulcer to lower back that was deteriorating. The area measured 16.33 cm long and 2 cm wide. The wound bed had 70% granulation and 30% slough. There was a moderate amount of serosanguineous exudate with an odor after cleansing. A nurse's note dated 01/13/26 at 1:34 P.M. revealed documentation noted to be incorrect, and the wound provider notified for clarification of wound information. The Braden Scale Observation assessment dated [DATE] revealed Resident #23 scored a 16 which indicated the resident was at risk for the development of pressure ulcers. Wound documentation dated 01/14/26 by NP #515, from an outside wound company, revealed Resident #23 had a surgical wound (no longer identified as an unstageable pressure ulcer) to lower spine with full-thickness depth exposure and the wound measured 4 cm long and 2 cm wide. The depth was not able to be determine and the wound bed was covered with 20% granulation and 80% slough. There was a moderate amount of serosanguinous exudate, and the wound bed was ecchymotic. The wound had declined. Debridement was completed using a scalpel and the wound was debrided down to the subcutaneous tissue. Post debridement measurements were 4.2 cm long and 2.6 cm wide and depth was not determined. The wound to the upper spine, identified as Wound #3, was now described as a surgical wound (no longer identified as a Stage III pressure ulcer) that was present upon admission. There was full-thickness depth exposure, and the wound measured 2.5 cm long, 2.0 cm wide, and 0.1 cm deep. The wound bed had 90% granulation and 10% slough with moderate serosanguinous exudate. The wound had declined and the wound was identified as unavoidable. The treatment was to continue as ordered. An observation on 01/12/26 at 11:09 A.M. revealed Resident #23 was lying in bed. The resident did not have an air mattress in place. An interview on 01/15/26 at 10:25 A.M., RN #254 verified she was the facility wound nurse. RN #254 stated that she used a camera to take pictures of the wounds. A sticker was placed on the resident, and the camera measured the wound and the location of the wound. The angle of the camera, the way the resident was lying, or shadows could change the measurements of the wound. RN #254 demonstrated the location of Resident #23's wound was approximately between the lower shoulder blades on the spine area. RN #254 stated the mid back and lower back wounds were the same wound just identified differently. RN #254 verified the TARs for December 2025, and January 2026 revealed the treatments were not completed as ordered. RN #254 also verified Resident #23 did not have an air mattress in place but stated one had been ordered and would be put in place when it arrived. An interview on 01/15/26 at 4:03 P.M. with NP #515 revealed the areas to Resident #23's back were just pinpoint areas when the resident was admitted . The facility wound nurse (RN #254) was assessing those areas. The areas to the resident's back were not improving, and he was asked to look at the areas, and the wounds did not look good. NP #515 stated he did not hear RN #254 tell him the wounds were surgical and was confused when RN #254 told him on 01/14/26 that the areas were surgical. NP #515 stated there was miscommunication and he was going by what RN #254 said. NP #515 verified an air mattress should be put in place for anyone that was fragile and at risk for developing pressure ulcers. NP #515 verified Resident #23 should have had an air mattress put in place. An additional interview on 01/20/26 at 8:15 A.M., RN #254 verified the care plan was not updated to address the pressure ulcer to Resident #23's back. RN #254 stated Resident #23 had surgery to his back, and the area was closed with skin adhesive. RN #254 verified the area to Resident #23's back was not identified until two days (12/08/25) after the resident was admitted and an order for treatment was not put in place until 12/10/25. RN #254 stated she first identified the area to the resident's back as a surgical wound. RN #254 stated there was miscommunication between herself and NP #515 and the wound was changed to a pressure ulcer but was now changed back to a surgical wound. RN #254 verified there were two areas to the resident's back, but the wounds had been treated as one area. RN #254 also verified the treatments to Resident #23's back were not completed daily as ordered. An interview on 01/21/26 at 7:32 A.M., the Director of Nursing verified the Braden Assessments were incorrect, and Resident #23 was at high risk for the development of pressure ulcers. An interview on 01/21/26 at 9:39 A.M., NP #515 stated the areas to Resident #23's back were from incisions and not pressure. NP #515 verified the areas were on the resident's spine (bony prominence) and were not from dehiscence (spontaneous splitting or gaping open from an incision). NP #515 stated the areas were present upon admission and the resident possibly had developed an abscess due to copious amounts of drainage. NP #515 verified there was no documentation of copious amounts of drainage or possible abscesses. NP #515 verified the areas had gotten worse because the resident was very fragile. NP #515 stated the resident was noncompliant with repositioning because the resident yelled out when he was turned on his side. An interview on 01/21/26 at 9:45 A.M., RN #254 verified Resident #23 did not receive hospice services at this time but there had been a discussion with Resident #23's family about hospice services. RN #254 verified there was no documentation of Resident #23 being noncompliant with care. An observation on 01/21/26 at 9:50 A.M. of Resident #23's back revealed an area to the spine area above the waistline and an area to the upper back to the spine area between the shoulder blades. The wounds appeared to be approximately the size of a 50-cent piece and were covered with white/yellow slough. The skin around the wounds was reddened but blanchable. An interview on 01/21/26 at 10:56 A.M., Regional MDS #600 verified the 5-day MDS dated [DATE] identified the Stage II was to Resident #23's back and the skin tear was the wound to the resident's thigh. Regional MDS #600 verified no surgical wounds were identified during the assessment period. 2) Review of the medical record revealed Resident #8 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included neuropathy, sick sinus syndrome, dysphagia, congestive heart failure, urogenital implants, acute kidney failure, and anxiety disorder. Review of Resident #8's TAR revealed on 10/20/25, Resident #8 was to have a pressure reduction mattress every shift. The staff continued to sign the TAR through 01/14/26 verifying a pressure reduction mattress was in place. Review of the December (2025) and January (2026) TAR revealed no documentation of barrier cream being applied after each incontinence episode as needed. The plan of care dated 10/19/25 and revised on 11/01/25 revealed Resident #8 had the potential for skin breakdown/pressure ulcers. Interventions included administer treatments, assistance with turning and repositioning as indicated and tolerated, and skin to be checked during daily skin care. The 5-day MDS dated [DATE] revealed Resident #8 had severe cognitive impairment. The resident was dependent for mobility, bathing, and toileting. The resident required substantial/maximal assistance rolling left to right, sitting to lying, lying to sitting, and sitting to standing. Resident #8 had no skin concerns. Review of the resident's medical record revealed on 12/10/25, Resident #8 weighed 144 pounds. On 01/05/26, Resident #8 weighed 121 pounds. Facility skin issue documentation dated 01/13/26 revealed Resident #8 had a new skin issue. The resident had a Stage II pressure ulcer to the right gluteus that was in-house acquired. The wound measured 0.74 cm long and 0.35 cm wide. There was no exudate noted. The wound was to be cleansed with generic wound cleanser, zinc cream applied, and foam dressing applied. Additional care included incontinence management and mobility aid. An outside wound company note dated 01/14/26 revealed Resident #8 was being seen for an initial consultation for wound care. Resident #8 was seen today for a Stage II pressure ulcer to the right buttock. The pressure ulcer measured one cm long, 0.5 cm wide, and was 0.1 cm deep. There was light serous (clear, thin, watery, pale yellow body fluid) exudate. An order was received for the wound to be cleansed with normal saline and zinc oxide cream to be applied every shift. Facility skin issue documentation dated 01/14/26 revealed Resident #8 had a Stage II pressure ulcer to right gluteus that was in-house acquired. An observation on 01/12/26 at 3:00 P.M. revealed Resident #8 was lying in bed, and the air mattress setting was 170 pounds. An observation on 01/13/26 at 7:51 A.M. revealed Resident #8 was lying in bed, and the air mattress was 170 pounds. On 01/13/26 at 8:02 A.M. Registered Nurse (RN) #232 verified that the air mattress was set to 170 pounds. RN #232 verified he was not aware how much Resident #8 weighed and if the air mattress was at the correct setting. On 01/13/26 at 8:11 A.M. the facility wound nurse, RN #254, verified they were not aware how much Resident #8 weighed and what the setting on the air mattress should be set at. An interview on 01/15/26 at 9:57 A.M. with the Administrator verified there were no orders for Resident #8 to have an air mattress and the Administrator was unable to say how long the air mattress had been in place. An interview on 01/15/26 at 4:03 P.M. NP #515 verified Resident #8 had a new area to the right gluteus/buttock. NP #515 stated an air mattress would provide greater benefits than a regular pressure relieving mattress. NP #515 stated there would not be much of an impact if the air mattress was at the wrong setting for a short period of time; however, a firmer setting for a long period of time, could result in possible pressure areas. An interview on 01/20/26 at 8:47 A.M. with RN #232 verified Resident #8's area to the right gluteus/buttock was not present upon admission but was discovered on 01/13/26 while the resident was being bathed. At the time of this interview, an observation was also made of the wound to Resident #8's gluteus/buttock and revealed the wound was healing. 3) Review of the medical record for Resident #61 revealed an admission date of 11/28/20. Diagnoses included multiple sclerosis, polyneuropathy in diseases classified elsewhere, anxiety disorder, major depressive disorder, insomnia, auditory hallucinations, other specified dorsopathies of the cervical region, chronic pain syndrome, generalized muscle weakness, other muscle spasm, gastroesophageal reflux disease without esophagitis, Vitamin D deficiency, pityriasis versicolor, unspecified exotropia, and weakness. Review of the Quarterly MDS dated [DATE] identified the resident was cognitively intact with a BIMS score of 15, had impairment of both lower extremities, used a wheelchair, was independent with eating and upper body hygiene, and dependent for lower extremity dressing, footwear, and transfers. The resident was at risk for skin breakdown due to generalized muscle weakness, immobility, and maximal dependence on staff for repositioning. Review of physician orders revealed an active skin prevention order for a low air loss mattress, with instructions to check function every shift. There was no order specifying the appropriate weight dial setting for the mattress. Review of progress notes and skin assessments revealed the resident had a history of moisture-associated skin damage (MASD) to the right gluteus, with ongoing care including turning and repositioning, moisture barrier, incontinence management, and nutrition supplementation. Review of care plans revealed no documentation of interventions to ensure the air mattress was set appropriately for the resident's weight to prevent further skin breakdown. Observation on 01/20/26 at 10:27 AM revealed the air mattress was set to 325 pounds, while the resident's documented weight was 172.9 pounds on 01/01/26 at 7:11 P.M. Licensed Practical Nurse (LPN) #224 confirmed at the time of the observation that the dial was too high for the resident's weight and stated the DON instructed staff to raise the dial to make the bed firm enough for the resident. Review of the Wound Care policy (dated October 2010) revealed documentation of the type of wound care given, the date and time of wound care given, the position in which the resident was placed, any change in the resident's condition, all assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound, how the resident tolerated the procedure, and if the resident refused the treatment, should be recorded in the resident's medical record. The supervisor should be notified if the resident refused wound care. This deficiency represents non-compliance investigated under Complaint Numbers 1350537 and 2708970.

Based on observation, resident interview, and staff interview, the facility failed to ensure residents were served food that was palatable and at an appropriate temperature. This had the potential to affect all 65 residents who receive food from the kitchen. The facility census was 65.Findings include:Observation on 01/14/26 at 12:08 P.M. after all resident room trays had been delivered, the test tray temperatures were obtained by the Dietary Manager (DM) #216. The beef macaroni casserole had a temperature of 131 Fahrenheit (F) and the mixed capri vegetables had a temperature of 120F.Review of the test tray on 01/14/26 at 12:10 P.M. with the Dietary Manager (DM) #216 revealed the beef macaroni casserole was lukewarm. DM #216 confirmed the beef macaroni casseroled should have had a much higher temperature reading. DM #216 stated he was surprised the vegetables did not taste even colder, related to the low temperature reading. DM #216 thought the improper temperatures of the test tray were related to how long the food cart sat on the unit prior to being served.Interview on 01/12/26 at 11:13 A.M. with Resident #34 revealed he thought the food was served cold.Interview on 01/12/26 at 11:40 AM with Resident #01 revealed he disliked the food at the facility. Resident #01 stated he did not like what is served or how it is cooked. He stated the food is served cold.Interview on 01/12/26 at 12:49 P.M. with Resident #10 revealed she thought the food that was served at the facility tasted terrible. Resident #10 stated the food was always served cold.Interview on 01/13/26 at 9:12 A.M. with Resident #37 revealed she felt the food at the facility was served cold with improper serving sizes.This deficiency represents non-compliance investigated under Complaint Number 2590724.

Based on observation, interview, and record review the facility failed to maintain a clean and sanitary kitchen. This affected all 65 residents who receive food form the kitchen. The facility census was 65.Findings include:Observation on 01/12/26 at 8:40 A.M. during the initial tour of the kitchen revealed the ice machine was not working. Throughout the kitchen, including over food preparation areas, the ceiling tiles were heavily soiled with a black spotted substance. The ceiling vents throughout the kitchen were heavily soiled with dirt and debris. The tour continued to the dishwash machine room, and it revealed the gauges on the machine did not work. The Dietary Manager (DM) 216 was observed to run the dish machine five times and it did not reach an appropriate wash or rinse temperature. Observation of a large yellow light was hanging over a counter in the dish wash machine area. The yellow light was covered in numerous dead bugs. The floor under the dish wash machine and sink area were heavily soiled with dirt, debris, and grease. The floor was heavily soiled with a black substance under all the appliances.Interview on 01/12/26 at 8:40 A.M. with DM #216 confirmed the ice machine was not working and had not been working for over a week. DM #216 confirmed the ceiling tiles were heavily soiled with an unknown black spotted substance and brown substance. DM #216 confirmed the gauges on the dishwash machine do not work. DM #216 stated the wash temperature should be 160 Fahrenheit (F) and rinse should reach 180F. DM #216 stated he utilizes a thermometer and after five runs the wash only reached 114F and the rinse reached 139F. DM #216 stated the facility does track the dish washing machine temperatures and reached for a temperature log. DM #216 confirmed the temperature log consisted of check marks and did not have any temperatures written on it. DM #216 confirmed the yellow light hanging near the dish washing machine over the counter had multiple dead bugs hanging from it. DM #216 stated the light that has not been used and has hung in the same place in the kitchen for the past year. DM #216 confirmed the kitchen floors were blackened and heavily soiled under the appliances.Prior to the completion of the annual survey, the facility had corrected their dishwasher to ensure the wash and the rinse temperatures reached the measurement to ensure adequate sanitation. In addition, review of infection control tracking revealed no evidence of food borne illness related to inadequate wash and rinse temperatures of the dishwasher.Review of the facility policy titled, Sanitization, dated 2001 confirmed the food service area is maintained in a clean and sanitary manner. Kitchen areas and dining areas are kept clean, free from garbage, debris, and protected from rodents and insects. General recommendations for the dishwashing machine include a high-temperature dishwasher should reach 160F for washing, and 180F for sanitizing dishes.

Based on observation, facility record review, resident record review, staff interview, and facility policy, the facility failed to implement and maintain effective infection prevention and control practices by not consistently following required water management and Legionella control measures, by failing to ensure appropriate and readily available personal protective equipment in the laundry area, and by failing to prevent potential contamination during resident care and use of medical equipment, as evidenced by infection control concerns observed during incontinence care for Resident #68, a urinary catheter drainage bag observed resting on the floor for Resident #3. This affected two residents (#3, #68) of 65 residents with the potential to affect all 65 residents residing in the facility. The facility census was 65.Findings include:1. Observation on 01/21/2026 between 10:54 AM and 11:02 AM with Maintenance Director #225 identified the hot water temperature in room [ROOM NUMBER], identified as the farthest room from the water heater, measured 112.8 degrees Fahrenheit. During the same observation, the hot water tanks were observed with attached thermometers reading 165 degrees Fahrenheit. Interview with Maintenance Director #225 on 01/21/2026 at approximately 11:02 AM confirmed that the only water temperature monitoring logs maintained and up to date were for resident room sinks and kitchen sinks. He confirmed there were no logs available for hot water tank monitoring after 04/15/2025 and no documentation to support routine flushing of infrequently used water lines. Maintenance Director #225 stated he flushes less frequently used areas for approximately 10 to 15 seconds once weekly but confirmed there is no documentation to verify this practice. Review of facility water control measures revealed required interventions included cleaning the ice machine every six months, flushing infrequently used water outlets, maintaining water heaters through the preventive maintenance program, routine inspection and maintenance of respiratory therapy equipment, annual flushing of the sprinkler system, and cycling, disinfecting, or replacing faucet aerators and shower heads. Facility record review revealed no documentation of flushing of low-use water outlets, and no preventive maintenance records for water heaters beyond 04/15/2025. Preventive maintenance tasks outlined in the facility program included checking for leaks, flushing tanks to remove buildup, testing the relief valve, verifying thermostat function, confirming circulation pump operation, and ensuring mixing valves were operational, with no evidence these actions were completed after 04/15/2025. Review of maintenance and infection control records revealed the last documented annual sprinkler system flush was completed on 01/15/2025. There was no evidence that faucet aerators or shower heads were routinely cycled, disinfected, or replaced as required by the facility's water control measures. Review of environmental testing records revealed the last documented biofilm water test was completed on 03/21/2025. Aside from resident room and kitchen sink temperature checks, no additional water management monitoring or documentation was maintained to support compliance with the facility's Legionella prevention program. 2. Review of the facility laundry services and infection control practices revealed personal protective equipment was not readily available in the laundry room for staff handling isolation and soiled laundry. Interview on 01/20/2026 at 4:35 PM with Housekeeping Supervisor #308 revealed laundry services are completed daily, with facility linens washed each morning and resident personal laundry washed on Mondays, Wednesdays, and Fridays. Housekeeping Supervisor #308 stated that laundry from isolation rooms is placed in red bags and washed separately using hot water, with items run through an additional hot wash cycle. He stated staff wear masks, gloves, gowns, and face masks for COVID when collecting laundry from isolation rooms. During the same interview, Housekeeping Supervisor #308 described that soiled laundry contaminated with blood or feces is handled using the same process as isolation or chemotherapy laundry and placed in yellow bags. He stated hot water washers are used with Tide Professional detergent, Downy, and Clorox. Housekeeping Supervisor #308 confirmed laundry staff do not independently test washer water temperatures, stating maintenance tracks water temperatures. Observation of the laundry room on 01/20/2026 revealed operational equipment, clean lint traps, posted guidance for washing infectious linens, and separation of clean and soiled laundry areas. Clean linens were observed and did not have odors of urine or feces. However, observation revealed no personal protective equipment was stored or readily accessible within the laundry room at the time of the walkthrough. Housekeeping Supervisor #308 stated laundry staff do not keep PPE in the laundry room and instead retrieve PPE from resident care areas, removing PPE after entering resident rooms and bringing it back to the laundry area as needed. Interview on 01/21/2026 at 8:13 AM with Housekeeping Supervisor #308 confirmed there was no PPE available in the laundry room that was impervious to wet or heavily soiled laundry. He stated the only PPE available to laundry staff consisted of paper gowns, latex gloves, and face masks typically used for isolation rooms. He confirmed no additional protective gowns or barriers designed for handling wet, contaminated linens were maintained in the laundry room for staff use. 3. Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses that included necrotizing fasciitis, acute and chronic respiratory failure, type 2 diabetes, and obstructive and reflux uropathy. The admission MDS dated [DATE] revealed Resident #3 was cognitively intact. The MDS revealed the resident had an indwelling catheter. A plan of care dated 11/13/25 revealed Resident #3 had an indwelling catheter with interventions to monitor and document intake and output per the facility policy, An observation on 01/12/26 at 9:38 A.M. revealed Resident #3 was lying in bed and catheter bag was lying on the floor. An interview on 01/12/26 at 9:39 A.M. Registered Nurse (RN) #237 verified Resident #3's catheter bag should not be lying on the floor. Review of Catheter Care, Urinary policy dated August 2022 revealed the purpose of the procedure was to prevent urinary catheter-associated complications including urinary tract infections. The catheter tubing and drainage bag were to be kept off the floor. 4. Review of Resident #68's medical record revealed she was admitted on [DATE]. Diagnoses included diabetes, chronic obstructive pulmonary disease, chronic kidney disease, and atrial fibrillation. Review of the quarterly minimum data set assessment dated [DATE] revealed her cognition was intact. She requires set up or clean up assistance with eating, partial/moderate assistance for oral assistance, dependent for toileting, shower/bathing and substantial maximal assistance. Always incontinent of bowel and bladder. On 01/14/26 at 3:58 P.M. observation of incontinence care revealed Certified Nurses Assistant (CNA) #252 obtained water in the wash basin, applied gloves and removed the old brief. He washed the front, rinsed and dried, removed his gloves and put on new gloves without washing his hands and turned her to the side. He washed front to back with a smear of bowel movement noted, rinsed and dried, removed his gloves and obtained a new brief, put on new gloves without washing his hands and put on the new brief. This was verified during interview with CNA #252 on 01/14/26 at 4:12 P.M. Review of the facility Handwashing/Hand Hygiene dated 10/23 revealed hand hygiene is indicated immediately after glove removal.

Based on observation, resident interview, staff interview, and facility policy, the facility failed to store and label oxygen and nebulizer equipment properly for eight residents (#5, #7, #8, #14, #26, #27, #61, #68) of 27 residents who utilizes oxygen or nebulizers. The facility census was 65. Findings include: 1.Review of the medical record for Resident #5 revealed an admission date on 09/01/23 with diagnoses that included, but not limited to, respiratory failure, centrilobular emphysema, chronic diastolic congestive heart failure, severe dementia, dysphagia, convulsions, and atherosclerotic heart disease. The resident's Quarterly Minimum Data Set (MDS) dated [DATE] indicated a BIMS score of 2, reflecting severe cognitive impairment. The resident required extensive to total assistance with most activities of daily living and utilized a wheelchair for mobility. Review of the physician orders revealed an order dated 01/08/25 for oxygen at 1–2 liters per minute via nasal cannula every 12 hours as needed for shortness of breath and/or to maintain oxygen saturation at or above 90%. Review of the care plan, initiated and revised on 10/20/25, directed staff to provide oxygen per physician orders, monitor pulse oximetry to ensure adequate oxygenation, document signs of shortness of breath, check oxygen saturation as needed, and notify the physician or nurse practitioner if levels were low. Review of vital sign documentation revealed oxygen saturation readings recorded between 10/15/25 and 11/27/25, all obtained on room air, with values ranging from 95% to 97%. There was no documentation of oxygen saturation monitoring after 11/27/25, despite the continued active oxygen order and care plan interventions requiring monitoring as needed. Review of the medication administration record (MAR) and treatment administration record (TAR) showed no documentation indicating that oxygen was administered and no documentation reflecting reassessment of oxygen saturation levels beyond 11/27/25. Observation on 01/12/26 at 10:19 AM, oxygen equipment was observed in the resident's room. The oxygen tubing and nasal cannula in use were not dated. There was no visible label or indication to identify when the tubing had been initiated or last changed. The nasal tubing was not on the resident at the time and the tubing was hanging off the side of the bed not in a bag. Interview on 01/12/26 at approximately 10:28 AM, Registered Nurse (RN) #200, was interviewed regarding the resident's oxygen equipment. The RN confirmed that the oxygen tubing, nasal cannula, and humidifier water bottle were not dated and discarded the tubing and humidifier water bottle at the time of the observation. He confirmed that the resident's oxygen order was PRN every 12 hours. RN #200 was unable to provide documentation indicating when the oxygen tubing had last been changed and then proceeded to dispose of the O2 tubing and humidifier water bottle. There was no evidence presented to show a system in place to ensure oxygen and nebulizer tubing was dated upon initiation or changed per facility policy or infection control standards. 2. Review of the medical record for Resident #26 revealed an admission date of 06/06/25 with diagnoses that included, but were not limited to, acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, obstructive sleep apnea, morbid obesity with alveolar hypoventilation, morbid obesity due to excess calories, type 2 diabetes mellitus with hyperglycemia, cognitive communication deficit, heart failure, essential hypertension, aortic aneurysm without rupture, depression, anxiety disorder, insomnia, and vitamin B12 deficiency anemia. The resident's MDS dated [DATE] indicated a BIMS score of 15. The MDS further reflected the resident required assistance with multiple activities of daily living and utilized a wheelchair for mobility. Review of the physician orders revealed an active order dated 06/09/25 for oxygen at 4 liters per minute via nasal cannula as needed for shortness of breath. Review of vital sign documentation revealed oxygen saturation readings recorded between 11/19/25 and 01/07/26, with values ranging from 95% to 97%, documented both on room air and while receiving oxygen via nasal cannula. Review of the MAR/TAR showed no documentation indicating that oxygen was administered to the resident, despite multiple oxygen saturation readings being recorded while the resident was documented as receiving oxygen via nasal cannula. Observation on 01/12/26 at 4:26 PM, the surveyor observed oxygen running in the resident's room while the nasal cannula was not in use by the resident laying and the tubing was off the side of his bed. The oxygen concentrator tubing and humidifier tubing was not dated, and the humidifier water bottle was either empty. There was no visible label or indication to identify when the oxygen tubing or humidifier water bottle had been initiated or last changed. Interview on 01/12/26 at 4:48 PM with RN #200, regarding the oxygen equipment observed in the resident's room. RN #200 confirmed that the oxygen concentrator tubing and humidifier water bottle were not dated, that the oxygen was running at the time of observation, that the tubing was not placed in a bag while not in use, and that there was no water connected for the resident's use. RN #200 was unable to provide documentation indicating when the oxygen tubing or humidifier water bottle had last been changed. There was no evidence presented to demonstrate a system in place to ensure oxygen and nebulizer tubing and humidifier water bottles were dated upon initiation or changed in accordance with facility policy or infection control standards. 3. Review of the medical record for Resident #61 revealed an admission date of 11/28/2020 with diagnoses including, but not limited to, multiple sclerosis, polyneuropathy in diseases classified elsewhere, anxiety disorder, and major depressive disorder. Review of the resident's Quarterly Minimum Data Set (MDS) dated [DATE] indicated a BIMS score of 15, reflecting the resident was cognitively intact. The resident had impairment of both lower extremities, used a wheelchair for mobility, was independent with eating, required supervision for oral hygiene, and was dependent on staff for lower extremity dressing, putting on/off footwear, and transfers. Review of physician orders revealed an active order for Ipratropium-Albuterol Inhalation Solution 0.5–2.5 (3) MG/3ML, 1 inhalation orally three times a day for shortness of breath and congestion, administered via nebulizer. Observation on 01/12/2026 at 12:27 PM revealed that the nebulizer tubing and mask were not dated, or labeled to indicate when they were last replaced. Interview on 01/12/2026 at 12:27 PM, the resident stated that staff did not change her nebulizer tubing or mask for albuterol. Interview on 01/12/2026 at 12:50 PM, RN #200 confirmed that the tubing and mask should be changed and should be dated to track when replacement was due. RN #200 verified that the tubing and mask were not dated and discarded the items to have them replaced. 4. Review of the medical record for Resident #68 revealed an admission date of 03/11/2022 with a re-entry on 11/10/2022. Diagnoses included, but were not limited to, paroxysmal atrial fibrillation, type 2 diabetes mellitus with diabetic peripheral angiopathy, chronic obstructive pulmonary disease. Review of the resident's Quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had no upper or lower extremity impairments but used a wheelchair for mobility, required assistance for toileting and showering, maximal assistance with dressing, and was dependent for chair-to-chair and tub transfers. The resident received hospice services, was always incontinent of bowel and bladder, and experienced shortness of breath. Review of physician orders revealed an active order for oxygen at 2–4 L via nasal cannula PRN every 24 hours as needed for shortness of breath. Observation on 01/12/2026 at 9:44 AM revealed that the resident's oxygen was not in use, was wrapped on the concentrator out of reach, and the oxygen tubing and water bottle was not dated to indicate when it had been changed. Interview on 01/12/2026 at 10:19 AM, RN #200 stated that oxygen tubing and water bottle should be changed as needed, confirmed that the tubing should be dated, and verified that because the tubing observed had no date, it should be replaced. RN #200 discarded the undated tubing at that time and confirmed that proper labeling and dating are required for ongoing safety and infection control. Review of the facility policy titled, oxygen therapy – mask and nasal cannula, revealed when the cannulas become soiled with secretions, it needs to be changed. Additionally, when the masks and cannulas are not in us they are to be stored in a plastic bag obtained from the central service department and that the humidifier water bottle should be changed every 10 days with a note stating humidifier bottles must be dated. 5. Review of Resident #14's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included moderate protein malnutrition, cystic fibrosis, ALS, anxiety, gastrostomy, chronic pain syndrome, major depression and functional quadriplegia. Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition is intact. He is dependent for eating, oral hygiene, toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. Frequently incontinent of urine and always incontinent of bowel. Review of physician's orders revealed an order on 11/07/25 for Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliters (ml) inhale orally via nebulizer two times a day for cough. On 01/12/26 10:00 A.M. observation revealed the nebulizer and tubing with mask sitting on bedside stand uncovered and not dated. On 01/12/26 at 11:30 A.M. observation and interview with Registered Nurse (RN) #200 verified the resident's tubing and mask were on the bedside stand and uncovered. 6. Record review revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included protein calorie malnutrition, chronic obstructive pulmonary disorder, peripheral vascular disease, and atherosclerosis of arteries of the left leg with ulceration of other part of left lower leg. Review of the quarterly MDS dated [DATE] revealed her cognition was intact, she required set up or clean up assistance for eating, dependent for oral hygiene, toileting, shower/bathing, dressing, personal hygiene. and turning and repositioning. On 01/12/26 at 10:00 A.M. observation revealed the nebulizer and tubing with mask sitting on floor uncovered and not dated. On 01/12/26 at 11:30 A.M. observation and interview with Registered Nurse #200 verified the resident's mask and tubing was on the floor and uncovered. 7. Review of Resident #7's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included diabetes, morbid obesity, adult failure to thrive, chronic obstructive pulmonary disease, chronic resp failure, asthma, schizoaffective disorder, anxiety, depression, personality disorder and PTSD. Review of the quarterly minimum data set assessment dated [DATE] revealed her cognition was intact. She required set up or clean up assistance for eating, independent with oral hygiene, toileting, dressing and personal hygiene. Review of the physician's orders for 09/03/25 revealed an order for oxygen at two liters per minute via nasal cannula as needed for episodes of shortness of breath or dyspnea as needed. On 01/12/26 at 11:23 A.M. observation revealed the oxygen tubing was observed not dated; Resident #7 said you have to ask for them to change the tubing. On 01/12/26 at 11:29 A.M. observation and interview with RN #200 verified Resident #7's oxygen tubing was not dated. 8. Review of the medical record revealed Resident #8 was admitted [DATE] and readmitted on [DATE] with diagnoses that included neuropathy, sick sinus syndrome, dysphagia, congestive heart failure, and anxiety disorder, A plan of care dated 10/20/25 revealed Resident #8 had the potential for unmanaged respiratory function with interventions that included oxygen therapy as ordered, A physician order dated 10/18/25 revealed Resident #8 was to have continuous oxygen at two liters via nasal cannula. The 5-day MDS assessment dated [DATE] revealed Resident #8 had severe cognitive impairment. An observation on 01/13/26 at 7:50 A.M. revealed Resident #8 was lying in bed. The resident's oxygen concentrator was located to the residents left against the wall near the head of the bed. Resident #8's nasal cannula and oxygen tubing was lying on the floor next to the oxygen concentrator. An interview on 01/13/26 at 7:50 A.M. Registered Nurse #232 verified Resident #8's nasal cannula was lying on the floor. Review of the Oxygen Therapy-Mask and Nasal Cannula Policy (no date) revealed when the oxygen cannula was not in use, it should be stored in a plastic bag obtained from the central service department.

Based on medical record review, staff and resident interview, and policy review the facility failed to complete initial care plan conferences and quarterly care plan conferences for residents and responsible parties as required. This affected seven residents (#4, #7, #13, #26, #27, #78, and #114) of 24 residents reviews. The facility census was 65.Findings include: 1.Review of Resident #114's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included moderate protein malnutrition, cystic fibrosis, ALS, anxiety, gastrostomy, chronic pain syndrome, major depression and functional quadriplegia. Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition was intact. He was dependent on staff for eating, oral hygiene, toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. The resident was frequently incontinent of urine and always incontinent of bowel. Review of the care conferences revealed they were completed on 02/10/25 and not again until 10/15/25. On 01/15/26 at 8:59 A.M. interview with Social Service Director #264 verified the Care conferences were not held quarterly for Resident #114. 2. Review of Resident #7's medical record revealed she was admitted to the facility on [DATE]. The resident's diagnoses included diabetes, morbid obesity, adult failure to thrive, chronic obstructive pulmonary disease, chronic resp failure, asthma, schizoaffective disorder, anxiety, depression, personality disorder and PTSD. Review of the quarterly minimum data set assessment dated [DATE] revealed the resident's cognition was intact. She required set up or clean up assistance for eating, independent with oral hygiene, toileting, dressing and personal hygiene . Further review revealed no documented evidence of plan of care conferences for Resident #7. On 01/15/26 at 8:59 A.M. interview with Social Service Director #264 verified the care conferences were not held quarterly for Resident #7. 3. Record review revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included protein calorie malnutrition, chronic obstructive pulmonary disorder, peripheral vascular disease, and Atherosclerosis of arteries of the left leg with ulceration of other part of left lower leg. Review of the quarterly MDS dated [DATE] revealed her cognition was intact, she required set up or clean up assistance for eating, dependent for oral hygiene, toileting, shower/bathing, dressing, personal hygiene. and turning and repositioning. Review of the care conferences revealed care conferences were completed on 02/05/25 and 04/11/25 for Resident #27. On 01/15/26 at 8:59 A.M. interview with Social Service Director #264 verified the plan of care meetings were not completed quarterly for Resident #27. Review of the Patient Care Conferences policy, not dated, revealed patient care conferences will be held within seven days of admission, when there has been a significant change and quarterly there after. 4. Review of the medical record revealed Resident #13 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes, acquired absence of right leg below knee amputation, moderate protein-calorie malnutrition, and chronic kidney disease. The 5-day MDS assessment dated [DATE] revealed Resident #13 was cognitively intact. Review of the medical record revealed no evidence of care conferences being held with Resident #13 and/or responsible party. An interview on 01/12/26 at 10:00 A.M. with Resident #13 revealed they had not attended any care conferences. An interview on 01/15/26 at 10:20 A.M. Social Service Director #264 verified no care conferences had been held with Resident #13. Social Service Director #264 stated care conferences were not done because Resident #13 had inappropriate sexual behaviors and Resident #13's family could not be reached. Review of the care conference policy (no date) revealed the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. If the participation of the resident and his/her representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies. 5. Review of the medical record revealed Resident #4 was admitted on [DATE] acute on chronic diastolic heart failure, ulcer of anus and rectum, and type 2 diabetes, An admission care conference was held on 06/30/25. Notes from the care conference revealed Resident #4 wanted to return home and the resident's wife was currently looking for another place to live due to steps at the current home. Resident #4 requested that her wife not be notified of the care conference and the resident's wishes were honored. The quarterly MDS dated [DATE] revealed Resident #4 was cognitively intact. An interview on 01/15/26 at 10:20 A.M. Social Service Director #264 verified quarterly care conferences had not been completed for Resident #4. Social Service Director #264 stated the care conferences had not been completed because Resident #4's wife lived in another town. An interview on 01/15/26 at 11:54 A.M. Resident #4 stated they were not aware of any care conferences being held. Review of the care conference policy (no date) revealed the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The resident is informed of his or her right to participate in his or her treatment and provided advance notice of care planning conferences. If the participation of the resident and his/her representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies. 6. Review of the medical record revealed Resident #78 was admitted on [DATE] and discharged on 04/23/25 with malignant carcinoid tumor of the stomach, severe protein-calorie malnutrition, type 2 diabetes, and vascular dementia. The medical record revealed Resident #78's son was listed as emergency contact. The 5-day admission MDS dated [DATE] revealed the resident had severe cognitive impairment. Review of the medical record revealed no evidence of an initial care conference being held with Resident #78 or the responsible party. An interview on 01/15/26 at 10:20 A.M. Social Service Director #264 verified there was no evidence of an initial care conference being done with Resident #78 or the responsible party. Social Service Director #264 stated she was unsure why the care conference was not done. 7. Review of the medical record for Resident #26 revealed an admission date of 06/06/2025. Diagnoses included acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, obstructive sleep apnea, and morbid obesity with alveolar hypoventilation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had intact cognition (BIMS 15) and no significant impairments to upper or lower extremity function, but required set-up assistance for eating and oral hygiene and maximum or dependent assistance for other ADLs. Additional documentation that the resident rejected care 1–3 days. Review of the medical record for Resident #26 revealed no indication that a care conference had been conducted or attempted. Interview on 01/12/26 at 4:28 PM with Resident #26 revealed that he was not being asked to participate in care plan meetings. The resident stated he wanted to go home and did not like the social work interactions, indicating he had no opportunity to engage in the care planning process. Interview on 01/15/26 at 9:00 AM with Social Work Director #264,, confirmed that while quarterly care conferences are part of facility policy, there was no documentation of a care conference for Resident #26. She stated that she had spoken with the resident in July 2025 about a potential care conference but there was no written documentation of that discussion, and no subsequent attempts were made to schedule or conduct any care conferences for this resident. Review of the facility policy titled Care Plans, Comprehensive Person-Centered (version 2.0, revised March 2022) revealed that care conferences support resident participation in care plan development and updates. Residents have the right to identify participants, request meetings or revisions, establish goals and outcomes, determine care details, receive planned services, and sign the plan after significant changes, with refusals documented in the record. The facility provides advance notice of conferences and informs residents of participation rights, documenting explanations if involvement is impracticable. Conferences are held for significant condition changes, unmet outcomes, hospital readmissions, or quarterly MDS assessments to ensure person-centered revisions incorporating preferences, strengths, and specialized needs. This deficiency represents non-compliance investigated under Complaint Number 1350535.

Based on observations, record review, resident interview, staff interview, and facility policy review, the facility failed to complete ordered treatments for Resident #7, failed to properly assess and address Resident #9's skin impairment to the toe, failed to initiate Resident #19's physician order dated 12/31/25 until 01/03/26, failed to ensure ordered TED hose were applied for Resident #24 for three days, failed to transcribe and implement discharge orders from the after visit summary (AVS) for Resident #25, failed to properly treat Resident #26's irritated skin as ordered, failed to complete ordered treatment to the buttocks for Resident #61, and failed to complete ordered treatment for Resident #83. This affected eight residents (#7, #9, #19, #24, #25, #26, #61, #83) out of 32 residents reviewed in the sample. The facility census was 65.Findings include:1.Review of the medical record for Resident #26 revealed an admission date of 06/06/25. Diagnoses included acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, obstructive sleep apnea, and morbid obesity with alveolar hypoventilation. Review of the plan of care dated 06/09/25 and revised 06/12/25 identified interventions requiring staff to provide bathing per schedule and preference, including total dependent assistance with bed mobility and application of topical medications as ordered, such as Nystatin powder for the right neck fold to be applied twice daily and as needed. Review of the physician orders included right neck fold wash with soap and water, pat dry, apply Nystatin powder twice daily and as needed for 7 days (Active 09/12/25). Additionally, apply barrier cream after each incontinence episode (Active 06/06/25). Review of the medication administration record (MAR) and treatment administration record (TAR) revealed the order for Nystatin powder was active 09/12/25, yet there was no documentation that the medication had been administered from September 2025 through 01/14/26, except for a brief 9/12/25–9/19/25 period. Bathing documentation indicated multiple days, including 11/04/25, 11/08/25, 11/18/25, 12/13/25, and 12/23/25, with no indication that the resident received a bed bath or topical application as ordered. Shower sheets were inconsistently completed, with only 12/06/25 documented, showing no skin issues and no indication of treatment or monitoring for the neck fold. Observation on 01/12/26 at 4:20 PM revealed the resident had raw, red, and painful skin under the neck fold, and he stated that staff were not addressing the area during bed baths or with creams. Interview on 01/14/26 at 7:55 AM, Licensed Practical Nurse (LPN) #224 stated she had noticed redness under the resident's neck a couple of weeks prior, had not observed any improvement, and confirmed that the Nystatin powder had not been administered since September 2025. She administered the Nystatin after discussion with the surveyor, and stated she would notify the night nurse and nurse practitioner (NP) regarding ongoing care. Interview on 01/14/26 at 8:06 AM, Certified Nursing Assistant (CNA) #252 reported that he had been providing bed baths for the resident and had noticed the redness under the neck for 2–3 weeks but had not reported or documented it. Interview on 01/14/26 at 8:36 AM, Director of Nursing (DON) confirmed that the Resident #26 had not received proper topical treatment for his neck fold. He also noted that shower sheets were inconsistently completed, contributing to discrepancies in documentation. Interview on 01/14/26 at 9:22 AM, licensed practical nurse (LPN) #224 confirmed that the resident's neck fold was very red and painful. She applied the Nystatin powder that morning after surveyor intervention, and the resident reported that this irritation had been present for months. 2. Review of the medical record for Resident #25 revealed an admission date of 10/14/25. Diagnoses included other acute osteomyelitis of the right ankle and foot, type 2 diabetes mellitus with foot ulcer, acquired absence of other right toe(s) status post right toe amputation, cellulitis of the limb, lymphedema, edema, and other reduced mobility. Review of the 5-day Medicare MDS dated [DATE] identified the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15, had impairment of one lower extremity, was dependent for lower extremity dressing and footwear, and had open lesions on the foot. Review of the Braden assessments dated 10/14/25 and 10/29/25 reflected the resident was at risk for skin breakdown with scores of 15 and 16. Review of physician orders identified multiple wound care and compression treatment orders for the right great toe amputation site and left lower extremity, with several active and discontinued orders between 10/29/25 and 01/09/26. Orders for the right great toe amputation site included cleansing the wound with normal saline or wound cleanser, patting dry, and packing with various products, including Betadine-soaked gauze (10/29/25–11/11/25), collagen (11/26/25–12/02/25), silver alginate (12/03/25–12/06/25, 12/07/25–01/08/26), and combinations thereof, covered with ABD pads and secured with Kerlix. These orders specified treatment frequencies ranging from every shift daily to every Monday, Wednesday, and Friday, depending on the order and product used. Orders for the left lower extremity included application of Tubigrip and Ace wraps (11/25/25–active) and daily Kerlix and Coban layering with specific spiral technique instructions (discontinued 10/29/25), intended for compression and lymphedema management. Review of the MAR/TAR revealed the right great toe amputation site treatment ordered to be completed daily was not documented as provided on multiple dates including 12/09/25, 12/11/25, 12/14/25, 12/17/25, 12/19/25, 12/21/25, 12/23/25, and 12/31/25. The TAR indicated the resident was out of the facility on 01/03/26 and treatment was not provided, however there was no corresponding progress note to support that the resident was out of the building on that date. Review of wound assessments revealed no documented measurements, wound status, or indication of improvement, decline, or stability of the right great toe amputation site. A note dated 11/11/25 stated the wound was closed, however wound care orders remained active and continued to require treatment without documentation supporting reassessment or discontinuation. Review of hospital and wound clinic after visit summaries revealed multiple discrepancies between wound clinic instructions and the facility's physician orders. The AVS dated 10/20/25 instructed daily dressing changes for the right great toe amputation site, but the facility order at that time was every Monday, Wednesday, and Friday. The same AVS also directed application of an Ace wrap to the affected leg(s) from toes to knee with 50% stretch and overlap, to be reapplied as needed during the day and removed at bedtime, yet the facility orders did not reflect this until 10/29/25 and then only for a single day. The AVS dated 10/27/25 again directed daily dressing changes for the right great toe and application of a 3M Coban 2 multilayer compression wrap to the left leg, neither of which were included in the facility's orders. The AVS dated 11/04/25 instructed daily right great toe dressing changes and left leg multilayer compression wrap, but these instructions were not reflected in the facility's orders or the TAR, and no documentation verified that treatments were completed. No AVS documentation was available for wound clinic visits between 11/04/25 and 12/01/25, resulting in a lack of updates on wound status or care instructions. The AVS dated 12/01/25 directed daily dressing changes for the right great toe and application of Coban wrap to the right lower leg, but these instructions did not match the orders in PCC. The AVS dated 12/08/2025 included daily dressing changes for the right great toe and multilayer compression wrap to the left leg, which were not reflected in facility orders. The AVS dated 12/29/25 instructed daily right great toe dressing changes and application of medium Spandagrip and Ace wrap to the left leg from toes to just below the knee, but again these directions did not match the facility's orders, and there was no documentation of treatment completion. Additionally, after visit summaries for 01/07/26 and 01/14/26 were not present in the medical record, leaving gaps in clinical guidance and updates regarding the right great toe amputation wound and bilateral lower extremity compression. Review of a nurse's progress note dated 11/10/25 indicated the resident returned from a doctor appointment with new wound orders and directed staff to refer to the MAR and TAR, however the corresponding after visit summary was not present and no updated orders were identified. Interview on 01/14/26 at 3:45 PM with Registered Nurse (RN) #237 revealed that if the wound nurse completes dressing changes, the wound nurse does not always mark the treatment as completed on the TAR. Interview on 01/14/26 at 3:52 PM with Wound Nurse #254 revealed she was unsure why dressing changes were blank on the TAR and confirmed she could not provide evidence that the dressing changes were completed appropriately. She stated that if wound care was completed, it should be marked on the TAR. She also could not confirm the resident was out of the facility on 01/03/26. Interview on 01/15/26 at 10:30 AM with Wound Nurse #254 revealed the resident attends weekly wound clinic appointments at Ohio Health and that she does not routinely receive or request ongoing information from those visits unless there is a treatment change. She confirmed she was unsure of the current status of the resident's right great toe wound and that the AVS' did not include updates on how the wound was progressing. Interview on 01/15/26 at 11:09 AM with Wound Nurse #254 revealed she reviews after visit summaries only for care instruction changes and confirmed there was no documentation in the record describing wound measurements or wound progression. Interview on 01/15/26 at 11:41 AM with Resident #25 revealed he does not usually have ace wraps on his legs and stated that only the wound nurses have been told to wrap his legs. Observation at that time revealed the resident did not have ace wraps applied despite active physician orders. Interview on 01/15/26 at 11:49 AM with Licensed Practical Nurse (LPN) #318 confirmed the ace wraps were not in place and confirmed they should have been applied due to the resident's bilateral lower extremity lymphedema. Interview on 01/15/26 at 4:11 PM with the Director of Nursing confirmed that wound care and compression orders were not being completed appropriately. Interview on 01/20/26 at 7:57 AM with Wound Nurse #254 confirmed that after visit summary orders did not match the physician orders in the facility system. She confirmed that after visit summaries from 11/04/25 through 12/01/25 could not be located and that after visit summaries for 01/07/26 and 01/14/26 were also missing. She further confirmed there were no wound measurements or wound status updates documented in the medical record and she was unable to state the current condition of the resident's right great toe wound. Observation/interview on 01/20/26 at 10:39 AM with RN #237 revealed the resident was up in a chair without ace wraps applied to either leg despite active physician orders. The resident stated his lymphedema pump treatment had been completed earlier that morning but his legs were not wrapped after the treatment. The nurse applied the ace wraps following surveyor intervention. 3. Review of the medical record for Resident #61 revealed an admission date of 11/28/20. Diagnoses included multiple sclerosis, polyneuropathy in diseases classified elsewhere, anxiety disorder, major depressive disorder, insomnia, auditory hallucinations, other specified dorsopathies of the cervical region, chronic pain syndrome, generalized muscle weakness, other muscle spasm, gastroesophageal reflux disease without esophagitis, vitamin D deficiency, pityriasis versicolor, unspecified exotropia, and weakness. Review of the quarterly MDS dated [DATE] indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, required maximum assistance for upper extremity dressing and dependent assistance for lower extremity dressing and putting on/off footwear, was dependent for personal hygiene, rolling, sit-to-stand, and transfers, and used a wheelchair for mobility. Review of physician orders identified active orders for the treatment of bilateral buttocks moisture-associated skin damage (MASD) with a topical mixture of zinc oxide 20% dated 11/04/25, triamcinolone 0.1% dated 11/04/25, and terbinafine 1% dated11/05/25, to be applied three times daily. Orders specified cleansing the affected area with soap and water prior to application and maintaining clean, dry skin, with no dressings to be applied. Review of the MAR/TAR revealed multiple missed treatments for December 2025 and January 2026 for all three topical orders for bilateral buttocks MASD: Zinc Oxide 20% External Paste: Missing administrations included morning and afternoon treatments on 12/05/25–12/07/25 and 12/09/25, evening treatments on 12/10/25, 12/17/25, 12/19/25, 12/20/25, 12/24/25, and 12/26/25, all three treatments on 12/27/25, evening treatments on 12/28/25–12/31/25, evening treatment on 01/01/26, all three treatments on 01/02/26, evening treatments on 01/05/26–01/11/26, and the morning treatment on 01/20/26. Triamcinolone Acetonide 0.1% External Cream: Missing administrations included morning and afternoon treatments on 12/05/25–12/07/25 and 12/09/25, evening treatments on 12/10/25, 12/17/25, 12/19/25, 12/20/25, 12/24/25, and 12/26/25, all three treatments on 12/27/25, evening treatments on 12/28/25–12/31/25, evening treatment on 01/01/26, all three treatments on 01/02/26, evening treatments on 01/05/26–01/11/26, and the morning treatment on 01/20/26. Terbinafine HCl 1% External Cream: Missing administrations included morning and afternoon treatments on 12/05/25–12/07/25 and 12/09/25, evening treatments on 12/10/25, 12/17/25, 12/19/25, 12/20/25, 12/24/25, and 12/26/25, all three treatments on 12/27/25, evening treatments on 12/28/25–12/31/25, evening treatment on 01/01/26, all three treatments on 01/02/26, evening treatments on 01/05/26–01/11/26, and the morning treatment on 01/20/26. Review of progress notes indicated ongoing MASD with care planning in place; however, repeated treatments for all three orders were not documented as completed. Review of prior skin assessments and progress notes from 12/15/25 and 12/29/25 confirmed the presence of MASD on the right gluteus, with staff education and care planning in place for moisture control, incontinence management, turning/repositioning, and topical treatment. Interview on 01/12/26 at 3:12 PM with Resident #61 revealed she stated that when she is changed, staff are supposed to apply cream to her coccyx, but treatments were not being completed as ordered. Interview on 01/20/26 at 1:17 PM with the Director of Nursing (DON) confirmed that there was no documentation explaining the missed treatments for the buttocks cream, and no interventions had been implemented to ensure compliance with the orders. 4. Review of Resident #19's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, diabetes, anxiety, depression, absence of the right great toe and peripheral vascular disease. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact. He requires supervision or touching assistance for eating, oral hygiene, toileting, shower/bathing, dressing, personal hygiene and independent for turning and repositioning. Occasionally incontinent of urine and always continent of bowel. Review of the progress notes on 12/31/25 revealed a new skin issue, location: left dorsum first interdigital space (foot). Diabetic ulceration (new wound). Wound acquired in house. Exact date 12/30/25, staged by healthcare provider. Length 5.49 centimeters (cm) by width 3.96 cm by 0 depth. Area (cm2) 16.94. Cleanse with normal saline, iodine moistened gauze and ABD pad and kerlix wrap. Further review of physician orders revealed the treatment order was not written until 01/02/26 and review of the treatment record revealed it was not documented as completed until 01/03/26. On 01/15/26 at 11:07 A.M interview with Registered Nurse (RN) #254 verified the order for Resident #19's diabetic ulcer was not transcribed until 01/02/26 and not documented as completed until 01/03/26 (three days after the treatment was originally ordered). 5. Review of Resident #24's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included acute kidney failure, severe protein calorie malnutrition, COPD, A FIB, depression, anxiety and weight loss. Review of the quarterly MDS dated [DATE] revealed her cognition is intact, she is independent with eating, oral hygiene, toileting, shower/bathing, dressing and personal hygiene. Is occasionally incontinent of urine and continent of bowel. Review of the physician orders revealed on 01/09/26 an order for knee high ted hose (compression stockings) to both legs one time a day for swelling and remove per schedule. Review of the treatment record revealed the compression stockings were to be applied on dayshift. Observation on 01/12/26 at 3:29 P.M., 01/13/26 at 2:10 P.M., 01/14/26 at 2:22 P.M. and 01/15/26 at 10:45 A.M. revealed Resident #24 was not wearing ted hose. Interview with Licensed Practical Nurse (LPN) #224 on 01/15/26 at 10:46 A.M. verified Resident #24 did not have her ted hose on as ordered. 6. Review of Resident #7's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included diabetes, morbid obesity, adult failure to thrive, chronic obstructive pulmonary disease, chronic resp failure, asthma, schizoaffective disorder, anxiety, depression, personality disorder and PTSD. Review of the quarterly minimum data set assessment dated [DATE] revealed her cognition was intact. She required set up or clean up assistance for eating, independent with oral hygiene, toileting, dressing and personal hygiene. Review of the physician orders revealed a treatment on 09/19/25 to the right groin wound and apply mupirocin ointment, cover with abdominal (ABD) pad two times a day for wound care and on 11/11/25 to the left genital region cleanse with normal saline or wound cleanser, pat dry and apply mupirocin ointment to wound bed, pack wound bed with wet to dry gauze, cover with ABD pad two times a day for wound care. Review of the TAR for December 2025 revealed the treatment to the right groin area was to be completed at 9:00 A.M. and 8:00 P.M. Documentation at 9:00 A.M. revealed the treatment was not documented as completed on 12/05, 12/06, 12/07, 12/09, and 12/27. Documentation for the treatment at 8:00 P.M. revealed the treatment was not documented as completed on 12/10, 12/17, 12/19, 12/20, 12/22, 12/25, 12/26, 12/2712/28, 12/29, 12/30 and 12/31. Review of the treatment record for January 2026 revealed the treatment to the right groin area was to be completed at 9:00 A.M. and 8:00 P.M. Documentation at 9:00 A.M. revealed the treatment was not documented as completed on 01/02. Documentation for the treatment at 8:00 P.M. revealed the treatment was not documented as completed on 01/01, 01/02, 01/05, 01/06, 01/07, 01/08, 01/09, 01/10 and 01/11/26. On 01/21/26 at 11:00 A.M. interview with Registered Nurse #254 verified the missing treatment order for Resident #7's groin wound for December 2025 and January 2026. 7. Medical record review for Resident #9 revealed she was admitted to the facility on [DATE]. Her diagnoses included, obesity, gastro-esophageal reflux disease (GERD) , essential primary hypertension, obstructive sleep apnea, hyperlipidemia, gout, dysphagia, anxiety, diabetes mellitus (DM), peritonitis, insomnia, and malignant neoplasm of the neck. Resident #09 required hospice services. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 12/12/25 revealed she was mildly cognitively impaired. Resident #9 was dependent on staff for medication administration, and required supervision from staff with eating. Resident #9 required moderate assistance from staff with oral hygiene, toilet use, bathing, upper body dressing, lower body dressing, and personal hygiene. She required maximum assistance from staff with putting on shoes. Review of the MDS assessment revealed Resident #9 required Hospice Services. Review of the progress notes for Resident #9 dated 01/07/26 at 7:34 P.M. revealed a note that stated, no wound noted at resident's left great toe, hospice updated. Further review of the progress notes dated 01/13/26 at 4:05 P.M. revealed a significant change note for Resident #9 and it stated a nursing observation of a reddened skin area of .03x.03x0.0 with no drainage noted with no identification of location. The primary care response recommendations were ABI betadine and leave open to air and a new testing for venous doppler. A late entry note for 01/13/26 at 4:05 P.M. revealed wound nurse was called to Resident #9's room and a reddened area to the left great toe was present and it measured .3x.3x0. Wound Nurse Practitioner (WNP) #515 notified and new orders for betadine every day leave open to air. Review of the skin assessment for Resident #9 dated created on 01/20/26 for the following dates 12/17/25, 12/24/25, 12/31/25, 01/07/26, and 01/14/26 locked on 01/20/26. Observation on 01/13/26 at 4:02 P.M. with Registered Nurse (RN) #227 revealed Resident #9 had a large round scabbed area about the size of a quarter at the top of her left great toe. Resident #09's left great toe was reddened and had two cracked skin around the large scab that appeared to have two small cracks that were opened around the large scab. Observation revealed RN #227 pushed on the reddened left great toe and observed Resident #9 wince in pain. Resident #9 confirmed the pressure on the toe caused pain. Interview on 01/13/26 at 4:02 P.M. with RN #227 confirmed the progress note in Resident #9's medical record was very confusing. RN #227 stated she could not determine by the note written on 01/07/26 if Resident #9's big toe on her left foot had been assessed. RN #227 confirmed the facility has not had any treatments for Resident #9's great toe on her left foot. RN #227 confirmed Resident #9 does have a large scabbed area on the top of her left great toe and two open cracked skin areas around the scab and the toe was reddened. RN #227 confirmed Resident #9 stated the toe was painful when pressure was applied. Interview on 01/14/26 at 12:34 P.M. with Resident #9's hospice case manager, Registered Nurse (RN) #619 confirmed on 01/06/26 the hospice aide identified a darkened area on Resident #9's left great toe. RN #619 stated a hospice nurse evaluated the toe and identified it as a deep tissue injury (DTI) and notified the facility. RN #619 stated the hospice nurse felt the DTI could have been from Resident #9's shoes. RN #619 stated the facility notified RN #619 on 01/07/26 that Resident #9 did not have any area to the toe and did not recommend a treatment. Review of the order summary report for Resident #9 revealed an order dated 01/13/26 revealed an order for a left lower leg doppler to rule out arterial. An order dated 01/13/26 with a start date 01/14/26 for left great toe treatment: cleanse with normal saline or wound cleanser, pat dry. Paint with betadine, leave open to air every day shift for wound care. Review of the email dated 01/14/26 at 4:29 P.M. to the facility wound nurse (FWN) #254 from the WNP #515 confirmed he assessed Resident #9's left great toe on 01/07/26. WNP #515 confirmed a 100% epithelialized and blanching but fragile area was noted. WNP#515 recommended panting with betadine and leaving open to air and to be re-evaluated. Interview on 01/21/26 at 10:04 A.M. with the Wound Nurse Practitioner (WNP) #515 confirmed he assessed Resident #9's left big toe on 01/07/26 and determined that Resident #9 required preventative measure be taken for Resident #9's discolored large big toe. He confirmed he requested a preventative order be put in place to start on 01/07/26 to paint with betadine and leave open to air. Interview on 01/13/26 at 4:20 P.M. with the FWN #254 confirmed the facility failed to start the preventative order requested on 01/07/26 by WNP #515 to paint Resident #9's great left toe with betadine and leave open to air. Subsequent interview on 01/21/26 at 10:00 A.M. with FWN #254 confirmed the facility failed to have skin assessments completed for Resident #9. FWN #254 confirmed the following skin assessments for Resident #9 were created on 01/20/26 for the following dates 12/17/25, 12/24/25, 12/31/25, 01/07/26, and 01/14/26 locked on 01/20/26. 8. Review of the medical record revealed Resident #83 was admitted on [DATE] and discharged on 01/08/26 with diagnoses that included lumbago with sciatica, left side, COVID-19, elevated white blood cell count, acute respiratory failure, bradycardia, hyperlipidemia, and emphysema. The hospital discharge records dated 01/02/26 revealed orders for Resident #83's incision to be left open to air. The skin around the incision was to be washed daily with mild soap and water and patted dry. The admission evaluation/assessment dated [DATE] revealed Resident #83 had an incision to mid back vertebrae that measured 16 centimeters (cm) long and one cm wide. Review of the medication and treatment administration records revealed no evidence of Resident #83's skin around the incision to be washed and dried every day. A plan of care dated 01/12/26 revealed Resident #83 was at risk for skin breakdown/pressure ulcers. Interventions included to administer treatments as ordered and notify the physician and/or responsible party of non-compliance with treatment interventions. An interview on 01/21/26 at 11:16 A.M. the Director of Nursing verified the order to wash and dry the skin around Resident #83's incision every day should have been on the treatment administration record and completed as ordered. This deficiency represents non-compliance investigated under Complaint Number 2708970, 2594008.

Based on observation, resident interview, staff interview, and facility policy review the facility failed to provide a safe and homelike environment for residents including unsecured medications, fall prevention interventions, and functionality of facility doors. This affected five residents (#5, #10, #19, #31, #37) of five residents reviewed. The facility census was 65.Findings include: 1. Medical record review for Resident #31 revealed he was admitted to the facility on [DATE]. His diagnoses included obstructive sleep apnea, asthma, depression, allergic rhinitis, diabetes mellitus (DM), hypothyroidism, peripheral vascular disease, anxiety disorder, and venous insufficiency. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact. Resident #31 was dependent on staff for medication administration. Resident #31 required set up assistance from staff with eating, oral hygiene, toilet use, lower body dressing, putting on shoes, and personal hygiene. He required supervision with showers. Review of the physician Order Summary for Resident #31 revealed an order for the following medications; for Promethazine (for nausea and vomiting) 25 milligram (mg) dated 01/07/26 as needed with self-administration with nurse supervision, alzelastine (allergies) .1% dated 07/16/24 two sprays daily, dulera (asthma) inhaler dated 09/20/24 two puffs inhaled daily, Albuterol inhaler aerosol inhalation (shortness of breath)108 dated 11/20/24 two puffs every six hours as needed, Fluticasone propionate suspension (allergies) 50 mcg (microgram) dated 07/16/24,dulera (asthma) inhalation aerosol 100-5 mcg/act two puffs dated 09/20/24, Albuterol sulfate (shortness of breath) dated 11/20/24 two puffs every six hours as needed, betamethasone Dipropionate cream (for scars) .1% apply to left and right knee daily dated 04/03/24, clotrimazole-betamethasone external cream (foot fungal infection) 1-0.05% dated 07/18/24 apply to feet two times daily, and ammonium lactate 12% (affected skin areas) dated 11/12/24 apply to affected skin once daily Observation on 01/12/26 at 9:49 A.M. revealed Resident #31 was in his room. Identified the following medications in his room. Observed some of the medications were lying at the foot of his bed in a clear plastic return from the hospital bag and others were stuffed in his backpack. Observed Promethazine on the bedside table, and the following additional medications in Resident #31's room , alzelastine (allergies ) .1% , dulera (asthma) inhaler, Albuterol inhaler aerosol inhalation (shortness of breath), dulera (asthma) inhalation aerosol, Albuterol sulfate (shortness of breath), betamethasone Dipropionate cream (for scars), clotrimazole-betamethasone external cream (foot fungal infection, and ammonium lactate 12% (affected skin areas), Symbicort (shortness of breath), and Breo Ellipta (asthma). Interview on 01/12/26 at 9:49 A.M. with Resident #31 confirmed he keeps medication in his room. Resident #31 pointed at the medication on his bedside table (Promethazine) and stated he is allowed to take that when he needs it. Resident #31 confirmed he had other medications in his room and some of the medications he did not have orders for. Resident #31 pulled bags of medication from his hospital stay bags lying in his room. Resident #31 stated he keeps medications in his room as evidence that the facility is not following doctor's orders. Interview on 01/12/26 at 10:29 A.M. with Registered Nurse (RN) #287 confirmed the following medications were found in Resident #31's room; observed Promethazine on the bedside table, and the following additional medications in Resident #31's room , alzelastine (allergies ) .1% , dulera (asthma) inhaler, Albuterol inhaler aerosol inhalation (shortness of breath), dulera (asthma) inhalation aerosol, Albuterol sulfate (shortness of breath), betamethasone Dipropionate cream (for scars), clotrimazole-betamethasone external cream (foot fungal infection, and ammonium lactate 12% (affected skin areas), Symbicort (shortness of breath), and Breo Ellipta (asthma). RN #287 confirmed Resident #31 did not have an active order for the Breo Ellipta (asthma) medication or Symbicort (shortness of breath) medications. Interview on 01/12/26 at 4:25 P.M. with the Administrator confirmed she was aware that Resident #31 kept a medication in his room and that is because he has am assessment and order to self-administer medication. The Administrator confirmed there is only one medication that had an order to self-administer under the supervision of a nurse and that was the medication Promethazine. She confirmed Resident #31 did not have an order to self-administer any other medications. 2. Medical record review for Resident #37 revealed he was admitted to the facility on [DATE]. His diagnoses included cardiomegaly, mixed hyperlipidemia, primary osteoarthritis, sleep apnea, primary osteoarthritis, obstructive sleep apnea, obesity, congestive heart failure, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact. Resident #37 was dependent on staff for medication administration; Resident #37 was independent with eating and personal hygiene. He required moderate assistance from staff with putting on shoes. He required maximum assistance from staff with toilet use, bathing, upper body dressing, lower body dressing, Review of the physician orders for Resident #37 confirmed the following medications were ordered; Spironolactone (hypotension) 25mg dated 03/10/25, Senna -s (constipation) 8.6-50 mg dated 04/03/25, amiodarone (abnormal heart rhythm) 200 mg dated 03/10/25, empagliflozin (diabetes mellitus) 10 mg, dated 03/11/25, Losartan (high blood pressure) 25mg start dated 03/11/25, Metoprolol Succinate (high blood pressure) 50 mg dated 03/10/25, potassium chloride ER 20 milliequivalent (mcg) (diuretic therapy) dated 10/14/25. Observation on 01/12/26 at 10:30 A.M. revealed Resident #37 had a cup of medications on his bedside table. The cup contained a total of six pills. Interview on 01/12/26 at 10:31 A.M. with Registered Nurse (RN) #287 confirmed Resident #37 had the following medications in a medicine cup on his bedside table. RN #287 confirmed it was the morning medication for Resident #37. She confirmed the following medications were in the cup located on the bedside table; potassium chloride 20 MEQ, Senna 8.6-5-mg, amiodarone 200 mg, empagliflozin 10 mg, lozartin 25 mg, Metoprolol 50 mg, and Spironolactone 25 mg. RN #287 confirmed Resident #37 is unable to self-administer medications. Review of the facility policy titled, Medication Administration, undated, confirmed all medications are administered safely and appropriately aide residents to overcome illness. Further review of the policy confirmed medications are administered only by licensed nursing personnel or a physician. Review of the facility policy titled, Medication Labeling and Storage, dated February 2023, confirmed the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Review of the facility policy titled, Homelike Environment, dated February 2021, confirmed residents are provided with a safe homelike environment. 3. Record review for Resident #10 revealed she was admitted to the facility on [DATE]. Her diagnoses included spinal stenosis, diabetes mellitus, bipolar disorder, anxiety disorder, attention-deficit disorder, depressive disorder, gastro-esophageal reflux disorder (GERD), major depressive disorder, primary osteoarthritis, and insomnia. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 10/29/25 revealed Resident #10 was cognitively intact. Further review for Resident #10 revealed she was dependent on staff for medication administration. She required supervision from staff with eating, toilet use, bathing, Resident #10 was independent with oral hygiene, upper body dressing, lower body dressing, putting on shoes, and personal hygiene. Review of the progress notes for Resident #10 revealed a late entry fall note was written on 10/14/25 at 8:40 A.M. for 10/09/25 at 11:46. This note confirmed Resident #10 had a fall from her bed and sustained a skin tear to the right forehead that measured 2 centimeters (cm) by .75 cm. the wound was cleansed and applied dry dressing. Review of the fall care plan for Resident #10 dated 10/10/25 revealed to assure Resident #10 to utilize 1/2 handrail to the right side of the bed. Interview on 01/15/26 at 3:05 P.M. with the DON confirmed the facility failed to identify Resident #10's fall on 10/09/25 until a late entry fall note was written on 10/14/25 at 8:40 A.M. The late entry note revealed Resident #10 had a fall on 10/09/25 at 11:46 P.M. Resident #10 stated she was reaching for something on her bedside table and ended up on the floor. Resident #10 sustained a skin tear to the right forehead. Further review of the notes confirmed the facility initiated the fall intervention to utilize arm rails until 10/14/25. 4. Review of Resident #19's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, diabetes, anxiety, depression, absence of the right great toe and peripheral vascular disease. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed his cognition was intact. He requires supervision or touching assistance for eating, oral hygiene, toileting, shower/bathing, dressing, personal hygiene and independent for turning and repositioning. Occasionally incontinent of urine and always continent of bowel. Review of the progress notes dated 12/31/25 at 10:20 A.M. revealed a skin issue to the left big toe and a treatment was started. On 01/14/26 at 7:40 A.M. interview with Resident #19 revealed the wound to his toe happened when the front door was broken and it had slammed on his toe. On 01/15/26 at 11:07 A.M. interview with Registered Nurse (RN) #246 revealed she received communication from the facility nurse revealed Resident #19 had gotten his toe crushed in the front door on 01/03/26 (door was broken at that time). She also verified it was not documented on the incident accident log and no documentation in the medical record. On 01/15/26 at 1:27 P.M. interview with the Maintenance Director revealed the front door was fixed by an outside vendor on 01/06/26. It was first reported broken on 12/14/25. The reason it took so long was because they had to order parts. 5. Review of the medical record for Resident #5 revealed an admission date of 09/01/23. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, psychomotor deficit following cerebral infarction, respiratory failure, hypertensive heart disease with heart failure, chronic diastolic congestive heart failure, centrilobular emphysema, severe dementia, dysphagia, depression, mood disorder, convulsions, obesity, and atherosclerotic heart disease. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severely impaired cognition, with a BIMS score of 2. The MDS further indicated the resident required extensive to total assistance for bed mobility and transfers, was dependent for toileting hygiene and lower extremity dressing, required maximum assistance with upper extremity dressing and rolling left and right, and utilized a wheelchair for mobility. Section J documented one fall since the last assessment with no injury. Review of the fall risk assessment dated [DATE] revealed the resident was assessed as a high fall risk, with a score of 18. Review of the plan of care revealed the resident was identified as being at risk for falls due to impaired mobility, cognitive impairment, and a history of falls. Fall-related interventions included: Assure 1/2 side rails bilaterally to assist with turning and repositioning and encourage appropriate use, initiated on 09/02/25 and revised on 10/20/25. Placement of fall mats to bilateral sides of the bed, initiated on 08/31/25 and revised on 11/05/25. Adjust air mattress to the resident's comfort to enable sitting on the side of the bed with needed support, initiated and revised on 10/20/25. Anticipate resident needs including hunger, thirst, toileting needs, comfort level, turning/repositioning, minimizing noise, and pain management, initiated on 07/15/25 and revised on 10/20/25. Encourage use of wheelchair to go to the bathroom, initiated on 10/05/23 and revised on 07/15/25. Encourage use of proper, well-maintained non-skid footwear as tolerated, initiated and revised on 11/03/25. Ensure call light is within reach and encourage use for assistance as needed, initiated on 07/15/25. Offer toileting after all meals and provide check and change as needed, initiated on 01/22/24 and revised on 11/03/25. Reposition the resident to the center of the bed as needed to enhance safety and minimize fall risk, initiated on 09/02/25. Evaluate effectiveness of psychotropic medications with the physician for possible dose decrease or discontinuation, initiated on 09/04/23 and revised on 01/09/25. Observe for adverse medication effects including dizziness, drowsiness, and sedation and assist with ADLs and notify the physician or nurse practitioner if symptoms are observed, initiated on 09/04/23. Review of physician orders identified fall-related safety devices and interventions consistent with the care plan, including use of fall mats and bed rails for assistance with maneuverability. Review of the bed rail assessment dated [DATE] revealed the 1/2 bed rails were to assist with maneuverability. Review of nursing notes dated 08/31/25 at approximately 6:45 PM revealed the resident was found partially on the floor, lying on his back with his head against the bed and his right arm and hand stuck between the bed rail and frame. The fall was unwitnessed. The resident was confused and unable to state why he was on the floor. The resident complained of right shoulder, arm, and hand pain, with bruising noted. Three staff assisted the resident back to bed using a mechanical lift. Review of nursing notes dated 11/01/25 at approximately 2:30 PM revealed the resident was found on his knees on the floor mat next to the bed, holding the bed rail with his left hand. The fall was unwitnessed. The resident stated he wanted to go to the restroom. A skin tear to the right wrist was noted. The resident complained of knee pain and received PRN pain medication. The post-fall documentation indicated all safety interventions were in place at the time of the occurrence. Review of the post-fall assessment dated [DATE] indicated the resident remained alert and oriented with confusion, consistent with baseline, and neuro checks were initiated. An intervention to offer toileting after meals and provide check and change as needed was documented. Observation on 01/12/26 at 10:03 AM revealed the resident's bed was raised and a fall mat was present on both sides of the bed; however, the fall mat on the left side was pushed almost completely underneath the bed, limiting its ability to provide protection in the event of a fall. Interview on 01/12/26 at approximately 10:28 AM with Registered Nurse (RN) #200 confirmed the resident's bed was not in the lowest position and the fall mat on the left side was positioned too far under the bed. RN #200 stated that if the resident were to fall from the bed, he would fall directly onto the floor. RN #200 repositioned the fall mat at the time of the interview. RN #200 stated there was no specific physician order for the bed to be maintained in the lowest position, but that it was facility protocol to keep beds in the lowest position for resident safety. Review of the facility policy titled Falls and Fall Risk, Managing (revised March 2018) revealed that staff implement resident-centered fall prevention interventions based on specific risk factors and causes. Interventions are introduced gradually (one or a few at a time) and may include exercise/balance training, better footwear, room rearrangement, improved lighting, medication review/adjustment with physician and pharmacist input, hip padding or osteoporosis treatment, and addressing environmental hazards like wet floors, poor lighting, obstacles, improper bed height, or unsafe wheelchairs. Position-change alarms support monitoring but are not primary or sole interventions, with prompt staff response required. If falls continue, staff add or change interventions until falls decrease or unavoidable causes are documented. Ongoing monitoring tracks response, with re-evaluation and physician input for persistent issues, and notation of irreversible risks. This deficiency represents non-compliance investigated under Complaint Number 2669834, 1350536.

Based on observations, interviews, standards of care, and policy review, the facility failed to have adequate linens available for resident use. This had the potential to affect all 24 residents located on the first floor. The facility census was 65.Findings include: An interview on 01/12/26 at 11:39 A.M. with Resident #34 (resides on the first floor of the facility) revealed there were not enough towels and washcloths for residents to use to be showered as scheduled. An observation on 01/14/26 at 10:14 A.M. revealed the room on the first floor where linens were kept had 14 bath towels, no washcloths, no bed pads, and no fitted sheets. At the time of the observation, Certified Nursing Assistant (CNA) #279 verified this was the only area clean linens were kept on the first floor. CNA #279 stated the staff could go to the laundry room to see if there were clean linens there. An observation on 01/14/26 at 10:21 A.M. of the laundry room revealed there were no dirty linens waiting to be washed and there was only one washer with items being washed. There were eight fitted sheets, eight bed pads, 12 towels, and 17 washcloths washed and folded in the laundry room. An interview on 01/14/26 at 10:32 A.M. with Housekeeping Supervisor (HS) #308 revealed he had recently put out 300 towels and many washcloths. HS #308 verified the staff reported there were not enough linens to provide care for the residents. HS #308 stated that some of the items could be thrown away but a lot of times the extra linen was found in resident rooms. HS #308 stated the CNA's took large amounts of linens to resident rooms and would leave the unused linens in resident rooms. HS #308 verified the staff had complained about not having enough linen and that was why extra linens were recently put out in the clean linen rooms located on the first and second floor. On 01/14/26 at 1:29 P.M. a resident council meeting was held. Residents #10 and Resident #59 (residing on the first floor) revealed showers could not be done because there were no towels. There have also been times when clean linens cannot be put on the beds because there were no fitted sheets. Resident #59 also stated she was given a fitted sheet that was supposed to be clean but smelled of urine and was soiled. Review of the Certified Nursing Assistant (CNA) Standards of Care revealed showers and nail care to be completed as assigned or requested and linens were to be changed on shower days and as needed. Review of the Homelike Environment Policy dated February 2021 revealed the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include clean bed and bath linens that are in good condition. This deficiency represents non-compliance investigated under Complaint Number 2594008

Based on observation, staff interview, and policy review, the facility failed to ensure all medications, including tuberculin solution, were accurately labeled and discarded upon expiration. This affected seven residents (#7, #19, #24, #57, #61, #64, #68) of 65 residents. The facility census was 65.Findings include: 1.Review of the medication carts and medication storage room on [DATE] at 3:04 PM by Licensed Practical Nurse (LPN) #224 revealed multiple opened medications without documentation of the date they were opened, in violation of safe medication storage standards. Two medication carts and one medication room were reviewed. Observations included: Resident #7's insulin pen with no open date; Resident #64's Lotan eye drops open with no date; Resident #68's Albuterol open with no date; Resident #7's Tiotropium (Spiriva) open with no date; Resident #24 Advair inhaler (fluticasone/salmeterol) open with no date; Resident #19's Albuterol inhaler open with no date; Resident #61's Tiotropium open with no date; Resident #61's Albuterol open with no date; Resident #7's Albuterol inhaler open with no date; Resident#61's Fluticasone nasal spray with an open date of [DATE]; and Resident #7's Fluticasone nasal spray open with no date. Review of the medication storage room revealed two additional boxes of Albuterol assigned to Resident #57 with expiration dates of [DATE] and [DATE]. Review of the medication guidelines revealed that opened medications have manufacturer-recommended discard timelines to ensure safety and effectiveness. Specifically: Insulin pens should be discarded 28 days after opening; Latanoprost eye drops should be discarded 42 days after opening; Tiotropium (Spiriva) inhalers should be discarded 3 months after opening/assembly; Advair (fluticasone/salmeterol) should be discarded 1 month after opening the protective pouch; Albuterol inhalers should be discarded 6 months after opening or when the dose counter reaches zero; and Fluticasone nasal sprays should be discarded 90 days after opening or per manufacturer instructions. Interview on [DATE] at 3:04 PM during the observations of the med cart and med storage room with LPN #224 confirmed that staff were aware medications should be dated when opened and discarded according to manufacturer or pharmacy guidance, but acknowledged that this process was not followed for the medications observed in both the med carts and the storage room. Review of the facility policy titled Medication Labeling and Storage revealed that multi-dose vials that have been opened or accessed (e.g., needle punctured) must be dated at the time of first use and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the opened vial. Unopened multi-dose vials are discarded according to the manufacturer's expiration date. These requirements ensure safe use and prevent administration of expired or contaminated medications, aligning with standard pharmaceutical practices for labeling opened multi-dose products. 2. An observation on [DATE] at 3:12 P.M. of the medication room on the first floor revealed an open and undated vial of tuberculin solution in the medication refrigerator. Registered Nurse (RN) #232 verified the vial of tuberculin solution was open and undated. RN #232 verified he did not know when the vial was opened and discarded the tuberculin solution. Review of the facility policy titled Medication Labeling and Storage revealed that multi-dose vials that have been opened or accessed (e.g., needle punctured) must be dated at the time of first use and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the opened vial. Unopened multi-dose vials are discarded according to the manufacturer's expiration date. These requirements ensure safe use and prevent administration of expired or contaminated medications, aligning with standard pharmaceutical practices for labeling opened multi-dose products.

Based on medical record review, staff interview and facility policy and procedure review, the facility failed to ensure resident Pre-admission Screening and Resident Review (PASARR) were updated after receiving new diagnoses. This affected three residents (#6, #12 and #65) of three residents reviewed for PASARR screening. The census was 65. Findings include:1.Review of Resident #65's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included dementia, bipolar disorder, depression, anxiety, peripheral vascular disease, diabetes and chronic kidney disease. Review of the quarterly minimum data set assessment (MDS) dated [DATE] revealed her cognition was not intact, she was dependent on staff for eating, oral hygiene, toileting, dressing, personal hygiene and turning and repositioning. She was incontinent of bowel and bladder. Review of the Preadmission Screening and Resident Review (PASARR) dated 09/03/23 revealed a diagnosis of dementia. Further review revealed new diagnoses on 11/01/24 of bipolar disorder and anxiety, On 09/01/25 a new diagnosis of depression was added with no evidence of an updated PASARR. On 01/15/26 at 8:59 A.M. interview with Social Service Director #264 verified there was no updated PASARR completed. Review of the PASARR-Pre admission Screening and Resident Review policy dated 11/2016 and revised 03/28/24 with an effective date 03/28/24 revealed the Social Service Director and/or designee shall be responsible for keeping track of each resident's PASSAR screening status and referring to the appropriate authority. 2. Review of the medical record for Resident #6 revealed an admission date of 06/23/22, with a re-entry date of 06/12/24. Diagnoses included, but were not limited to, neurocognitive disorder with Lewy bodies, unspecified dementia with behavioral disturbance, dementia in other diseases with mood disturbance, cognitive communication deficit, bipolar disorder, major depressive disorder, anxiety disorder due to a known physiological condition, insomnia, neutropenia, syncope and collapse, anorexia, hypotension, venous insufficiency, peripheral vascular disease, acute embolism and thrombosis of an unspecified vein, edema, hypokalemia, and hyperlipidemia. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of one, reflecting severe cognitive impairment. Review of the Quarterly MDS dated [DATE] continued to reflect a BIMS score of one, indicating severe cognitive impairment. Review of the medical record revealed the resident was diagnosed with multiple new mental health and cognitive conditions during the stay, including dementia in other diseases with mood disturbance (diagnosed 01/31/25), anxiety disorder due to a known physiological condition (diagnosed 01/31/25), insomnia (diagnosed 03/18/25), neurocognitive disorder with Lewy bodies (diagnosed 06/25/25), and cognitive communication deficit (diagnosed 09/11/25). Review of Preadmission Screening and Resident Review (PASARR) documentation revealed that these newly diagnosed mental health conditions did not trigger a new PASARR at the time they were identified. The most recent PASARR prior to surveyor intervention was completed on 09/02/23 and did not reflect the resident's current mental health diagnoses. Review of PASARR records further revealed that a new PASARR was not completed until 01/15/26, following surveyor intervention. Review of the PASARR completed on 01/15/26 revealed it continued to omit the resident's newly diagnosed mental health and cognitive conditions, including dementia with mood disturbance, anxiety disorder due to a known physiological condition, and insomnia. The PASARR dated 01/15/26 indicated that a Level II evaluation was not required; however, the PASARR documentation did not accurately reflect the resident's current diagnoses at the time the determination was made. Interview on 01/15/26 at approximately 9:00 A.M. with Social Work Director #264 revealed she had been employed in her role since February 2025. She was unable to identify documentation demonstrating that the resident's newly diagnosed mental health conditions triggered a timely PASARR update prior to 01/15/26 and confirmed that the PASARR completed on 01/15/26 did not include the resident's newly identified diagnoses. 3. Medical record review for Resident #12 revealed she was admitted to the facility on [DATE]. Her diagnoses included, gastro-esophageal reflux disease (GERD), peripheral vascular disease, major depressive disorder, atrial fibrillation, essential primary hypertension, insomnia, anemia, paranoid schizophrenia, heart failure, dementia, and acute kidney failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had impaired cognition. Resident #12 was dependent on staff for medication administration. She required set up assistance from staff with eating and oral hygiene. Resident #12 required supervision from staff with toilet use, upper body dressing, and personal hygiene. She required moderate assistance from staff with showers, lower body dressing, personal hygiene, and putting on shoes. Review of the Pre admission Screening/Resident Review (PAS/RR) dated 07/17/21 revealed the facility failed to identify Resident #12's diagnoses of paranoid schizophrenia. Interview on 01/15/26 at 12:04 P.M. with the Director of Social Services (DSS) #264 confirmed the Resident #12 has a diagnosis of paranoid schizophrenia that the facility failed to identify on her most recent PASARR review. DSS #264 confirmed the paranoid schizophrenia diagnosis was added to Resident #12's medical record in December 2024 and another PASARR screening should have been completed at that time. Review of the facility policy titled, PASARR-Pre admission Screening Resident Review, dated 03/28/24 confirmed PASARR Level 1 initial prescreening is completed prior to admission. Level 1 Screen-permits admission to proceed to the facility and ends the PASRR process unless a possible serious mental health disorder or intellectual diagnoses is added later.

Based on medical record review, staff interview, and policy review the facility failed to document a resident's discharge and develop a discharge plan for one Resident #74. This affected one resident (#74) of two residents reviewed for discharge. The facility census is 65.Findings include:Medical record review for Resident #74 revealed she admitted to the facility on [DATE] for a respite stay and discharged from the facility on 12/31/25 with Heartland Hospice. Her diagnoses included, gastro -intestinal hemorrhage, protein-calorie malnutrition, intestinal malabsorption, pulmonary hypertension, congestive heart failure (CHF), and hyperlipidemia. Resident #74 required a hospice stay. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #74 revealed she had moderately impaired cognition. She was dependent on staff for medication administration. Resident #74 required set up assistance from staff with eating. She required maximum assistance from staff with oral hygiene, toilet use, bathing, upper body dressing, lower body dressing, putting on shoes, and personal hygiene. Review of the Care Plans for Resident #74 revealed the facility failed to complete a care plan related to discharge planning. Review of the progress notes dated 12/31/25 at 3:44 P.M. for Resident #74 revealed discharge order was received from the Hospice company, for Resident #74 to discharge to Hospice at 1:30 P.M. Resident #74 was stable at time of discharge. Review of the Discharge Summary for Resident #74 revealed there was no Discharge Summary. Interview on 01/13/26 at 2:50 P.M. with the Director of Nursing (DON) confirmed the facility failed to document a discharge plan for Resident #74. The DON confirmed the facility failed to provide of a clear understanding of where Resident #74 went after discharge form the facility. The DON was unable to confirm if Resident #74 discharged to her home or to an inpatient hospice. The DON confirmed the facility failed to provide written instructions for Resident #74 at discharge. The DON confirmed the facility failed to document if Resident #74's representative was notified of the discharge from the facility. Review of the facility policy titled, Transfer or Discharge, dated March 2025 confirmed once a Resident is admitted to the facility, residents have the right to remain in the facility. Transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record. Further review of the policy confirmed once a resident transfers or discharges from the facility the following information is documented in the resident's medical record; the bases for transfer, the new location of the resident, a summary of the residents overall medical, physical, and mental condition, disposition of medicine, disposition of personal effects, the signature of the person recording the data. Review of the facility policy titled, Discharge Summary and Plan, dated March 2025 confirmed when a resident's discharge is anticipated, a discharge summary is created, and the discharge plan is finalized to assist the Resident with plans for care after discharge. Further review of the policy confirmed a copy of the discharge summary is included in the resident's medical record. A discharge summary includes a recapitulation of a resident's stay at the facility, a final summary of the resident's status at the time of discharge, and a reconciliation of all pre-discharge medication with the president's post discharge medications.

Based on medical record review, staff interview, and policy review the facility failed to provide a resident with a proper discharge including a discharge plan or summary. This affected one resident (#74) of two residents reviewed for discharge from the facility. The facility census is 65. Findings include:Medical record review for Resident #74 revealed she admitted to the facility on [DATE] for a respite stay and discharged from the facility on 12/31/25 with Heartland Hospice. Her diagnoses included, gastro -intestinal hemorrhage, protein-calorie malnutrition, intestinal malabsorption, pulmonary hypertension, congestive heart failure (CHF), and hyperlipidemia. Resident #74 required a hospice stay. Review of the Minimum Data Set (MDS) dated [DATE] for Resident #74 revealed she had moderately impaired cognition. She was dependent on staff for medication administration. Resident #74 required set up assistance from staff with eating. She required maximum assistance from staff with oral hygiene, toilet use, bathing, upper body dressing, lower body dressing, putting on shoes, and personal hygiene. Review of the progress notes dated 12/31/25 at 3:44 P.M. for Resident #74 revealed discharge order was received from the Hospice company, for Resident #74 to discharge to Hospice at 1:30 P.M. Resident #74 was stable at time of discharge. Review of the Care Plans for Resident #74 revealed the facility failed to complete a care plan related to discharge planning. Review of the Discharge Summary for Resident #74 revealed there was no Discharge Summary. Interview on 01/13/26 at 2:50 P.M. with the Director of Nursing (DON) confirmed the facility failed to document a discharge plan for Resident #74. The DON confirmed the facility failed to provide a clear understanding of where Resident #74 went after discharge form the facility. The DON was unable to confirm if Resident #74 discharged to her home or to an inpatient hospice. The DON confirmed the facility to provide written instructions for Resident #74 at discharge. The DON confirmed the facility failed to document if Resident #74 representative was notified of the discharge from the facility. The DON confirmed the facility failed to complete a Discharge Summary. Review of the facility policy titled, Transfer or Discharge, dated March 2025 confirmed once a Resident is admitted to the facility, residents have the right to remain in the facility. Transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record. Further review of the policy confirmed once a resident transfers or discharges from the facility the following information is documented in the resident's medical record; the bases for transfer, the new location of the resident, a summary of the residents overall medical, physical, and mental condition, disposition of medicine, disposition of personal effects, the signature of the person recording the data.Review of the facility policy titled, Discharge Summary and Plan, dated March 2025 confirmed when a resident's discharge is anticipated, a discharge summary is created, and the discharge plan is finalized to assist the Resident with plans for care after discharge. Further review of the policy confirmed a copy of the discharge summary is included in the resident's medical record. A discharge summary includes a recapitulation of a resident's stay at the facility, a final summary of the resident's status at the time of discharge, and a reconciliation of all pre-discharge medication with the president's post discharge medications.

Based on review of the Medicare beneficiary notices and staff interview, the facility failed to notify two residents (#1, #49) of three Medicare beneficiary notices reviewed. The census was 65. Findings include:1. Review of Resident #1's Medicare beneficiary discontinuation of services letter revealed Resident #1 was notified on 08/05/25 of skilled services being discontinued on 08/08/25. The notification only identified skilled services were being cut on 08/08/25 and failed to identify the actual service. 2. Review of Resident #49's Medicare beneficiary discontinuation of services letter revealed Resident #49 was notified on 08/27/25 of skilled services being discontinued on 08/29/25. The notification is only identified skilled services were being cut on 08/29/25 and failed to identify the actual service. On 01/21/26 at 10:32 A.M. interview of the Social Service Director verified the Medicare beneficiary discontinuation of services letters for Residents #1, #49 were not specific to the service being discontinued.

Based on medical record review, review of a fall investigation, resident and staff interviews, and facility policy review, the facility failed to effectively manage one resident's (Resident #43) pain following an unwitnessed fall which resulted in a T12 spinal fracture. Actual harm occurred on 10/07/24 when Resident #43 reported head, neck, and low back pain to Unit Manager (UM) #267. Resident #43 reported an unwitnessed fall occurred in her room on 10/06/24. Resident #43 received scheduled pain medications at 8:04 A.M. Certified Nurse Practitioner (CNP) #700 assessed Resident #43 on 10/07/24 at approximately 9:00 A.M. The resident reported 10 out of 10 pain where 10 is the worst pain possible and was visibly crying while ambulating with her walker. CNP #700 ordered Resident #43 to be transported to the hospital for further evaluation via non-emergency transportation. Resident #43 did not receive any non-pharmacological interventions or pain medication. Resident #43 arrived at the hospital at 12:39 P.M. (almost four hours after being evaluated by CNP #700) with severe low back pain. A Computed Tomography (CT) scan of Resident #43's thoracic and lumbar spine confirmed Resident #43 sustained an acute fracture of the T12 vertebrae (a type of vertebral fracture that occurs when the T12 vertebrae in the thoracic spine collapses or shrinks when too much pressure is applied to the spine from major or minor trauma and can affect lower body functions). This affected one (Resident #43) out of four residents assessed for pain. The facility census was 99. Findings Include: Review of the medical record for Resident #43 revealed an admitted on 07/18/18. Medical diagnoses included spinal stenosis thoracolumbar region, unspecified dementia, wedge compression fracture of third lumbar vertebra (07/03/23), age-related osteoporosis without current pathological fracture, post-traumatic headache (10/08/24), low back pain (10/08/24), and repeated falls (10/08/24). The acute fracture of Resident #43's T12 vertebra was not listed as a diagnosis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had impaired cognition and scored eight out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #43's primary language was Chinese. Resident #43 used a walker for ambulation. Resident #43 required setup or clean-up assistance with ambulation. Resident #43 received scheduled pain medication but did not receive as needed (PRN) pain medications or any non-medication interventions for pain. Resident #43 had frequent pain during the review period and reported a pain level of five out of ten where ten was the worst pain possible. Resident #43 had one fall with major injury since admission/readmission or prior assessment. Review of the Medication Administration Record (MAR) dated October 2024 revealed Resident #43 received two scheduled Tylenol 325 milligrams (mg) tablets, one scheduled Oxycodone Hydrochloride (HCl) 5 mg tablet, and one scheduled Gabapentin 400 mg capsule (for nerve pain) at 8:04 A.M. on 10/07/24. No additional scheduled pain medications were administered. The pain level indicated was 0. Resident #43 had the following PRN pain medications ordered: Acetaminophen 325 mg two tablets every four hours for pain, Lidocaine Patch 4% apply to affected area topically every 24 hours for pain, and Oxycodone HCl 5 mg every six hours for pain. Resident #43 was not administered any PRN pain medications on 10/07/24. There was no evidence non-pharmacological interventions had been attempted to manage Resident #43's pain. Review of the pain levels dated 10/07/24 revealed Resident #43 had a pain level of zero at 8:04 A.M. recorded by PRN Licensed Practical Nurse (LPN) #701. There was no additional pain levels recorded until 2:50 P.M. (two hours after Resident #43 had already been transported to the hospital). Review of the facility Fall Review assessment dated [DATE] at 10:35 A.M. and completed by LPN #701 revealed Resident #43 had new pain at a level of hurts a little more on the Wong-Baker FACES pain scale (a non-verbal pain scale) due to head and right buttock pain. The assessment was completed by UM #267. Review of the progress notes revealed a late entry note dated 10/07/24 at 10:35 A.M. revealed UM #267 was notified by Resident #43 of complaints of head and right buttock pain. Resident #43 stated she had an unwitnessed fall in her room on 10/06/24 while attempting to move a chair. CNP #700 was notified and ordered for Resident #43 to be transferred to the hospital for further evaluation. Per the Wong-Baker FACES pain scale (a non-verbal pain scale), Resident #43 had a pain level of three to four (described as hurts a little more). Pain was noted to be new since the residents ' fall. (This late entry note was created on 10/11/24 at 8:59 A.M. for an effective date on 10/07/24 (four days after the incident occurred by UM #267). On 10/07/24 at 10:50 A.M., CNP #702 assessed Resident #43 related to a chief complaint of: fall/hit head on the floor/right buttocks. The resident was assessed at the nurse's station where Resident #43 told the interpreter she fell on [DATE], hit her head and right buttocks on the floor. Resident #43 was crying in pain, noted to be 10 out of 10 pain on a pain scale where 10 was the worst pain possible. CNP #702 notified CNP #700. CNP #700 arrived on-site at the facility and ordered Resident #43 to be transferred to the hospital for further evaluation. Review of CNP #700's progress note, dated 10/07/24 and signed at 12:18 P.M., revealed Resident #43 was assessed due to an acute fall from 10/06/24 with complaints of headache along with right thigh, leg, and back pain. Resident #43 was crying in pain. Resident #43 already received a scheduled dose of Oxycodone with no relief. Resident #43's Power of Attorney (POA) was contacted and requested the resident be transferred to the hospital for further evaluation. Resident #43 was noted to be alert and oriented. There was noted tenderness to Resident #43's right hip, thigh, and lower back. Review of hospital records dated 10/07/24 revealed Resident #43 arrived at the hospital at 12:39 P.M. and was admitted at 12:43 P.M. for severe low back pain. An interpreter was used during the examination. Resident #43 fell on [DATE] at the facility and ever since had been experiencing excruciating pain along her right low back and right buttock. The resident denied having any other localized pain and was still ambulatory. Resident #43's blood pressure was elevated at 143/73, and she had a pulse of 100. A CT scan of Resident #43's thoracic and lumbar spine confirmed an acute fracture of T12 vertebral body without significant body height loss or retropulsion. Treatment options were discussed and due to Resident #43 being neurologically intact without any red flag signs or symptoms, urgent spine surgery was not warranted. Recommended continuing supportive measures for her T12 vertebral body fracture including a multimodal pain regimen and physical/occupational therapies as well as consideration for a Lumbar-Sacral Orthosis (LSO) or Thoracolumbar Sacral Orthosis (TLSO) (back braces) to be worn when out of bed for comfort. Resident #43 was discharged back to the facility on [DATE]. Review of Resident #43's care plan revealed a revision date on 10/21/24 (the same day surveyors entered the survey). Resident #43 was at risk for pain related to psychological distress (the focus area was initiated on 10/21/24). Interventions included administer pain medication per physician order, assess for pain, if experiencing pain rate pain per [NAME]-BAKER FACES PAIN SCALE and document/report complaints and non-verbal signs of pain, evaluate the effectiveness of pain interventions, and offer change in position and assistance as needed. An interview on 10/23/24 at 11:02 A.M. with UM #267 revealed Resident #43 reported complaints of head and back pain to her on 10/07/24 after a fall in her room occurred on 10/06/24 that was unwitnessed. The facility's nurse practitioner (CNP #702) as well as CNP #700 assessed Resident #43. UM #267 estimated the resident first complained of pain between 9:00 A.M. and 10:00 A.M. on 10/07/24 and was transferred out to the hospital within 20 to 30 minutes of being assessed. However, upon further review of the resident's hospital records, UM #267 confirmed Resident #43 did not arrive at the hospital until 12:39 P.M. (nearly four hours after being assessed). UM #267 confirmed Resident #43 did not receive any PRN pain medications or pain patch. UM #267 confirmed there was no evidence of any non-pharmacological interventions attempted. UM #267 confirmed there was no evidence of additional monitoring of Resident #43's pain level between when Resident #43 was assessed by CNP #702 and CNP #700 and when the resident was transferred to the hospital. Interviews on 10/23/24 at 3:51 P.M. and 10/24/24 at 9:29 A.M. via telephone with CNP #700 confirmed she assessed Resident #43 in the facility on the morning of 10/07/24. CNP #700 estimated the time of her assessment to have taken place around 9:00 A.M. CNP #700 confirmed Resident #43 was ambulatory but was observed crying and complaining of head, neck, and back pain at a severe level. CNP #700 ordered Resident #43 to be transferred out to the hospital for further evaluation due to concerns of uncontrolled pain levels and possible head injury. CNP #700 confirmed she did not feel the resident required emergent transport and agreed non-emergent transportation was appropriate. CNP #700 thought Resident #43 had been transported within 30 to 45 minutes of her assessment and was not aware Resident #43 did not arrive at the hospital until almost 1:00 P.M. (approximately four hours later). CNP #700 confirmed had she been aware of the delayed transport, she would have ordered an additional dose of Oxycodone be administered to Resident #43 as well as close monitoring until the resident was able to be transported. An interview on 10/24/24 at 1:38 P.M. with PRN LPN #701 via telephone confirmed she cared for Resident #43 during day shift on 10/07/24. LPN #701 stated when she entered Resident #43's room to administer morning medications, she noticed the resident to be visibly upset and was pointing at her leg area. LPN #701 stated she reported her observations to UM #267 and indicated she felt they needed to figure out what was going on because of the language barrier. UM #267 assessed Resident #43 and was able to determine that the resident had a fall in her room on 10/06/24 that was unwitnessed. The CNP (CNP #700) was notified and arrived on-site to assess Resident #43 around 9:00 A.M. she thought. CNP #700 ordered for Resident #43 to be transferred to the hospital for further evaluation due to uncontrolled pain and a possible head injury. LPN #701 stated Resident #43 was supposed to be picked up within 30 to 45 minutes but was not transported until around 12:30 P.M. for unknown reasons. LPN #701 confirmed Resident #43 was still able to ambulate but did appear to have pain. LPN #701 confirmed she had not attempted any non-pharmacological interventions, did not administer any PRN pain medications, did not notify CNP #700 of the delayed transport, and could not recall when or if she had completed another pain assessment on Resident #43. LPN #701 stated she felt Resident #43 was okay because she was still able to ambulate. Review of the facility policy, Pain Assessment and Management, reviewed 11/30/23, revealed the policy indicated, Pain Management was defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Conduct a comprehensive pain assessment upon admission to the facility, post fall, and the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Observe the resident (during rest and movement) for physiological and behavioral (non-verbal) signs of pain. Ask the resident if he/she is experiencing pain. Attempt non-pharmacological interventions prior to administering medication. Review the medication administration record to determine how often the individual requests and receives pain medication, and to the extent the administered medications relieve the resident's pain. This deficiency represents non-compliance investigated under Complaint Number OH00158407.

Based on closed medical record review, hospital record review, pharmacy medication regimen review, interviews with staff, Medical Director #404, Pharmacy Clinical Director #406, and Family Member #500, review of information on the American Heart Association Website www.heart.org, review of the Eliquis online customer information, and consultant pharmacy contract review, the facility failed to prevent a significant medication error for Resident #105. This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #105, who had a history of atrial fibrillation (a condition of rapid heartrate), and cerebral vascular accident (CVA/stroke) did not receive physician ordered anticoagulation therapy (Eliquis) to prevent blood clot formation from [DATE] to [DATE]. On [DATE], Resident #105 was transferred to the hospital with presenting symptoms of facial droop and aphasia (difficulty speaking). The resident was admitted to the hospital on [DATE] with an embolic stroke and subsequently passed away on [DATE] with hospice services. This affected one resident (#105) of five residents reviewed for anticoagulant therapy. The census was 103. On [DATE] at 11:20 A.M., the Administrator and Clinical Services Manager (CSM) #408 were notified Immediate Jeopardy began on [DATE] when the facility failed to ensure hospital orders to increase Resident #105's Eliquis were implemented resulting in a significant medication error. The facility failed to administer the medication between [DATE] and [DATE]. On [DATE], Resident #105 was assessed to have facial drooping and aphasia (difficulty speaking). The resident was emergently transported to the hospital on [DATE] and was admitted due to suffering an embolic stroke. The resident passed away on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 5:35 P.M. Resident #105 was transferred to the hospital for a change in condition. On [DATE] at 1:10 P.M., the daughter of Resident #105 spoke with Licensed Social Worker (LSW) #246, in person, regarding a status update on the resident and reported a concern that Resident #105 may not have been taking the correct medications (Eliquis). On [DATE] at 10:00 A.M., Resident #105's daughter came to the facility to collect the resident's belongings and informed Receptionist #292 that the resident had passed away. On [DATE] at 8:00 A.M., CSM #408 provided in-person and via phone education to all 24 floor nurses including Licensed Practical Nurses (LPN) #248, #250, #252, #254, #256, #258, #260, #262, #264, #266, #268, #270, #272, #274, #276, #278, #280; Registered Nurses (RNs) #298, #300, #302, #304, #306, #308, #310, and two administrative nurses, RN #296 and the DON, on the policies for order transcription and the admission process/checklist. The admission checklist was updated on [DATE] to include, but not limited to, entering orders from the hospital and admission/readmission orders to the facility. On [DATE] at 8:00 A.M., 27 residents (#1, #2, #3, #7, #8, #11, #12, #16, #29, #38, #42, #47, #48, #58, #62, #65, #68, #72, #79, #80, #88, #94, #95, #96, #97, #98, #101) with anticoagulants orders were audited by [NAME] President of Clinical Services (VPCS) #517 and CSM #408 to ensure physicians orders were transcribed correctly with no discrepancies identified. On [DATE] at 8:00 A.M. all current residents who had been admitted /readmitted to the facility from [DATE] through [DATE] were reviewed on [DATE] to ensure physicians orders were transcribed correctly. Thirty-three admission records were reviewed (#4, #7, #9, #16, #17, #28, #29, #30, #34, #36, #40, #43, #46, #54, #55, #56, #58, #66, #72, #76, #78, #79, #80, #83, #85 #88, #89, #92, #93, #97, #95, #98, #101) and 17 records (#7, #9, #16, #17, #28, #30, #36, #54, #55, #58, #66, #78, #79, #83, #85, #88, #97) had admission orders containing potential discrepancies. Potential discrepancies were between the hospital discharge orders and what was entered into the electronic medical record. The DON clarified these discrepancies with Nurse Practitioner (NP) #402 and orders were correctly transcribed. There were no negative outcomes because of the discrepancies. On [DATE] at 8:30 A.M., upon Quality Review of Resident #105's medical record completed by CSM #408, the root cause analysis identified that a transcription error had occurred during the readmission of Resident #105 on [DATE]. Eliquis had been increased during Resident #105's hospitalization but the order wasn't transcribed during readmission. On [DATE] at 10:00 A.M., an Ad Hoc Quality Assurance and Performance Improvement (QAPI) Meeting was held with the Administrator, DON, CSM #408, VPCS #517, Unit Manager #282, Assistant Director of Nursing (ADON), RN #312, and Medical Director #404 (via telephone), to review the root cause analysis completed by CSM #408 and the system in place to ensure that residents receive medications as ordered by the physician and to meet their total care needs. Policies reviewed were the electronic health record Order Entry Transcription and Admission Checklist. The checklist had been updated on [DATE] to include, but not limited to, entering orders from the hospital and admission/readmission orders to the facility. Beginning [DATE], the DON/Designee will complete a comprehensive medication order review of all residents who are admitted /readmitted to the facility within 24 hours of arrival. Medication order review will include verification of accurate transcription and implementation of medications, and proper medication administration of ordered medications. Ad Hoc education will be completed as indicated. On [DATE] at 12:30 P.M., an Ad Hoc QAPI meeting was completed with the Administrator, DON, CSM #408, VPCS #517, Unit Manager #282, RN #296, RN #312, and Medical Director #404 to re-evaluate the system implemented on [DATE] to ensure that residents received medications as ordered by the physician and to meet their total care needs. No changes were made, and policies and process remained appropriate. On [DATE] starting at 6:45 A.M., licensed nurses were re-educated on the policies and procedures for transcription of medication orders and the admission checklist to ensure continuity of care by the DON/Designee. Education completed included 24 licensed nurses including LPNs #248, #250, #252, #254, #256, #258, #260, #262, #264, #266, #268, #270, #272, #274, #276, #278, #280 and RNs #298, #300, #302, #304, #306, #308, and #310. Agency staff will receive education prior to their next scheduled shift. All newly hired licensed nurses will receive this education during orientation. On [DATE] at 9:00 A.M., Consultant Pharmacist (CP) #409 remotely completed a comprehensive medication regimen review for all residents admitted /readmitted from [DATE] through [DATE] which included Residents #9, #95, #101, #107, #108, #109, #110, #111 and #112 to determine medication compliance and ensure continuity of care. No discrepancies were identified. On [DATE] at 9:00 A.M., Pharmacist #516 was educated by Chief Nursing Officer (CNO) #515 regarding the expectation of a comprehensive medication regimen review. On [DATE] at 12:30 P.M., CNO #515, via phone, educated CP #409 regarding a comprehensive medication review and the facility will ensure all needed documents for a comprehensive review will be uploaded into the electronic health record within ,d+[DATE] hours after admission/re-admission. On [DATE] at 12:45 P.M., an Ad Hoc Resident Council Meeting was held with Activities Director #200, the Administrator and eight residents to review the order transcription and admission checklist process. Residents in attendance were #24, #23, #12, #72, #27, #71, #94, and #25. Resident Council verbalized understanding. Beginning [DATE], CP #409 will ensure the completion of a comprehensive medical record review to determine medication compliance, which supports continuity of care, within ,d+[DATE] hours of resident admission/re-admission to the facility. The facility will ensure within ,d+[DATE] hours of admission, the admission documents are uploaded into the electronic medical records. This will be completed by Medical Records #286/designee. All elements of the abatement plan were implemented by [DATE]. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Review of the closed medical record for Resident #105 revealed an initial admission to the facility on [DATE] with medical diagnoses including history of stroke, atrial fibrillation (AFib), type two diabetes mellitus, and breast cancer. Further review revealed Resident #105 was dependent on staff for activities of daily living (ADL) tasks and transfers, was non-ambulatory using a wheelchair for mobility and was verbally able to make needs known to staff. Review of Resident #105's care plan, dated [DATE], revealed anticoagulant therapy to treat arterial fibrillation with a goal of no adverse effects and interventions to administer per physician orders, and obtain vital signs as necessary. Review of the physician orders revealed an order for Eliquis, initiated on [DATE], 2.5 milligrams (mg) twice a day for atrial fibrillation. Review of Resident #105's quarterly Minimum Data Set (MDS) assessment, dated [DATE] revealed Section C - Cognitive Patterns marked as Resident #105 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (out of a score of 15), Section I - Active Diagnoses marked with an active diagnosis of longstanding persistent atrial fibrillation, and Section N - Medications marked for use of an anticoagulant medication. Review of the February 2024 Medication Administration Record (MAR) revealed Resident #105 was administered the anticoagulant medication Eliquis 2.5 mg two times daily from [DATE] to the morning dose on [DATE]. Review of the progress note dated [DATE] at 2:22 P.M., authored by Licensed Practical Nurse (LPN) #276, revealed Resident #105 had chief complaint of abdominal pain and stated she had suicidal ideations and verbalizations. LPN #276 notified the certified nurse practitioner (CNP) (unidentified) and received an order to send Resident #105 to the hospital emergency department for evaluation. LPN #276 notified Resident #105's power of attorney (POA) of the new order and transfer of Resident #105 to the hospital. The resident was hospitalized through [DATE] with Influenza A. Review of the hospital discharge summary and hospital discharge orders, dated [DATE], revealed an order to increase the anticoagulant medication dose of Eliquis to 5 milligrams (mg) two times daily for atrial fibrillation. Review of Resident #105's progress notes, dated [DATE] at 8:05 P.M. and authored by LPN # 256, revealed Resident #105 was readmitted from the hospital with the diagnosis of influenza A. All admission conditions and orders were reviewed and clarified by the on-call physician (unidentified). Review of the MAR dated [DATE] through [DATE] revealed no evidence the anticoagulant medication Eliquis for either the previous dosage of 2.5 mg twice a day or for the new increased dosage of 5 mg twice a day was noted as ordered upon discharge from the hospital on [DATE]. Review of the pharmacy dispensing report for February 2024 revealed Eliquis 5 mg was not delivered by the facility pharmacy during the time span from [DATE] through [DATE]. Review of Resident #105's quarterly MDS Assessment, dated [DATE] revealed Section C - Cognitive Patterns marked as Resident #105 was cognitively intact with a BIMS score of 15, Section I - Active Diagnoses marked with an active diagnosis of longstanding persistent atrial fibrillation, and Section N - Medications was not marked for use of an anticoagulant medication. Review of Resident #105's MAR dated [DATE], [DATE], and [DATE] revealed there were no orders for Eliquis at either the previous dosage of 2.5 mg or the new ordered dose of 5 mg. Review of the Pharmacy Medication Regimen Review dated [DATE] revealed CP #409 reviewed Resident #105's medication orders since readmission to the facility on [DATE] to [DATE]. There were no recommendations or clarifications requested for the physician to address or recommendations for the facility nursing department to address. There was no indication CP #409 identified Resident #105 was not receiving either the previous dose or the newly ordered dose of Eliquis, even though Resident #105 had the diagnosis of arterial fibrillation and had been previously ordered the medication. Review of the Pharmacy Medication Regimen Review dated [DATE] revealed CP #409 had two recommendations. First, for a gradual dose reduction for Resident #105's prescription for Ambien (medication to treat insomnia). The recommendation was declined by Medical Director (MD) #404. Second, for a laboratory test for lipids and for liver function tests, which was approved by MD #404. There was no indication CP #409 identified Resident #105 was not receiving either the previous dose or the newly ordered dose of Eliquis, even though Resident #105 had the diagnosis of atrial fibrillation or had been previously ordered the medication. Review of the Resident #105's annual MDS assessment dated [DATE] revealed Section C - Cognitive Patterns marked as Resident #105 was cognitively intact with a BIMS score of 15, Section I - Active Diagnoses marked with an active diagnosis of longstanding persistent atrial fibrillation, and Section N - Medications was not marked for use of an anticoagulant medication. Review of Resident #105's progress note dated [DATE] at 7:50 P.M., authored by LPN #252, revealed Resident #105's daughter was visiting, and Resident #105 was having difficulty responding to conversation during the daughter's visit. At the time of the transfer (to the hospital) Resident #105's blood pressure was ,d+[DATE] millimeters of mercury (mmHg), blood oxygen saturation level was 91 percent (%) with two liters of oxygen in place, and heart rate was 73 beats per minute. Review of the Stroke Network Virtual Neurology Assessment note dated [DATE] at 9:19 P.M. authored by Neurology Physician #512 (part of the resident's hospital record beginning on [DATE]) revealed Resident #105 with history of left frontal lobe ischemic infarction (stroke) with hemorrhage in 2018 resulting in aphasia (inability to speak) which has resolved, and diagnosis of arterial fibrillation prescribed Eliquis but unclear if Resident #105 is receiving the medication or not. Per the nursing facility, Resident #105 was taken off the Eliquis for reason as being unsafe for Resident #105 to be on the Eliquis. There was no additional information about what unsafe meant. Review of the Neurocritical Care History and Physical progress note dated [DATE] at 5:12 A.M. authored by hospital Neuro-physician #510 revealed Resident #105 arrived at the emergency department on [DATE] presenting with right facial droop, right sided weakness, non-verbal, and left gaze preference. Multimodal imaging results showed occlusion of the distal left internal carotid artery and occlusion in the left and proximal left branches of the internal carotid artery. Resident #105 was not a candidate for thrombolytic (clot buster) interventions due to unclear if Resident #105 was receiving Eliquis prior to emergency department transfer. Further review of the hospital record revealed the resident was taken to the cardiovascular laboratory (lab) for a thrombectomy (removal of the clots), but the catheters were unable to be advanced for removal and the procedure was aborted. Review of the hospital progress note dated [DATE] at 10:16 A.M., authored by Hospital Physician #410, revealed Resident #105 experienced an acute ischemic stroke with Computed Tomography (CT) Scan results which showed large left hemispheric region of the brain with ischemia (an area of the body that is not receiving blood and oxygen due to an occlusion) and associated swelling. Resident #105 also had acute metabolic encephalopathy (a change in the brain which affects how thinking and reasoning occurs and can be caused by a stroke), and acute hypoxic respiratory failure likely related to the ischemic stroke. Resident #105 was placed on palliative and comfort care due to her critical condition and worsening mental status. Resident #105 ultimately expired on [DATE]. Interview on [DATE] at 10:20 A.M. with Family Member #500 revealed Resident #105 had been ordered Eliquis for the treatment of atrial fibrillation since Resident #105's previous stroke which occurred in 2018. Family Member #500 was unsure why Resident #105 had not been placed back on the Eliquis when she was readmitted to the facility on [DATE]. Family Member #500 verified, prior to the stroke team attempting thrombolytic interventions, the emergency room physician questioned if Resident #105 was receiving Eliquis at the facility, but the family member was unsure as to why the resident was not receiving the Eliquis. Interview on [DATE] at 2:15 P.M. with Pharmacy Clinical Director #406 revealed there was no readmission order received from the facility for Resident #105's anticoagulant medication Eliquis when the dose was increased. Pharmacy Clinical Director #406 stated the last fill and dispense for Resident #105's anticoagulant medication, Eliquis 2.5 mg, was on [DATE]. There was no further filled or dispensed anticoagulant medications for Resident #105 from [DATE] to when Resident #105 was admitted to the hospital on [DATE]. Interview on [DATE] at 3:03 P.M. with the DON revealed the expectation for the nurses was to review and clarify medication orders with the physician upon admission or readmission to the facility. Once the orders had been reviewed and approved, the nurses were to transcribe the orders into Point Click Care (the computerized medical record). The DON confirmed there was not an anticoagulant medication order for Resident #105 since readmission to the facility on [DATE] despite the hospital order upon the resident's discharge from the hospital. The DON confirmed Resident #105 had been receiving Eliquis at 2.5 mg since the initial admission on [DATE] and there was no clarification or reasoning for the discontinuation of the Eliquis of the previous dose or on the new dose ordered upon readmission on [DATE]. Interview on [DATE] at 2:25 P.M. with Medical Director (MD) #404 revealed, on admission or re-admission of residents, MD #404 would review the admitting orders from the hospital, which was the source for approving, clarifying, or discontinuing medication orders. The physician shared the only reason he could think of the resident's Eliquis was being held or not administered would be for a breast biopsy due to her recent diagnosis of breast cancer but, even then the Eliquis would have been resumed and not held for three months. Resident #105 should have been on the Eliquis just due to history of an ischemic stroke and having atrial fibrillation. MD #404 shared there was a 20% chance of developing an embolus (clot) once the medication has been discontinued. Interview on [DATE] at 3:14 P.M. with CP #409 revealed completion of the monthly pharmacy medication regimen review involved the review of what the facility had uploaded or documented in the computerized medical record. CP #409 stated diagnoses and medications were reviewed and if there was a diagnosis of atrial fibrillation then the review would involve a more in-depth look at the ordered medications for appropriateness and accuracy. CP #409 confirmed Resident #105 did have a diagnosis of atrial fibrillation, but the pharmacy review did not have documentation to support further review of the resident's cardiac history and no anticoagulant use. Interview on [DATE] at 3:35 P.M. with LPN #256, the admitting nurse for Resident #105 on [DATE], revealed LPN #256 did not recall the details of Resident #105's readmission to the facility on [DATE]. Interview on [DATE] at 3:55 P.M. with CSM #408 revealed the facility missed the order on readmission for Resident #105 on [DATE] and the facility's check and balance systems and consultants did not identify the lack of the Eliquis order for Resident #105, even though she had been receiving the medication prior to the hospitalization on [DATE]. CSM #408 verified the resident returned to the hospital on [DATE] due to experiencing a stroke and expired in the hospital on [DATE]. Review of the consulting pharmacist contract dated [DATE] revealed, review each resident's clinical record monthly and evaluate for appropriateness of the therapy according to current medical practice standards. Review of the American Heart Association website, www.heart.org, defined atrial fibrillation as a quivering or irregular heartbeat, or arrhythmia. Atrial fibrillation, also known as AFib or AF, can lead to blood clots, stroke, heart failure and other heart-related complications. Normally, your heart contracts and relaxes to a regular beat. In AFib, the upper chambers of the heart, or the atria, beat irregularly. Because not enough blood is being pumped out of the atria, blood pools in the area. The pooled blood can clot - which can be extremely dangerous. If a blood clot forms, it can be pumped out of the heart to the brain. This blocks the blood supply to the brain and causes a stroke. About 15% to 20% of people who have strokes have this heart arrhythmia. The clot risk is why patients with this condition are prescribed blood thinners. Some medications are commonly called blood thinners because they can help reduce a blood clot from forming. There are two main types of blood thinners that patients commonly take: anticoagulants such as warfarin, dabigatran (Eliquis) and rivaroxaban (Xarelto), and antiplatelet drugs such as aspirin or clopidogrel. Each type of medication has a specific function to prevent a blood clot from forming or causing a blocked blood vessel, heart attack or stroke. Untreated AFib doubles the risk of heart-related deaths and is associated with a fivefold increased risk for stroke. Yet many people are unaware that AFib is a serious condition. Review of the Eliquis Customer Website, www.eliquis.bmscustomerconnect.com, revealed Eliquis use can reduce the risk of stroke and blood clots in people who have atrial fibrillation (AFib), a type of irregular heartbeat, not caused by a heart valve problem. For patients taking ELIQUIS for atrial fibrillation: stopping ELIQUIS increases your risk of having a stroke. Do not stop taking ELIQUIS without talking to the doctor who prescribed it to you. This deficiency represents non-compliance investigated under Complaint Number OH00154096.

Based on medical record review, resident and staff interviews, review of hospital medical records and policy review, the facility failed to monitor the urinary status of Resident #84 following the removal of an indwelling urinary catheter resulting in urine retention and hospitalization for treatment. This resulted in Actual Harm on 05/10/24 when Resident #84, who was admitted to the facility on [DATE] with an indwelling urinary catheter due to urine retention and failing a voiding trial, was not adequately monitored following the removal of the catheter. On 05/10/24 at 1:12 A.M. the resident complained of lower abdominal pain and distention of the lower abdomen. The resident was catheterized (urinary tube inserted through the urethra and into the bladder) to relieve the lower abdominal pain and distention, removing 1,300 milliliters (ml) of blood-tinged urine with sediment from the resident's bladder. The resident was subsequently transferred to the emergency room after she began to experience altered mental status, rapid pulse, rapid respirations and low blood pressure. The resident was admitted to the hospital with pyelonephritis (kidney infection) and bacteremia (bacteria in the blood). A Computed Tomography (CT) scan confirmed cystitis (an infection of the urinary bladder) with left ureteritis (inflammation of the thin tube that connects the kidney to the bladder) and pyelitis (bacterial infection of the renal pelvis). This affected one (#84) of three residents reviewed for urinary indwelling catheter use. The facility census was 103. Findings Include: Review of Resident #84's medical record revealed an admitted [DATE] with diagnoses including fractures of the right humerus (upper arm bone) and right pelvis, urinary retention, type two diabetes, and lupus. Review of Resident #84's admission assessment dated [DATE] revealed Resident #84 was admitted to the facility with an indwelling urinary catheter size 16 French for the diagnosis of urinary retention. Review of Resident #84's hospital discharge clinical summary dated 05/01/24 at 12:46 P.M. revealed Resident #84 had a diagnosis of urine retention with an indwelling urinary catheter placed on 04/18/24. The hospital attempted to remove the indwelling urinary catheter. However, the resident had a failed voiding trial (a medical procedure that assesses a resident's ability to urinate without a catheter. It involves removing a urethral catheter from the bladder and asking the resident to urinate in a container to measure the amount of urine emptied from the bladder). A bladder scan (uses ultrasound to measure the amount of urine left in a resident's bladder especially after urination) may also be performed to monitor the resident's progress. The hospital reinserted the indwelling urinary catheter on 04/25/24 with recommendation for the facility to attempt another voiding trial. Review of Resident #84's admission progress note dated 05/01/24 at 6:37 P.M. revealed the Foley catheter was in place on admission for urine retention and a history of Resident #84 failing a voiding trial while in the hospital. Review of Resident #84's progress note dated 05/03/24 at 12:03 P.M. and authored by the nurse practitioner, revealed Resident #84 had an indwelling urinary catheter for urinary retention and was requesting to have the catheter removed and a voiding trial to be started. The progress notes reflected removal of the catheter and voiding trial to be initiated on 05/07/24. Review of Resident #84's physician orders for May 2024 (after the urinary catheter was removed) revealed a voiding trial every six hours for urinary retention, bladder scan and straight catheter if greater than 350 milliliters (ml) of urine (identified with the bladder scan). Review of Resident #84's Treatment Administration Record (TAR) dated 05/06/24 to 05/10/24 revealed on 05/06/24 Resident #84's indwelling urinary catheter was removed, with a voiding trial to assess if Resident #84 was able to void on her own without the assistance of a urinary catheter. The order included a bladder scan to be completed with the amount of urine identified in the bladder to be documented on the TAR. The voiding trial was to be documented three times per day (every eight hours) and was initiated on 05/06/24 at 6:00 P.M. Further review of the TAR revealed the nurses were writing their initials for the completion of the assessment every eight hours but there was no documentation regarding the amount of urine that was found to be in the bladder, by obtaining a bladder scan, at the time of the completed assessment. Review of Resident #84's bladder tracking documentation, dated 05/06/24, revealed Resident #84's indwelling catheter was removed, and a voiding trial was initiated. Resident #84's bladder tracking was documented as the resident being dry (no urination) three times on 05/07/24 from 6:36 P.M. to 10:28 P.M. and incontinent of urine one time at 11:00 P.M. On 05/08/24 from 12:00 A.M. to 4:00 A.M., the resident's bladder tracking was marked as voided (urinated) without the amount of urine documented, from 5:00 A.M. to 12:32 P.M. Resident #84 was documented as incontinent of urine eight times on 05/08/24 and at 2:58 P.M., Resident #84 voided one time with no amount of urine documented. There were no further entries for Resident #84's bladder tracking dated 05/08/24. On 05/09/24 at 2:31 A.M., Resident #84's bladder tracking was marked as not applicable, the next bladder tracking entry was at 5:34 P.M to 6:00 P.M. and 10:19 P.M. marked as being incontinent. On 05/10/24, Resident #84's bladder tracking was marked as not applicable with the first entry being at 2:59 P.M. Review of Resident #84's care plan, dated 05/08/24, revealed Resident #84 had an alteration in elimination, with an indwelling urinary catheter in place, related to urine retention. Resident #84's interventions included assisting (the resident) with toileting when requested and provide care as needed. Review of Resident #84's progress note, dated 05/10/24 at 1:07 A.M., revealed the resident complained of abdominal pain. The abdomen was firm and distended. A bladder scan and (bladder) catheterization were completed per order. Thirteen hundred milliliters of urine was drained from the bladder. The urine was bloody with mucus/sediment. A new order for a urinalysis with culture and sensitivity was received. The resident's husband was present and aware of the new order. Review of the Nurse Practitioner progress note, dated 05/10/24 at 9:08 A.M., revealed the resident was lying in bed without distress, but has tachycardia (rapid heart rate), hypotension (low blood pressure), lethargy, tachypnea (rapid respirations), catheter tubing with thick, milky, red mucus and thin, red fluid with thick white tissue in the (bedside catheter drainage) bag. The resident wakes to touch and name, intermittently. The resident's spouse was at bedside and the resident and spouse were educated on the provider's plan to begin antibiotics as well as intravenous (IV) hydration. Understanding and agreement were stated by the resident and spouse. Three nurses attempted to insert an IV but were unsuccessful. The resident stated IVs are always difficult (to insert). The nurse administered an intramuscular dose of antibiotic (Rocephin). The resident's bladder is rigid, the catheter was flushed without full volume return. The catheter was removed to be changed due to sterile compromise. Resident remains tachypneic, hypotensive (no blood pressure readings provided), tachycardic, lethargic and febrile, over 103.0 degrees Fahrenheit, despite axilla ice packs. After approximately two hours, it is necessary to send the resident to the emergency room . Review of Resident #84's re-admission paperwork from the hospital, dated 05/21/24 at 1:17 P.M., revealed to follow up with urology in one week for voiding trial and a diagnosis of sepsis with suspected urology source from a recent urinary tract infection, having completed a course of antibiotic therapy of Zosyn during the hospital stay from 05/10/24 to 05/21/24. Interview on 05/23/24 at 10:42 A.M. with Resident #84 revealed the staff had removed the catheter and then didn't consistently check her output, like they should have. Resident #84 further explained she had been voiding small amounts of urine and then developed lower abdominal pain and distention along with elevated temperature on 05/10/24. Resident #84's spouse was visiting Resident #84 at this time and requested the nurse to assess Resident #84. The nurse assessed the resident, completed a bladder scan and inserted a catheter due to 1,300 ml of urine being drained from the resident's bladder. Interview on 05/23/24 at 2:00 P.M. with Unit Manager (UM) #282 revealed Resident #84 had been admitted to the facility with an indwelling urinary catheter with the catheter being removed on 05/06/24 and a voiding trial initiated with the order to scan the bladder for residual urine and if the amount was greater than 350 milliliters (ml) with the bladder scan, then a bladder catheterization had to be conducted. UM #282 stated she was working as the floor nurse, when on 05/10/24 at 1:03 A.M. she performed a bladder scan and urinary catheterization due to Resident #84's complaint of lower abdominal pain and distention. UM #282 verified there was a total of 1,300 ml of white colored urine removed from Resident #84. Interview on 05/28/24 at 3:03 P.M. with the Director of Nursing (DON) confirmed the voiding trial for Resident #84, dated 05/06/24 to 05/10/24 on the May TAR, revealed the results (of the bladder scan) were not documented despite the order. The DON stated the expectations for the facility nurses were to use the facility's bladder scanners and record the results on the TAR, to accurately monitor for potential urinary retention and address as ordered. Interview on 05/29/24 at 9:50 A.M. with State tested Nursing Assistant (STNA) #326 revealed Resident #84 did have an indwelling urinary catheter which was removed, and a voiding trial was started. STNA #326 stated Resident #84 would request assistance to the bathroom or would be incontinent of urine with her adult brief being damp or slightly wet. STNA #326 also stated Resident #84 would be dry multiple times during the shift and stated Resident #84 was able to make her needs known but required assistance with transfers and toilet use. Review of the facility's policy titled, Catheter Insertion and Removal (Female) including Bladder Instillation dated 06/08/22 revealed, the purpose for catheter included, to relieve bladder distention, to obtain a specimen for diagnostic purposes, to instill medication into the bladder, and to determine the amount of residual urine in the bladder after the resident urinates. This deficiency represents non-compliance investigated under Complaint Number OH00154103.

Based on medical record review, review of hospital records, resident interview, staff interview, observation, resident family interview, and policy review, the facility failed to ensure central venous line (a type of intravenous access that goes directly into central circulation near the heart) dressing changes were completed as ordered. This resulted in actual harm when Resident #43's central venous line dressing changes were not completed as ordered and Resident #43 was admitted to the hospital on 12/25/23 with sepsis from a central line-associated blood stream infection. Additionally, the facility failed to ensure peripherally inserted central catheter (PICC) (a type of intravenous access inserted through a peripheral vein which terminates in central circulation near the heart) dressings changes were completed as ordered. This affected two residents (Residents #43 and #130) of four residents reviewed for care of intravenous lines. The facility identified seven residents in the facility with intravenous access. The facility census was 113. Findings include: 1. Review of the medical record for Resident #43 revealed an admitted [DATE]. Resident #43's medical diagnoses included short bowel syndrome, postsurgical malabsorption, chronic respiratory failure, and chronic pain. Review of Resident #43's Annual Minimum Data Set (MDS) assessment, dated 01/12/24, revealed Resident #43 had intact cognition. Resident #43 was not noted to have any hallucinations, delusions, behaviors, or rejection of care. Resident #43 was noted to have intravenous access and receive intravenous medications. Review of Resident #43's hospital paperwork, dated 08/12/23, revealed Resident #43 had a tunneled single-lumen (one intravenous access port) central line that was placed on 01/06/22 at a local hospital by interventional radiology. Resident #43 had the central line throughout the duration of her stay at the facility. Review of Resident #43's discontinued physician orders revealed an order, dated 09/18/22, for Resident #43's central line dressing to be changed daily. The order was discontinued on 08/14/23 while Resident #43 was at the hospital. There was another order placed by the facility Nurse Practitioner on 11/27/23 for central line dressing changes once weekly and as needed. There was no schedule attached to the 11/27/23 order to indicate on which days or shift the treatment should be completed, and the order did not show up on Resident #43's Treatment Administration Record (TAR). There was no order for Resident #43's central line dressing to be changed between 08/14/23 and 11/27/23. Review of Resident #43's TAR for September 2023, October 2023, November 2023, and December 2023 revealed no documentation of any central line dressing changes listed on the TAR. Resident #43's medical record contained no evidence facility staff changed Resident #43's central line dressing from September 2023 through December 2023. Review of Resident #43's progress notes, dated 12/25/23 and timed 11:10 P.M., revealed Resident #43 was found lethargic and unresponsive. She was found to have an oxygen saturation level of 57% (normal value is 90% to 100%). She was placed on supplemental oxygen which began to increase her oxygen saturation level. The provider and a family member were notified, and Resident #43 was transported to a local hospital for further assessment. Review of Resident #43's hospital records, dated 12/25/23 to 01/05/24, revealed Resident #43 arrived at the emergency department of a local hospital on 12/25/23 after she appeared to be unresponsive and in respiratory distress at the facility. Resident #43 was found to have sepsis from a central line-associated blood stream infection and was admitted to the Intensive Care Unit (ICU). Resident #43's blood cultures which were drawn at the hospital on 12/25/23 were positive for enterococcus bacteria in her blood stream and were further confirmed by subsequent sets of blood cultures taken on 12/26/23 and 12/27/23. Resident #43 underwent a procedure performed by interventional radiology to remove her tunneled central line on 12/27/23. She underwent an additional procedure on 01/04/24 per interventional radiology to place a new double lumen central venous line prior to her return to the facility. Resident #43 required intravenous Vancomycin (an antibiotic) throughout the duration of her hospital stay. Resident #43 was discharged back to the facility with a double lumen tunnelled central venous catheter. Review of Resident #43's physician orders upon her return to the facility revealed an order, dated 01/05/24, to continue Vancomycin through 01/11/24. Resident #43's physician orders did not include an order for intravenous dressing changes until 01/16/24 when an order was placed for Resident #43 to have a PICC line dressing and cap changes completed every seven days and as needed. The order for the PICC line dressing was discontinued on 01/23/24 while Resident #43 was at the hospital. Observation on 01/31/24 at 3:04 P.M. with Registered Nurse (RN) #303 revealed Resident #43 had a double lumen central line present to the right chest. Interview on 02/06/24 at 12:31 P.M. with Resident #43 revealed sometimes the nurses changed her dressing. Resident #43 stated in November 2023 and December 2023, the central line dressing did not get changed frequently enough. Resident #43 estimated the central line dressing was changed every few weeks or if it fell off. Interview on 02/06/24 at 12:38 P.M. with RN #320 revealed he primarily worked on the skilled unit on the first floor. RN #320 revealed he was occasionally summoned to another floor or unit to assist with a task or medication that required an RN's skillset. RN #320 stated he was not very familiar with Resident #43's care needs or intravenous access. RN #320 stated when he was needed on other floors, he was alerted by that floor's on-duty nurse that assistance was needed. RN #320 revealed if no one communicated to him that assistance was needed then he would not be aware. Interview on 02/06/24 at 12:50 P.M. with Licensed Practical Nurse (LPN) #301 revealed if she had a medication or task which was out of her scope of practice then she would alert the RN in the building, and they would come to complete the task and would be responsible for completion of the documentation. LPN #301 further explained that if nothing shows up on the Medication Administration Record (MAR) or TAR, then nothing would prompt her that a task, such as a dressing, needed completed. Interview on 02/06/24 at 12:55 P.M. with LPN #205 revealed if one of her residents required a task outside of her scope of practice then she would inform the RN on duty. LPN #205 stated tasks or medications showed up on the MAR or TAR in yellow when they were due, and in red when they were overdue. LPN #205 revealed this alerted the nurse on duty that an order or task needed to be completed. LPN #205 stated if an order did not pop up, it was not due that day. Interview on 02/06/24 at 12:58 P.M. with Regional Clinical Manager (RCM) #201 verified Resident #43's TAR's for September 2023, October 2023, November 2023, and December 2023 contained no evidence that Resident #43's central line dressing was changed by facility nursing staff during those months. RCM #201 verified the facility Nurse Practitioner inputted the 11/27/23 order for central line dressings incorrectly and the order did not show up on the TAR which was what would have prompted the nurse to change the dressing. RCM #201 verified a nurse placed an order for the wrong type of intravenous line on 01/16/24, which was during the time the facility audited all orders related to intravenous lines and indicated Resident #43's orders were accurate even though they were not. RCM #201 verified Resident #43 should have had orders for central line dressing changes every seven days for the entire time she had her central intravenous access line. 2. Review of the medical record for Resident #130 revealed an admitted [DATE]. Resident #130 was transferred to a local hospital following a change in condition on 01/16/24 and did not return to the facility. Resident #130's medical diagnoses included pathological fracture in neoplastic disease of the right humerus, immunodeficiency, need for assistance with personal care, and severe protein-calorie malnutrition. Review of a physician order, dated 11/30/23, revealed Resident #130's PICC line dressing and intravenous caps (needleless adapters) were to be changed every seven days and as needed. The weekly PICC line dressing change was scheduled for Tuesdays on day shift (7:00 A.M. to 3:00 P.M.) and was to be recorded on the resident's TAR. Review of Resident #130's December 2023 MAR revealed the PICC line dressing and cap change was documented as completed on 12/12/23 and 12/19/23. The TAR contained no documentation the PICC line dressing or caps were changed as ordered on 12/05/23 and 12/26/23. Review of Resident #130's January 2024 MAR revealed no documentation that the PICC line dressing or caps were changed as ordered on 01/02/24 and 01/09/24. The 01/16/24 entry on the TAR noted Resident #130 was in the hospital. Interview on 01/29/24 at 2:47 P.M. with a family member of Resident #130 revealed they were present at the hospital on 01/16/24 with Resident #130. The family member revealed concerns were raised by the hospital staff regarding Resident #130's PICC line dressing being loose and dated 12/27/23 upon her arrival to the hospital. Interview on 02/01/24 at 10:41 A.M. with RCM #201 verified Resident #130's TAR and medical record was missing evidence the PICC line dressing and cap changes were completed at the facility on 12/05/23, 12/26/23, 01/02/24 and 01/09/24. RCM #201 stated the facility had been aware of this incident after receiving negative feedback from a family member. Review of the facility policy titled Central Venous Catheter Care and Dressing Changes policy, revised November 2022, revealed the purpose of the procedure was to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. The policy identified a sterile dressing should be maintained for all central vascular access devices and should be changed when visibly soiled, compromised, and at least every seven days. The policy additionally stated the documentation of the dressing change should be recorded in the resident's medical record. This deficiency represents non-compliance investigated under Master Complaint OH00150624 and Complaint OH00150384.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, hospital documentation review, staff and resident representative interviews, review of employee personnel files, review of disciplinary action documentation, review of an investigation, and review of facility initiated corrective action, the facility failed to ensure appropriate care was provided to prevent a resident fall. This resulted in actual harm when Resident #98 was transferred by a mechanical (Hoyer) lift incorrectly, and subsequently fell , causing a fracture to inferior pubic ramus and S3 fracture (sacral) which required hospitalization . Additionally, the facility failed to thoroughly investigate an incident when Resident #98 fell from the Hoyer lift. This affected one (#98) of three residents reviewed for falls. The facility census was 96. Findings include: Review of Resident #98's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to heart failure, type two diabetes, hypertension, acute kidney failure, and acute respiratory failure with hypoxia. The resident was in the facility for only one day. Review of the baseline care plan dated 12/22/23 revealed fall risk characterized by new environment, generalized weakness, and possible side effects of medications. Interventions included observe for adverse effects of medications, including dizziness, drowsiness, and sedation. If symptoms observed, assist with activities of daily living (ADL's), and notify doctor. Therapy to screen and treat as necessary per doctor's order. Review of the nurse's note dated 12/22/23 at 11:15 A.M. revealed Resident #98 was reported unresponsive at around 10:30 A.M., code blue was called. While staff were assessing the resident and placing the automated external defibrillator (AED) pads, the resident noted to become responsive and able to answer questions. AED use discontinued and was not needed for the event. Resident #98 endorsed generalized pain. Skin tear to right upper arm noted. Pressure dressing applied. Family at bedside and witness to resident care. Resident #98 assessed by Nurse Practitioner (NP). Resident #98 was taken to the hospital per family request after Emergency Medical Technicians (EMT's) noted to place resident in wheelchair from the floor after assessing resident. Per staff present in resident room providing care, and family member, the resident was in the middle of being transferred from the bed to wheelchair with Hoyer lift, with two staff members operating, for dialysis appointment when the resident fell out of mechanical lift sheet to the floor while being lowered into the wheelchair. Review of the incident investigation dated 12/22/23 revealed two (#537 and #522) State tested Nursing Assistants (STNA's) were transferring Resident #98 with the Hoyer lift from the bed to the wheelchair when the resident fell out of the mechanical lift sheet onto floor. Resident #98 was transported to the hospital with skin tear to right upper arm and hitting head. Review of the hospital document dated 12/22/23 revealed Resident #98 had a fall from Hoyer lift with Computed Tomography (CT) of musculoskeletal pelvis with age indeterminate inferior pubic ramus fracture and sacral fracture, CT anterior posterior with pubic ramus fracture and ascites/anasarca but no acute intra-abdominal or intra-pelvic pathology. No acute surgical intervention planned. Tylenol and Tramadol as needed for pain. Interview on 01/02/24 at 2:35 P.M. with STNA #537 stated that she was the aide caring for Resident #98 on 12/22/23. STNA #537 stated she went into Resident #98's room on 12/22/23 at 10:30 A.M. with another STNA to transfer Resident #98 with a Hoyer lift. One of the straps at the feet came undone when they tried to sit the resident up in an upright position to get him into the wheelchair. STNA #537 stated Resident #98 slid out the feet side of the lift pad onto bottom. STNA #537 stated Resident #98 was almost in wheelchair. STNA #537 denied tying the sling to the lift. Interview on 01/03/24 at 2:13 P.M. with the Administrator revealed both (#537 and #522) STNA's refused to give written statements regarding the incident where Resident #98 fell from the Hoyer lift on 12/22/23. Both stated they gave verbal statements to the Assistant Director of Nursing (ADON) and both STNA's still work at the facility. The Administrator stated he was initially told that the Hoyer sling came unattached, and Resident #98 was lowered to the floor. The Administrator stated Resident #98 was a dialysis patient, and the dialysis center sends their own Hoyer slings and the STNA's thought that sling would work in their lifts. The Administrator stated he was told the STNA's attempted to tie the corner of the sling to the lift. The Administrator was told the loop by the resident's right shoulder came undone and he fell out of the sling onto his bottom and fell back and hit his head on a piece of furniture. The Administrator stated STNA's #537 and #522 were disciplined, and all Hoyer lifts were put out of commission with the pads. A telephone interview on 01/03/24 at 3:14 P.M. with Licensed Practical Nurse (LPN) #625 stated that from what he understood STNA's #537 and #522 were attempting to transfer Resident #98 from the bed to the wheelchair when in the middle of the transfer Resident #98 ended up falling out of the lift sling. LPN #625 stated Resident #98 went unresponsive, so a code blue was called. By the time he arrived at the room with the NP, Resident #98 began to respond. LPN #625 stated Resident #98 was assessed by the NP and then the squad came. EMT's assisted and lifted the resident to the wheelchair. LPN #625 stated the sling was tied to the Hoyer lift. LPN #625 stated he found three of the straps that were not attached to the lift when he removed it to give to the EMT's. LPN #625 stated STNA's #537 and #522 used the dialysis' slings, which have loops instead of hooks. Interview on 01/03/24 at 3:22 P.M. with STNA #522 revealed they used the wrong Hoyer pad to transfer Resident #98 on 12/22/23 and the resident fell from the Hoyer lift and hit his bottom. STNA #522 told the Director of Nursing (DON) they needed to replace Hoyer slings in the facility. A telephone interview on 01/04/24 at 9:07 A.M. with Family Member (FM) #700 stated Resident #98 was dropped from a Hoyer lift and sustained a tailbone fracture. The resident had a few hairline cracks in the pubic area, but they were not sure if those happened during the fall. The resident is expected to recover from the fractures. FM #700 was present in the room when the incident occurred. FM #700 stated STNA's #537 and #522 did not cross the leg straps when hooking the resident up to the lift. FM #700 further explained the Hoyer pad had rectangular plastic tabs that attached to the bolt like things on the lift. When STNA's #537 and #522 lifted the resident, his legs came apart causing the sling to come unattached, and he fell out of sling onto the floor. The resident's legs came out first and he fell straight down onto his bottom and then fell back and hit his head. Interview on 01/09/23 at 9:35 A.M. with the DON verified the Hoyer sling went to the hospital with the resident and the facility did not obtain the Hoyer sling from the hospital. The DON further verified the facility was unsure which sling the STNA's used for the transfer, whether it was the dialysis sling or a facility sling. Review of the disciplinary documentation dated 12/22/23 revealed STNA #522 and STNA #537 received a written warning regarding failure to use medical equipment correctly resulting in the injury of a patient. Review of facility policy titled, Mechanical Lift reviewed 06/08/22 revealed partially lift the resident and check that the resident is safely positioned in the lift and the loops are secure before moving the resident's legs off the bed. This deficiency represents non-compliance investigated under Complaint Numbers OH00149713, OH00149513 and OH00148805. The deficient practice was corrected on 12/24/23 when the facility implemented the following corrective actions: 12/22/23 Resident assessed by NP and nursing staff. EMT's assessed resident and resident transported to the hospital at 11:09 A.M. 12/22/23 at 11:10 A.M. Hoyer in use with resident was pulled from service due to Hoyer pad going to the hospital with resident and unable to assess the pad. 12/22/23 at 11:20 A.M. Both STNAs involved were immediately educated and disciplined. 12/22/23 Root Cause Analysis completed identifying the root cause to be utilizing the incorrect sling for the transfer. QAPI Plan initiated including nursing education and all mechanical lifts were to be taken out of service with rental lifts to be brought in for use. 12/22/23 Initial audit completed identifying the residents needing to use a mechanical lift and verified their mechanical lift pads were appropriate for use. 12/22/23 at 11:20 A.M. Mechanical lift education started with all nursing staff following the incident and continued for two days, ending on 12/24/23. All staff were educated before working the floor. 12/22/23 at 12:30 P.M. New rental Hoyer lifts ordered. 12/23/23 rental Hoyer lifts in use until inspection of facility Hoyer lifts are completed and pads are inspected and compatible with Hoyer lifts. Observation on 01/03/24 with two STNA's performing a mechanical (Hoyer) lift transfer revealed no concerns. Interviews on 01/04/24 from 11:33 A.M. to 11:56 A.M. with STNAs #504, #503, #502, and #509, Registered Nurse (RN #619) and LPN #634 verified they had received training on the use of the Hoyer lift machine and Hoyer lift transfers.

Based on medical record review, observation, interviews with facility staff and the resident, interviews with the local police, review of hospital documentation, review of the police report, review of the facility ' s investigation, review of the National Weather Service report and review of the facility ' s policy on missing residents, the facility failed to ensure staff provided adequate supervision to prevent a resident, with a history of exit seeking behavior, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (#85) was placed at potential risk for serious life-threatening harm and injury when she eloped from the facility without staff knowledge. The resident was missing for approximately three hours when she was finally found by a police helicopter in a wooded area and was subsequently transported to the hospital for evaluation and treatment. The resident was diagnosed with [REDACTED].#85) of three residents reviewed for elopement. The facility identified seven current residents at risk for elopement. The facility census was 107. On 05/15/19 at 1:18 P.M., the Administrator and Regional Director of Operations #110 were notified that Immediate Jeopardy began on 03/19/19 at 8:30 P.M. when Resident #85 exited the building activating the door alarm, which an unidentified staff member turned off without initiating a resident search. Resident #85 was previously assessed as being at risk for wandering and elopement and a wanderguard (a bracelet type device worn to alert staff of unauthorized exits through doors equipped with an alarming system) was in place to ensure resident safety. On 03/19/19 at 11:45 P.M., Resident #85 was found about 100 feet from the facility in the southeast wooded area by the local police and was taken to the local hospital. The ambient air temperature outside was 28 to 30 degrees Fahrenheit on 03/19/19. At the time of discovery, the resident was noted with a wanderguard in place to her right ankle and was not wearing any shoes. She was treated in the hospital for hypothermia. The Immediate Jeopardy was removed on 05/17/19 when the facility implemented the following corrective actions: · On 03/19/19 at 11:45 P.M., Resident #85 was located by the police and the resident was taken to the local hospital. The resident was admitted to the hospital and returned to the facility on [DATE]. Upon readmission to the facility, Resident #85 was reassessed for wandering and a wanderguard was applied. · On 03/20/19 at 1:00 A.M., Former Director of Nursing #112 initiated education with all staff on emergency management and exit seeking behaviors. · On 03/20/19 at 1:00 A.M., Former Administrator #111 completed a door audit for the entire facility and found all doors to be in working order. · On 03/21/19 at 6:30 P.M., the door code distribution process was changed by Admission Director #03. Door codes will now expire when a resident is formerly discharged from the facility. In addition, a red sign was posted at the front door alerting visitors to not assist residents out of the facility. · On 05/15/19 at 10:00 A.M., the residents will be evaluated and reviewed for elopement risk upon admission, readmission or change in condition by the licensed nurses, and quarterly by the Interdisciplinary Team (IDT) and the plan of care updated as indicated. · On 05/15/19 at 10:00 A.M., the Director of Nursing (DON) will review new and readmitted residents at risk for elopement Monday through Friday during the IDT team meetings noting residents that need a secure care bracelet and to ensure they have appropriate interventions in place. · On 05/15/19 at 10:00 A.M., the DON will begin to monitor compliance by completing Exit Seeking audits weekly for four weeks. · On 05/15/19 at 2:00 P.M., the Administrator/designee and the DON/designee began staff education on emergency management of missing residents, exit seeking behaviors, and door alarms. As of 05/17/19 at 9:00 A.M., 143 staff were in-serviced, and 49 staff remain to be in-serviced. Any staff not educated by 05/17/19 would be unable to work until the in-service was completed. The total number of facility staff was 192. In addition, the DON will educate new hires on emergency management of missing residents and exit seeking behaviors. · On 05/15/19 starting at 2:16 P.M., the Administrator initiated missing resident drills, including door alarm response time. The missing resident drills will continue each shift for one week, then every shift three times per week for one week, then once per week on every shift and will continue then monthly on every shift. Drills will be conducted by the DON, Maintenance Director or Designee. · On 05/15/19 at 6:00 P.M., the Admissions staff were educated by the Administrator on door code distribution process and the alert sign posted at the front door stating not to assist residents from the facility. · On 05/15/19, record reviews for two additional residents (#29 and #356), identified at risk for elopement, revealed they were assessed to be at risk for wandering and had wanderguards in place. There were no concerns identified. · On 05/16/19 at 12:30 P.M., an observation revealed an unnamed male resident with a wanderguard was attempting to go out the front door. He pushed on the door and the alarm immediately sounded and three staff members came to the door. One male staff member took the resident's hand and had him walk away from the door with him. There were no issues with this encounter. · On 05/16/19 at 4:39 P.M., an observation of the drill for missing persons with the Administrator revealed the Unit Manager pushed on the café door for 15 seconds and went out the door. The alarm sounded immediately. An aide was at the door when he left and followed him, there were also four other staff members on site. The staff were at the door within five to ten seconds. There were no identified issues observed with this drill. · On 05/17/19 from 8:00 A.M. to 8:56 A.M., interviews with State tested Nursing Aide (STNA) #170 and #230, Registered Nurse (RN) #311 and Housekeeper #172 revealed knowledge of proper procedures for resident elopement, and what to do if a door alarms. Although the Immediate Jeopardy was removed on 05/17/19, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #85 revealed an initial admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/16/19, revealed Resident #85 had intact cognition with signs and symptoms of [MEDICAL CONDITION]. The resident was also assessed to have wandering behavior that occurred on four to six days. Review of the care plan, dated 01/09/19, revealed the resident to be at risk for elopement and exit seeking related to cognitive impairment. Interventions included an alert bracelet to the resident's left ankle, redirection to an appropriate area of the facility, education of family and visitors to advise staff when leaving, encourage socialization, administer medications per physician's orders [REDACTED]. Review of the physical restraint assessments, dated 01/13/19, 02/15/19 and 03/16/19, revealed the resident was assessed to be an elopement risk. The assessments stated a wanderguard was in place. Review of the nursing progress notes dated 01/12/19 through 03/25/19 revealed Resident #85 had a wanderguard bracelet placed to her left ankle due to continued roaming and attempts to exit the building. Documentation dated 03/19/19 revealed the resident was alert and oriented but confused. On 03/20/19, with a late entry time of 2:29 A.M., Licensed Practical Nurse (LPN) #150 documented Resident #85 had exited the facility, a search was conducted, the DON, the Administrator and the family were notified and emergency nine-one-one (911) was contacted. No further documentation concerning the elopement was documented in the nursing notes. Review of the police incident/investigation report, dated 03/19/19, revealed the facility notified the police Resident #85 was missing. The police searched the open local businesses and were unable to locate the resident. At an unknown time, the police requested additional police to assist with the search. The resident was found by a police helicopter at 11:30 P.M. on 03/19/19 in the southeast wooded area by the facility. Review of Resident #85's hospital emergency room report, dated 03/20/19 at 1:56 A.M., revealed Resident #85 arrived via medic. She was reported found by police helicopter wondering about a block and half away from the facility. The resident was observed wearing a coat but no shoes. A wanderguard was noted on the resident's right ankle. Resident #85 reported not being outside more than three hours. Vital signs were reported for rectal temperature at 93.2 degrees Fahrenheit (F), blood pressure was 137/97, the resident pulse was 58 and her oxygen saturation was 98 percent. The resident was stated to be initially hypothermic and a bear hugger (external warming device) was placed on the resident. Review of the National Weather Service Report for the night of 03/19/19 revealed the outside temperature was 28 to 30 degrees F. Review of the facility's investigation, dated 03/19/19, revealed Resident #85 was last seen by STNA #151 and #160 on 03/19/19 at 7:00 P.M. LPN #150 reported seeing Resident #85 around 7:15 P.M. sitting on her bed. Between 8:30 P.M. and 8:45 P.M., STNA #151 observed that the resident was not in her room as she was collecting dinner trays. STNA #151 proceeded to search the hallways of the unit but was unsuccessful in finding the resident. During the same time, LPN #150 could not find Resident #85 for evening medications. Between 8:45 P.M. and 9:00 P.M., STNA #151 let LPN #150 know that she was unable to locate Resident #85, and a Code Green (missing resident) was initiated. The facility staff started a building wide search. At 9:30 P.M., the DON was notified by the facility staff of the missing resident, at 9:32 P.M. the resident's family was notified, at 9:35 P.M. the DON notified the Administrator, the resident's physician and the police of the missing resident. The local police arrived at the facility at 9:45 P.M. and assisted in the search. A complete head count of the facility's resident population was completed at 11:30 P.M. On 03/19/19 at 11:30 P.M., Resident #85 was located by the police. The facility investigation of the elopement was initiated on 03/20/19 at 12:00 A.M. with staff interviews. On 03/20/19 at 1:00 A.M., the Administrator completed a door audit of the entire facility and all doors were found to be in working order, and the DON initiated education with all nursing staff on emergency management and exit seeking. The door code distribution process was changed, and a sign placed by the front door alerting visitors not to assist others out the door. On 03/25/19 Resident #85 returned from the hospital and was reassessed for elopement with a wanderguard placement. On 05/14/19 at 7:11 P.M., an observation and interview with Resident #85 revealed she had no memory of the elopement. She denied knowing when or how she left or what she was wearing. Resident #85 stated no one had checked her wanderguard bracelet that day and couldn't remember having it checked for a long time. She stated she was thinking of cutting it off to see how long it would take for someone to notice she didn't have it on. The wanderguard was observed to be on the resident's left ankle. On 05/14/19 at 7:40 P.M., an observation of the exit door next to room [ROOM NUMBER] was conducted with the Administrator. The exit bar was pushed, and the alarm was activated. The bar was held for 15 seconds until the door unlocked. Several front office staff came to see about the alarm within five seconds. No other staff working in that area came to respond to the alarm. On 05/14/19 at 7:42 P.M., STNA #204 opened the resident's door next to the exit door. She confirmed she had heard the alarm but was in the middle of resident care. On 05/14/19 at 7:43 P.M., STNA #151 opened the resident's door across from the exit door. She confirmed she had heard the alarm but was in the middle of resident care. On 05/14/19 at 7:48 P.M., an interview with LPN #150 revealed the LPN had last seen Resident #85 during shift report around 7:15 P.M. on 03/19/19. LPN #150 stated around 9:00 P.M., she noticed the resident was missing when she went to give her evening medications. At that point, the LPN stated she asked STNA #151 and #160 to help search the facility for Resident #85. LPN #150 stated she called the DON around 9:15 P.M. and was told to do another search of all rooms. The LPN called a Code Green after that search and she also called 911. The police arrived quickly, but unknown time, and helped search the facility again. They also searched outside and couldn't find her. She was notified later that the police found her at 11:55 P.M. On 05/14/19 at 8:00 P.M., an interview with STNA #151 revealed she learned that Resident #85 was missing when she came back from her break the night of 03/19/19 around 7:30 P.M. She started searching every room and upstairs, then outside with STNA #160. She stated she heard the door alarms multiple times that night, one was before 8:00 P.M. and one was at 8:00 P.M. She stated she went and checked both times and didn't see anyone. She stated she does not do head counts every time she checks the sounding door alarm. On 05/14/19 at 8:19 P.M., an observation and interview with LPN #150 revealed she couldn't find the alert bracelet test monitor at this time, but then had located it on the second floor. LPN #150 was then observed to test Resident #85's wanderguard bracelet. The wanderguard was observed on the resident's left ankle. LPN #150 was observed to wave the test monitor over the resident's bracelet with no response. The LPN repeated this process two more times without response. The monitor was observed by the surveyor to be turned off. LPN #150 then realized the monitor was not turned on and turned the dial to test. LPN #150 then waved the monitor next to the resident's bracelet and it tested positive. A positive response indicated the bracelet was working. On 05/14/19 at 8:36 P.M., an observation of the front door alarm activation by the Administrator revealed the door alarm was activated when pushed and held. The alarm sounded for approximately 15 to 20 seconds before the DON arrived. A floor nurse arrived to check out the front door alarm approximately 22 to 25 seconds after the door alarm was initiated. On 05/15/19 at 8:18 A.M., an interview with the Administrator and Regional Director of Operations #110 verified head counts were not performed when the doors alarm. Head counts were done when a Code Green was called. They confirmed a wanderguard will activate a door alarm when it was within three feet of an exit door. If the door was closed, it will lock, but if it was opened already just the alarm will sound. The staff were to respond and check the area each time the alarm sounds. The Regional Director of Operations (#110) confirmed the building did not have video surveillance of the doors. On 05/15/19 at 11:18 A.M., an interview with LPN #257 revealed she will check the door and surrounding area every time she hears the alarm go off. She stated she turns off the alarm and then will make sure all her residents are accounted for. She denied having any education concerning response to missing residents following the elopement on 03/19/19. On 05/15/19 at 11:50 A.M., an interview with Admissions staff #03 revealed the front door was locked from 8:00 P.M. to 8:00 A.M. and a code must be manually entered to unlock the door. He stated a unique code was given to residents to share with their families. He also stated residents who were deemed not cognitively competent do not receive the code. He stated their Power of Attorney or family will receive a code. On 05/15/19 at 11:51 A.M., an interview with Receptionist #123 revealed she was at the front desk from 8:00 A.M. to 4:00 P.M. and had not seen any resident leave on 03/19/19. She also stated the desk was occupied by an evening receptionist from 4:00 P.M. to 8:00 P.M., but after that the doors were locked. On 05/15/19 at 11:53 A.M., an observation with the Administrator with a wanderguard in hand, revealed when she was close to the front door, the alarm sounded, and the door locked. In a second test, at the same time, a visitor exited through the front door. The Administrator walked behind the exiting visitor and the door alarm sounded but the door did not lock. Several staff members came within 15 seconds to check the alarm. The Administrator also activated the alarm and put a working family code in, but the alarm continued to sound. The alarm was silenced by Receptionist #123 on a second key pad, only accessible to staff. On 05/20/19 at 7:41 P.M., an interview with Police Dispatcher #300 revealed the police received the initial call from the facility about a missing person on 03/19/19 at 10:07 P.M. and the police were dispatched to the facility at 10:08 P.M. The representative stated there were a lot of police involved in this missing person incident. This timeline was noted to be different from the facility's investigation. On 05/20/19 at 7:54 P.M., an interview with Police Officer #400 revealed the first police officer to arrive at the facility was at 10:14 P.M. and he was one of the first officers to arrive at the nursing home. He stated they checked the entire facility and were unable to locate the resident. They dispatched four more police officers at 10:19 P.M., and at 10:33 P.M., more police officers arrived, including a police helicopter to aide in the search. He stated the facility seemed confused with their timeline and could not give them the accurate timeline of events. He stated the facility said they had a lot of false alarms and assumed this was a false alarm as the resident would have sounded the alarm when she left the facility. He stated the resident was located by the police helicopter and he was the first officer to arrive on scene where the resident was, which was at 11:45 P.M. She was in the wooded area about 100 feet from the facility and he found the resident kneeling down on the ground. She was wearing a light coat, socks, no shoes and had a bowling bag with her. She seemed very confused and not familiar with her surroundings. She was put in a police cruiser due to the cold weather until the medics arrived. Review of the facility's policy titled Missing Patients, dated 11/2017, revealed the facility's procedure was to account and search for missing residents, and to communicate with outside agencies when a resident is discovered missing.

Based on observation, medical record review, hospital record review, resident interview, staff interview, and review of the facility policy on suprapubic catheter site care, the facility failed to ensure a resident with a suprapubic catheter was provided with the appropriate treatment and services to prevent urinary tract infections. Actual harm occurred to Resident #78 when the resident experienced three urinary tract infections and hospitalization without evidence of any catheter care being provided from 02/18/19 through 05/16/19. This affected one (#78) of one resident reviewed for urinary tract infections. The facility census was 107. Findings include: Review of the medical record for Resident #78 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment, completed 02/25/19, revealed the resident had intact cognition. It indicated the resident had an indwelling catheter (including suprapubic) and had experienced a urinary tract infection in the last 30 days. An MDS assessment completed 04/15/19 indicated the resident had an indwelling catheter and required extensive assistance from two staff for toileting and personal hygiene. Review of the plan of care revealed a suprapubic catheter was used and the goal was no acute complications from use. The interventions included catheter care and changes as ordered. Review of physician's orders revealed an order, dated 03/25/19, to maintain the resident ' s suprapubic catheter with 16 French (Fr) 10 cubic centimeters (cc.) balloon for [MEDICAL CONDITION] bladder. Review of nursing progress notes revealed on 01/02/19 at 12:24 P.M. a urine specimen was obtained for a urinalysis and culture due to cloudy urine with catheter leakage. A nurse practitioner (NP) note on 01/02/19 at 2:13 P.M. stated the resident reported she feels OK but thinks she was developing a urinary tract infection. The urine was noted by the NP to be dark yellow with thick cloudy sediment. Review of the urine culture results, dated 01/05/19 revealed Resident #78 was noted to have a urinary tract infection of >100,000 colony-forming unit (CFU)/milliliter (ml.) of Escherichia Coli (E. coli) Extended-Spectrum Beta-Lactamase (ESBL) positive. A nursing progress note, dated 01/05/19 at 6:50 P.M., stated the resident had a urinary tract infection and was started on an antibiotic ([MEDICATION NAME]) for seven days and was placed on contact isolation. A nursing progress note, dated 01/16/19 at 1:37 P.M., stated the resident was removed from isolation precautions after a urine culture with no growth was received. Review of a nursing progress note, dated 01/22/19 at 2:23 P.M., revealed a cloudy urine was noted in catheter bag and the resident requested her urine to be tested . A NP note, dated 01/24/19 at 11:19 A.M., stated the resident was seen as nursing reports her urine was still very milky and thick looking as well as the urine indicated infection with culture pending. The resident stated she does not feel well today and was more tired. The urinalysis results were with three plus leukocytes and an acute [DIAGNOSES REDACTED]. Upon review of the urinalysis and given the patient's history of urosepsis, the NP ordered an antibiotic ([MEDICATION NAME] one gram) injection times one dose that day while culture results were pending. Review of the urine culture results, dated 01/25/19, revealed a growth of 10,000-50,000 CFU/ml of [MEDICAL CONDITION] (MRSA). The resident was placed on isolation precautions. Review of a NP progress note, dated 01/28/19 at 10:45 A.M., revealed Resident #78 had been recently diagnosed with [REDACTED]. She was currently being treated with an antibiotic (Bactrim DS) for seven days. The note stated the resident had three urinary tract infections that month and continued to be at a high risk for urinary infections related to her [MEDICAL CONDITION]. The NP recommended to continue suprapubic catheter care as ordered. Record review revealed that in (MONTH) 2019, cleansing of the catheter site and application of a dressing was being provided daily. The catheter was also being flushed twice daily. Review of a recheck of Resident 78's urine on 02/10/19 revealed a urine culture result indicating greater than 100,000 CFU/ml of Serratia Marcescens organism. A NP note, dated 02/11/19 at 2:43 P.M., stated the resident was positive for a urinary tract infection and had been started on antibiotics ([MEDICATION NAME]) for three days on 02/09/19. Review of a NP note, dated 02/15/19 at 1:59 P.M., revealed the chief complaint for the resident was running a fever and does not look good. The nursing staff reported a temperature of 100.6 Fahrenheit (f) and not looking well. Her blood pressure was 100 over 60 and her heart rate was 108. The NP said the resident would be transferred to the hospital for further evaluation. The nursing progress note stated the resident was transferred to the hospital on [DATE] at 2:00 P.M. Review of the hospital records revealed the resident was admitted from 02/15/19 through 02/18/19. A hospital history and physical stated the resident presented with malaise, foamy urine, and diarrhea. The impression [MEDICAL CONDITION] (an infection in the bloodstream) secondary to a complicated urinary tract infection. The resident was started on two different antibiotics. The hospital record stated urology was consulted for a catheter change. It stated she was supposed to get monthly changes of the catheter but the resident reported the last change was two months ago. The hospital documented there was no record of this anywhere and the last recorded change was (MONTH) (YEAR). Review of the facility records revealed a catheter change was documented on 11/29/18. There was no evidence of a catheter change in (MONTH) (YEAR), (MONTH) 2019, or (MONTH) 2019 prior to being hospitalized . Review of the hospital discharge records, dated 02/18/19, stated the recommendations were for the suprapubic catheter care per facility protocol and change catheter monthly. A nursing progress note, dated 02/18/19 at 7:40 P.M., stated the resident returned from the hospital with new orders including antibiotics [MEDICAL CONDITION]. Upon return from the hospital on [DATE], there was no evidence of a physician's order to provide cleaning of the catheter site (catheter care) or to change the catheter monthly. Review of a NP note, dated 02/19/19 at 12:51 P.M., revealed the resident was hospitalized until 02/18/19 due to urinary tract infection [MEDICAL CONDITION]. Nursing was to ensure follow up with urologist and to have catheter changed every month. However, no physician order was written to change catheter monthly. Review of a NP note, dated 02/22/19 at 10:06 A.M., revealed the resident continued to be at a high risk for urinary infections related to [MEDICAL CONDITION]. Suprapubic catheter care continued as ordered and continued to flush catheter daily. However, the resident had no physician's order for catheter care or catheter flushes after returning from the hospital 02/18/19. Review of the treatment administration record for (MONTH) 2019 revealed no evidence of any catheter care or catheter change done in (MONTH) 2019. Review of a NP note, dated 03/22/19 at 8:57 A.M., revealed the resident was seen due to fever of 101.6 F, heart rate at 125, respirations at 34. She had thick yellow urine and was complaining of back pain and supra pubic pain. She was confused and has a tendency to go septic rather quickly. The resident required 911 to transport to the hospital due to a quick decline in status. A nursing progress note indicated the resident was transported to the hospital on [DATE] at 8:50 A.M. The resident was admitted to the hospital. Review of hospital records revealed the resident was hospitalized from [DATE] to 03/24/19 for a urinary tract infection. Antibiotics were given. Upon return from the hospital, there was no evidence of any orders to provide catheter care or change the catheter monthly. Review of a urology consult report, dated 03/25/19, revealed an order was given for the nurses to change her suprapubic catheter every four weeks using a 16 Fr catheter and flush every catheter change and as needed. There was no evidence the order was written on the physician's order sheet for the order to be carried out. Review of a NP note, dated 03/29/19 at 9:30 A.M., stated to continue supra pubic catheter care as ordered and to continue to flush catheter daily. However, there were no physician's orders for catheter care or flushing of the catheter. A NP note, dated 04/05/19, stated her white blood cells were elevated to 14.8 and she has a history or urosepsis. A urine test and culture was ordered. A NP note, dated 04/09/19 at 2:58 P.M., stated the resident was feeling blah. A urine culture was positive with greater than 100,000 CFU/[MEDICAL CONDITION]. The NP ordered to begin antibiotics (Bactrim) twice daily for seven days and for the resident to be on contact isolation. A NP note, dated 04/18/19 at 10:51 A.M., stated to continue supra pubic catheter care as ordered and continue to flush catheter daily. Review of the treatment administration record (TAR) for (MONTH) 2019 revealed no evidence of any catheter care done in (MONTH) 2019. There was also no evidence of any flushing of the catheter in (MONTH) 2019. Review of a nursing progress note, dated 05/02/19, revealed an indwelling catheter evaluation was completed which stated the toileting plan was to provide suprapubic catheter care and changes as ordered. However, there continued to be no physician's orders for catheter care or changes. Review of a NP note on 05/08/19 at 5:34 P.M. revealed the resident was having complaints of pain in back despite having pain medication. Questionable onset of urinary tract infection. Will send urine for testing and culture to ensure this is not the cause. Nurses progress notes on 05/11/19 at 4:20 P.M. stated urine culture results received and antibiotics ([MEDICATION NAME]) started twice daily for seven days. Review of a urine culture report dated 05/12/19 revealed >100,000 CFU/ml of Escherichia coli in the urine. A NP note on 05/13/19 at 3:49 P.M. stated seen to follow up on recent urinalysis that has returned positive for E coli. and [MEDICATION NAME] faecalis. [DIAGNOSES REDACTED]. Antibiotic changed to [MEDICATION NAME] to cover multiple organisms. Review of the TAR for (MONTH) 2019 and the current physician's orders revealed no evidence of any catheter care ordered or provided, no order to change catheter monthly, and no order for flushing of catheter. Interview with Resident #78 on 05/16/19 at 9:20 A.M. revealed she gets frequent urinary tract infections. She stated she has one now and was on antibiotics. She stated the nurses clean around her catheter insertion site (catheter care) about once per week. Interview with Registered Nurse (RN) #165 on 05/16/19 at 9:40 A.M. revealed the nurses were the ones to provide catheter care for resident's with suprapubic catheters. She stated Resident #78 received catheter care as needed, if the resident requests it, or if the aides would say it needed done. She confirmed the plan of care stated to provided catheter care and changes as ordered. She confirmed the resident did not have any orders to provide catheter care or changing the catheter. She confirmed there was no documentation to indicate any catheter care was being provided. Interview with NP #318 on 05/16/19 at 2:19 P.M. revealed Resident #78 should receive catheter care once per day and the catheter should be changed every 30 days and as needed if it gets clogged. She confirmed the nurses were to do the catheter care. She confirmed there was currently no physician's orders for catheter care or changes. She stated not providing catheter care daily could lead to the development of urinary tract infections. She confirmed that after the resident returned from the hospital in February, she no longer had physician's orders for catheter care. A physician's order was obtained by the facility on 05/16/19 for cleansing of the suprapubic catheter site with wound cleanser, pat dry, and apply drain gauze daily. Observation of the catheter care on 05/16/19 at 4:05 P.M. revealed Licensed Practical Nurse (LPN) #115 to provide catheter care for Resident #78. The resident did not have a dressing over the area upon starting the care. LPN #115 applied non-sterile gloves and cleansed around the catheter insertion site with wound cleanser. She removed the gloves, used alcohol hand sanitizer, and put on clean non-sterile gloves. She dried the area, removed the gloves, used hand sanitizer, applied clean non-sterile gloves, and put a split gauze dressing around the area. Review of the facility policy on suprapubic catheter site care and dressing change, dated 11/2011 and updated 12/2012, revealed staff were to apply non-sterile gloves and remove the soiled dressing. Perform hand hygiene, open sterile dressing kit, apply sterile gloves, clean site, apply dressing and tape in place. Interview with the Director of Nursing on 05/16/19 at 4:25 P.M. confirmed the facility policy stated to apply sterile gloves to cleanse the site. He further confirmed there was no evidence catheter care had been provided for Resident #78 since returning from the hospital in (MONTH) 2019. He stated that, although the hospital records said to provide catheter care per facility protocol, the facility did not have a protocol for how often to provide catheter care. He confirmed catheter care should be provided daily. This deficiency substantiates Complaint Number OH 961.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical records review, in-service records, facility audit reviews, the National Pressure Ulcer Advisory Panel pressure staging guide, hospital staff and facility staff interviews, the facility failed to provide care and treatment to prevent the development of avoidable pressure ulcer and provide continued assessment of pressure ulcers after the development. This resulted in actual harm when Resident #1 was admitted to the facility without pressure ulcers and developed bilateral heel pressure ulcers that were unstageable. This affected one (#1) of three residents reviewed for care and treatment of [REDACTED]. Findings include: Review of Resident #1's closed medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of the discharge history and physical for Resident #1 revealed a discharge from the hospital on [DATE] with no pressure wounds. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 10 indicating moderately cognitively impaired. Resident #1 required a two plus physical assist for bed mobility and transfers, toilet use, and activities of daily living (ADL's). The Resident #1 had a pressure reducing device for his chair and his bed and no current pressure sore. Review of physician orders [REDACTED].#1 revealed wound care for open area to right medial foot: Cleanse with in house wound cleanser (IHWC), pat dry; apply triple antibiotic treatment, cover with Abdominal pad (ABD) and wrap with Kerlix to pad and protect. A physician orders [REDACTED]. A physician orders [REDACTED]. Review of nursing documentation dated 06/02/17 revealed wound measurements for the Resident #1 as right lateral foot measurements 0.5 centimeter (cm) x 3 cm, right medial foot measurements as 0.8 cm x 3 cm, and left lateral foot measurements as 0.5 cm x 5 cm. Review of nursing documentation dated 06/07/17 revealed wound measurements for the Resident #1 as right lateral foot measurements 0.5 cm x 4 cm, right medial foot as 0.7 cm x 3 cm, and left lateral foot measurements 0.5 cm x 4 cm. Review of the nursing notes dated 07/05/17 at 8:37 P.M. revealed an unstageable pressure ulcer noted to the Right heel measuring 6 cm x 7.5 cm. No drainage noted. Wound bed is 100% necrotic. Surrounding skin is intact, blanching but appears fragile. Resident denies pain at site. An unstageable pressure ulcer noted to the Left heel measuring 5 cm x 9.5 cm. with scant, sanguineous drainage noted. Wound bed is 100% necrotic. Surrounding skin is intact, blanching but appears fragile. Resident denies pain at site. Upon admission, resident had calluses to bilateral heels and skin was intact, hard to palpate and unable to visualize wound bed beneath the calluses. Skin assessment on 06/07/17, showed open areas noted on Right lateral foot, Right medial foot and Left lateral foot. Treatments were initiated per Certified Nurse Practioner (CNP) orders. Pressure areas to bilateral heels appear to have resulted from resident sliding down in bed and hitting the footboard. Resident wears shoes when out of bed and states that friction may have been caused between his heels and shoes. Educated resident to wear non-skid socks instead of shoes and he was provided a pair of socks. Will have maintenance assess for bed extender. CNP ordered wound consult. Interview on 08/10/17 at 2:30 P.M. with the Director of Nursing (DON) verified there are only two sets of measurements for the Resident #1's wounds prior to 07/05/17. The DON stated the facility completes measurements weekly along with weekly skin assessments but revealed the measurements for the Resident #1 wounds were not completed between 06/07/17 to 07/05/17. On 07/05/17, the facility recognized the lack of assessments and began corrective action. Interview on 08/10/17 at 3:30 P.M., via telephone with hospital Registered Nurse (RN) #30 revealed she first provided care for Resident #1 after his surgery in 05/2017. RN #30 revealed the Resident #1 was discharged on [DATE], without any pressure ulcers. RN #30 revealed she began providing care for Resident #1 again on 07/24/17 at the hospital where he was readmitted . RN #30 revealed the Resident #1 was admitted on [DATE] with black eschar to both his heels. RN #30 stated, his right heel wound measured upon admission, 7 cm x 0.5 cm x 0.1 depth and his left heel wound was 7 cm x 8.5 cm x 0 depth. Review of information from the National Pressure Ulcer Advisory Panel (NPUAP) revealed an unstageable pressure ulcer is a 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. The facility took the following corrective action and corrected the deficiency on 08/02/17 prior to the survey: · On 07/05/17, the facility assessed Resident #1 and began treatment of [REDACTED]. · On 07/05/17, the facility began in-servicing all nurses on weekly skin assessments and completed on 07/06/17. · On 07/05/17, skin assessments of all residents were completed to assess for skin impairments. · On 07/06/17, Resident #1 was seen by the wound clinic and treatments and assessments were completed. · On 07/06/17, weekly audits began of all residents with skin impairments for assessments and implementation of care. · On 08/02/17, weekly audits of four weeks were completed of residents with skin impairments. · On 08/10/17, review of two (#2 and #3) additional resident medical records for care and treatment of [REDACTED]. This deficiency substantiates Master Complaint Number OH 809 and Complaint Number OH 643.

Based on medical record review, staff and resident interview, the facility failed to provide the appropriate supervision and assistance needed when transferring. This affected one Resident (#87) of three residents sampled for falls of five sampled residents. This resulted in actual harm for Resident #87 when a staff member turned away from the resident while providing assistance, the resident fell and sustained a pelvic fracture. The facility identifed four residens who had falls with injuries in the past 60 days. The census was 88. Findings include: Review of Resident #87's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the minimum data set assessment dated [DATE] revealed Resident #87's cognition was intact, the resident required limited assistance of one staff member for transfers, extensive assistance for dressing and required supervision of one staff member with physical assistance for toileting. Further review of the medical record revealed on 02/27/16, Resident #87 was found lying on her back and leaning across the walker. The resident indicated she was trying to get a sweater when she fell landing on her left arm. Resident #87 indicated she thought her arm was broken. Resident #87 was assessed by the nurse who noted injury to the left arm. Resident #87 complained of pain to the left arm and was medicated for pain. The physician was notified and ordered Resident #87 be sent to the emergency room . The resident returned with a left humerus fracture and was placed in a sling and swath. Further review of the progress notes revealed on 03/11/16 Resident #87 fell off the toilet and landed on her right hip. Resident #87 was having pain and rated it as a ten out of a scale of one to ten with ten being the worse. The Certified Nurse Practioner and the family was notified and an order was obtained to send the resident to the emergency room . On 03/15/16 Resident #87 returned to the facility with a [DIAGNOSES REDACTED]. Interview of Resident #87 on 04/01/16 at 11:40 A.M. revealed on the day she broke her arm she was up in her room with her walker getting in her closet and fell . On the day she broke her pelvis she was in the bathroom (sling to the left arm) and was lowering herself to the toilet. A State tested Nurses Aide (STNA) was in the room providing assistance but the STNA turned away from the resident. The resident was not able to maintain her own balance and she went side ways and landed on the floor. Interview of the Director of Nursing (DON) on 04/01/16 at 11:45 P.M. revealed she was not aware of the discrepancies in the events leading up to the residents fall on 03/11/16 and she did not investigate the fall. The DON also revealed she was not aware of the pelvic fracture. The DON did confirm the resident required physical assistance of one staff for toileting and at the time of the fall the resident had her left arm in a sling. The STNA that was present during the fall was not on duty, she was agency staff and the DON indicated she would contact the agency for the STNA's phone number. On 04/01/16 at 1:20 P.M. the surveyor attempted to call the STNA that had been on duty the day of the fall (03/11/16) and received their voice mail. This deficiency substantiates Complaint Number OH 261.