Every finding on record at East Park Care Center

Based on interview, review of staff statements, medical record review, and review of facility policy, the facility failed to develop and implement a comprehensive and effective pressure ulcer program to ensure wound care was provided to prevent a decline Resident #150's wound status. Actual Harm occurred beginning on 07/24/25 when Resident #150 returned from a hospitalization and wound care orders to treat a chronic right heel wound were not transcribed into the facility's electronic health record (EHR) for implementation. Between 07/24/25 and 08/20/25, Resident #150 had no wound care orders in place and had no documented wound dressing changes recorded. Resident #150 was seen by Wound Nurse Practitioner (NP) #706 on 08/20/25 who noted the wound had deteriorated and had an increase in wound exudate. Resident #150 was hospitalized on [DATE] and required a debridement (a medical procedure to remove dead, infected, or damaged tissue from a wound) for gas gangrene (bacterial infection that destroys muscle tissue) of the right foot and osteomyelitis (infection of the bone) of the right heel. The debridement procedure resulted in significant exposure of the plantar calcaneus (bottom part of the heel). Resident #150 was admitted to the hospital for eight days and required intravenous antibiotics to treat his wound infection. On 09/07/25 staff identified the presence of maggots in Resident #150's right heel wound. The resident was transferred to the hospital for treatment of infection of the area. This affected one resident (#150) of three residents reviewed for wound care. The facility census was 50.Findings include:Review of the medical record for Resident #150 revealed an initial admission date of 02/14/24 with diagnoses including Stage IV (a full-thickness wound involving muscle, tendon, and/or bone) pressure ulcer of right heel, local infection of skin and subcutaneous tissue, chronic osteomyelitis with draining sinus of left ankle and foot, non-pressure chronic ulcer of left heel and mid foot with necrosis of bone, congestive heart failure, diabetes mellitus, myiasis (parasitic infection of fly larvae in human tissue), and epilepsy. Record review revealed Resident #150 had multiple hospitalizations while residing in the facility.Review of the plan of care initiated 02/29/24 revealed Resident #150 was at risk for pressure ulcer development related to history of pressure ulcers, decline in activities of daily living and mobility, and incontinence status. Interventions included administer treatments as ordered, monitor for effectiveness of treatments, educate on causes of skin breakdown, inform of any new areas of skin breakdown, monitor dressing to ensure it is intact, monitor nutritional status, obtain labs as ordered, and treat pain as ordered. The plan of care was cancelled on 09/01/25. An additional plan of care was initiated on 09/03/25 and revised on 09/08/25 to include the resident had an alteration to his skin to include osteomyelitis affecting bilateral heels. Listed interventions included administer treatments as ordered and monitor for effectiveness, assess, record, and monitor wound leaking as ordered, pressure reducing mattress to the bed, and assist the resident to turn and reposition as needed. The care plan did not mention any offloading of the heels or heel boots that Resident #150 should wear. Review of the census list for Resident #150 revealed the resident was hospitalized from [DATE] to 07/03/25. Review of the Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 07/04/25 revealed Resident #150 was at moderate risk for developing pressure injuries. Review of a wound assessment report dated 07/09/25 authored by Wound Nurse Practitioner (NP) #706 revealed Resident #150 had an unstageable (indicating a wound bed and depth of a wound is unable to be visualized) diabetic ulcer of the right heel measuring 5.0 centimeters (cm) in length by 5.5 cm in width with 0.1 cm depth. (This ulcer was subsequently assessed during a July 2025 hospitalization to be a pressure ulcer.) The report revealed the wound was acquired on 11/14/24. There was 90 percent (%) eschar (layer of dead tissue that forms over wound) and 10% epithelial tissue (thin layer of new tissue). There was no exudate (fluid that leaks out of blood vessels into surrounding tissue in response to inflammation or injury) noted. The recommended wound treatment was to cleanse the right heel with normal saline, apply Betadine (antiseptic solution), and abdominal (ABD) pad, and rolled gauze, change daily and as needed. The wound was noted to be stalled. Review of a wound assessment report dated 07/16/25 authored by Wound NP #706 revealed Resident #150's right heel wound measured 5.0 cm in length, 5.5 cm in width, and 0.1 cm depth. The wound was 90% eschar and 10% epithelial tissue. There was no noted exudate. The wound remained stalled. The recommended treatment remained to cleanse with normal saline, apply Betadine, and ABD pad, and rolled gauze with frequency of daily and as needed. Review of a progress note dated 07/19/25 timed 11:15 P.M. revealed Resident #150 was having difficulty managing his blood glucose levels and the physician recommended to send the resident to the hospital for evaluation. An additional progress note dated 07/20/25 timed 4:17 A.M. revealed Resident #150 was admitted to the hospital for hyperglycemia, osteomyelitis, and anemia. The resident was hospitalized until 07/24/25. Review of a hospital Physician Consultation Report dated 07/20/25 revealed Resident #150 presented to the hospital for elevated blood glucose levels. An x-ray examination of his right foot showed soft tissue ulceration overlying the right posterior calcaneus (a bone in the foot near the heel) with underlying cortical destruction consistent with osteomyelitis. Review of a hospital skin assessment dated [DATE] revealed Resident #150's right heel measured 7.3 cm in length by 8.0 cm in width and had an undetermined depth. The wound was 90% brown eschar and 10% small area of mixed yellow and red noted caudally (towards the posterior aspect of the wound). There was moderate serosanguineous drainage which was somewhat malodorous. Iodoflex (a wound treatment designed to absorb slough, soft necrotic tissue, and exudate), ABD pad (a highly absorbent dressing, used for heavily draining wounds) and rolled gauze were applied and heel lift boots were applied. Review of hospital discharge instructions dated 07/24/25 revealed Resident #150 had diagnosis of acute osteomyelitis of the right heel. Resident #150 had an order for Vancomycin one gram intravenously every 12 hours for a duration of four weeks. There was no evidence of wound care orders noted on the hospital discharge instructions. Review of a clinical admission noted dated 07/25/25 revealed no note regarding Resident #150's right heel wound. Resident #150 was noted to have a left heel diabetic foot ulcer. Review of a skilled nursing evaluation dated 07/27/25 revealed no note regarding Resident #150's of right heel wound. The evaluation did reference Resident #150 was noted to have a left heel diabetic foot ulcer. Review of a wound assessment report dated 07/30/25 authored by Wound NP #706 revealed Resident #150's right heel wound measured 7.3 cm in length by 7.5 cm in width with 0.1 cm depth. The wound was 90% eschar and 10% epithelial. There was no noted drainage. The wound remained stalled. The recommended wound treatment remained to cleanse with normal saline, apply Betadine, and ABD pad, and rolled gauze with a frequency of daily and as needed. Review of a wound follow up note dated 08/01/25 authored by Wound NP #706 revealed Resident #150's right heel wound was stable, and debridement was considered to destabilize necrotic tissue. An addendum was added on 08/24/25 stating Resident #150's right heel diabetic wound had deteriorated and was now an unstageable pressure injury. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for July 2025 revealed no evidence of wound care orders or evidence of any wound care provided to Resident #150's right heel following his return to the facility from the hospital on [DATE]. Review of a skilled nursing evaluation dated 08/03/25 revealed no note regarding Resident #150's of right heel wound. The evaluation did reference Resident #150 was noted to have a left heel diabetic foot ulcer. Review of a wound assessment report dated 08/06/25 authored by Wound NP #706 revealed Resident #150's right heel wound measured 9.0 cm in length by 8.0 cm with 0.1 cm depth. The wound was 90% eschar and 10% epithelial tissue. There was no noted drainage. The wound was noted to have remained stalled. The recommended wound treatment remained to cleanse with normal saline, apply Betadine, and ABD pad, and rolled gauze with frequency of daily and as needed. Review of a wound follow up note dated 08/06/25 authored by Wound NP #706 revealed Resident #150's wound was considered stable. An addendum was added on 08/24/25 stating Resident #150's right heel diabetic wound had deteriorated and was now an unstageable pressure injury. Review of skilled nursing evaluation dated 08/09/25 revealed no note regarding Resident #150's of right heel wound. The evaluation did reference Resident #150 was noted to have a left heel diabetic foot ulcer.Review of a wound assessment report dated 08/13/25 authored by Wound NP #706 revealed Resident #150's right heel wound measured 7.0 cm in length by 7.5 cm with 0.1 cm depth. The wound was 90% eschar and 10% epithelial. There was no noted drainage. The wound was noted to have remained stalled. The recommended wound treatment remained to cleanse with normal saline, apply Betadine, and ABD pad, and rolled gauze with frequency of daily and as needed. Review of skilled nursing evaluation dated 08/18/25 revealed no note regarding Resident #150's of right heel wound. The evaluation did reference Resident #150 was noted to have a left heel diabetic foot ulcer.Review of a wound follow-up note dated 08/20/25 for service on 08/13/25 authored by Wound NP #706 revealed Resident #150's wound was considered stable. Additional interventions included Prafo heel boots (pressure relief ankle foot orthosis used to always take pressure off the back of the foot) to be worn at all times. An addendum was added on 08/24/25 stating Resident #150's right heel diabetic wound had deteriorated and was now an unstageable pressure injury. Review of a wound assessment report dated 08/20/25 authored by Wound NP #706 revealed Resident #150's right heel wound measured 7.5 cm in length by 9.5 cm in width by 0.1 cm depth. The wound was 80% eschar, 10% epithelial tissue, and 10% granulation tissue. There was moderate serosanguinous drainage. The wound was noted to be deteriorating. The recommended wound treatment was changed to cleanse with normal saline, apply Medi-honey (wound ointment which helps maintain a moist wound environment, has antibacterial properties, and aids in autolytic debridement) and Calcium Alginate (wound dressing used to manage drainage and promote a moist wound environment), ABD pad, and rolled gauze with instructions to change daily and as needed. Review of progress note dated 08/20/25 timed 2:19 P.M. revealed Resident #150 was sent to the hospital for lethargy and a change in mental status. Resident #150 was noted to have blood-tinged urine, was unable to swallow at lunch, and was difficult to rouse.Review of census list for Resident #150 Resident #150 was hospitalized on [DATE]. Review of hospital paperwork from admission date of 08/20/25 to discharge date of 08/28/25 revealed Resident #150 was admitted for altered mental status. Resident #150 had a debridement procedure on 08/22/25 for gas gangrene of the right foot and osteomyelitis (bone infection) of the right heel. Cultures taken during the debridement procedure grew moderate Bacteroides fragilis group with mixed flora isolated including mixed gram-negative rods. Resident #150 was seen by podiatry on 08/25/25. The right heel wound measured 6.5 cm by 9.5 cm by 1.5 cm. Resident #150's wound was noted to probe to the bone and had large amount of serous drainage. Review of podiatry follow up on 08/26/25 revealed there was significant exposure of the plantar calcaneus observed. Wounds were dressed with Betadine and wet to dry dressing. The podiatrist noted there would likely be a need for amputation in the future however at current to continue local wound care and long-term intravenous antibiotics. Review of a NP wound follow up note dated 08/21/25 revealed Resident #150's wound had deteriorated. It was noted the dressing removed during service on 08/20/25 was not the supplies ordered for treatment. It was also noted there was no pad and protect dressing or heel boots in place. The note instructed to change dressings as ordered, only use supplies recommended for treatment, and use heel boots at all times. Review of the MAR and TAR for August 2025 revealed there was no evidence of any wound care provided to Resident #150's right heel until 08/28/25, following his return to the facility from the hospital. Starting on 08/28/25, Resident #150's right heel was cleansed with normal saline, betadine and a wet-to-dry dressing was applied daily. Additionally, there was no evidence that Resident #150 had orders for Prafo boots as recommended in Wound NP #706's wound notes. Review of Order Listing Report from 07/01/25 to 08/31/25 revealed Resident #150 had no wound care orders for treatment of the right heel wound care between 07/24/25 and 08/20/25. Review of a NP wound assessment report dated 09/03/25 revealed Resident #150's right heel wound measured 9.0 cm by 10.0 cm by 0.5 cm. The wound was 50% epithelial and 50% granulation. There was moderate serosanguinous drainage. The wound was noted to be deteriorating. The recommended wound treatment was changed to cleanse with normal saline, apply Betadine followed by wet to dry dressing, ABD pad, and rolled gauze with frequency of daily and as needed. Review of a NP wound follow up note dated 09/03/25 revealed Resident #150 had a recent hospitalization in which there was heel debridement procedure completed. It was noted there was exposure of bone and tendon to the right heel. Additional interventions noted to utilize a low air loss mattress and use Prafo heel boots at all times. The note stated not to use plastic heel boots. Review of Resident #150's plan of care initiated on 09/03/25 revealed Resident #150 had a Stage III pressure ulcer on his sacrum and osteomyelitis affecting bilateral heels. Interventions included administer treatments as ordered, assess and monitor wound healing, assist with turning and repositioning as needed, inspect skin daily during routine care, obtain labs as ordered, pressure reducing cushion to chair, and pressure reducing mattress. Review of skilled nursing evaluation noted dated 09/07/25 revealed Resident #150's bilateral heel wounds showed decline. Review of a census list for Resident #150 revealed hospitalization from 09/07/25 to 09/17/25. Review of a progress note dated 09/07/25 timed 12:38 P.M. revealed Resident #150 was receiving personal care and there were noted necrotic (dead tissue) areas, warmth, and purulent drainage to the bilateral heel wounds. It was noted that Resident #150's wounds appeared more swollen, and the resident had increased pain at the sites. The NP was notified and gave order to send to hospital for evaluation and treatment of possible infected wounds. Review of a statement dated 09/07/25 by Certified Nursing Assistant (CNA) #818 revealed while changing Resident #150 it was noted the dressing on his heel needed changed. The dressing was dated 09/05/25, was extremely discolored, and was falling apart. CNA #818 indicated she noted movement in the wound and found maggots crawling in the wound. CNA #818 informed both nurses on duty. Review of a statement dated 09/07/25 by CNA #857 revealed while performing care for Resident #150 it was noted the dressing was falling off his right foot. CNA #857 stated she picked up Resident #150's right foot and saw maggots crawling on his foot. It was also noted the dressing was dated 09/05/25. Review of a statement dated 09/07/25 by Licensed Practical Nurse (LPN) #807 revealed the aides reported during personal care for Resident #150, his dressing to his right heel fell off. The aides reported maggots were present in the right heel wound bed. LPN #807 went to room with another nurse to assess the area. There was a pungent odor noted. The two nurses observed the maggots in Resident #150's right foot wound. The other nurse began cleansing the wound. LPN #807 called 911 for emergency services due to the necrotic and foul-smelling wound. LPN #807 contacted the Director of Nursing (DON) who instructed the nurses to cleanse and re-wrap the wound. The NP was notified of the resident's change and need for emergency services. LPN #807 noted the dressing on Resident #150's right heel was dated 09/05/25. Review of fire department Prehospital Care Report Summary dated 09/07/25 revealed Resident #150 was transported by emergency medical services (EMS) to the hospital. The chief complaint was listed as maggots in a foot wound. It was noted facility staff stated as they were getting Resident #150 ready to transfer out of his bed, they noticed maggots in the pressure ulcer on the right heel. Staff stated they cleaned out the wound with sterile water prior to EMS arrival. Review of a physician consultation report dated 09/07/25 revealed Resident #150 presented to hospital from skilled nursing facility (SNF) after staff noticed maggots, malodor, and drainage from a right heel wound. There were no maggots seen in the right heel wound at time of hospital observation. Examination of Resident #150's right foot revealed an extensive wound to the posterior planter aspect of the right heel measuring 6.0 cm in length by 9.0 cm in width with depth noted to the bone. There was significant exposure of the plantar calcaneus and noted malodor and pus in the right heel wound. The treatment plan was listed as betadine with a wet-to-dry dressing. The note referenced the plan was for Resident #150 to be admitted for an infected Stage IV decubitus ulcer (a full-thickness pressure ulcer with exposed muscle, tendon, or bone) to the right heel with potential surgical intervention pending final culture reports and x-ray examinations. Review of a critical care progress note dated 09/15/25 revealed Resident #150 was sent to hospital from nursing home with complaints of generalized weakness. He was found to have larvae infestation of the wound in the right lower extremity and anemia. It was noted per podiatry there was poor outlook of the right lower extremity (RLE) and Resident #150 had previously refused a below the knee amputation (BKA) on multiple occasions. Resident #150 had debridement procedure on 09/11/25 of right heel bone cortex. Treatment for right heel was to apply Dakins solution (a solution used to clean and disinfect wounds) with gauze pads, ABD pads, kerilx (rolled gauze) wrap, and ACE (compression) wraps. During the hospital stay Resident #150 had a rapid called for altered mental status and hypothermia, with metabolic encephalopathy in the setting of sepsis (systemic infection) suspected. Review of hospital podiatry follow up note dated 09/15/25 revealed Resident #150's right heel wound measured 10.0 cm in length by 7.5 cm in width with depth to the bone. The wound bed was exclusively bone of the heel. The note referenced the resident had refused a BKA and wound care was the only option at this time to prevent further infection. The note referenced Resident #150 was stable from a podiatry perspective with a need for close outpatient follow up. Review of discharge summary report dated 09/16/25 revealed Resident #150 was to follow up with the podiatry office in one week and the right heel wound was to utilize Dakin's solution, gauze pads, ABD pads, kerlix and ACE wraps to be changed daily. Review of a NP wound assessment report dated 09/17/25 revealed Resident #150's right heel wound measured 7.0 cm in length by 8.0 cm in width and 0.5 cm in depth. The wound was 10% eschar, 10% slough, and 80% granulation. The wound was noted to be deteriorating. There was moderate serosanguinous drainage noted and there was exposed tissue to adipose, muscle/fascia, tendon/ligament, and bone level. The recommended wound treatment was changed to cleanse with normal saline, apply Dakins moistened gauze followed by ABD pad and rolled gauze with frequency of three times per day (TID) and as needed. Review of a wound follow up note dated 09/19/25 authored by Wound NP #706 revealed Resident #150's right heel had severely deteriorated and was noted to be severely deformed. Additional interventions included changing dressings as ordered, wearing heel boots at all times, and maintaining a low air loss mattress. Review of the MAR and TAR for September 2025 revealed no order or corresponding documentation of Resident #150 utilizing a low air loss mattress or Prafo boots as recommended in Wound NP #706's September 2025 wound notes. Interview on 10/21/25 at 12:13 P.M. with Assistant Director of Nursing (ADON) #829 revealed she was the wound nurse for the facility. ADON #829 reported Resident #150 had the right heel wound since before she started in February 2025. ADON #829 stated they had been treating the wound in-house, however, since September 2025 Resident #150 had been going to outside podiatry appointments for wound management. ADON #829 stated Resident #150 had history of osteomyelitis and they had to discuss the potential for amputation. ADON #829 stated she was notified staff had noted maggots in the resident's wound on 09/07/25. ADON #829 stated the wound was cleansed and Resident #150 went to the hospital. ADON #829 stated she did not observe maggots in the wound herself and was unsure how they would have infested the wound. A follow-up interview at 1:25 P.M. with ADON #829 confirmed Wound NP #706 had noted Resident #150's wound was deteriorating on or about 08/20/25. ADON #829 stated the eschar had started to come off and the wound was measuring larger. ADON #829 stated Resident #150 required extensive debridement during a recent hospitalization. Interview on 10/21/25 at 3:01 P.M. with a family member of Resident #150's revealed Resident #150 was currently in the hospital. The family member reported Resident #150 was admitted from a podiatry appointment as he was bleeding too much and was on Coumadin. The family member reported the facility was no longer allowed to care for Resident #150's wound per podiatry. The family member indicated she preferred it this way as Resident #150 had been to the hospital several times for wounds and had multiple infections due to a lack of appropriate and necessary staff treatment. The family member indicated she had once seen Resident #150 at the facility and his wound was not taken care of. The family member stated she had to get on the facility to make sure his wounds were taken care of appropriately. The family member indicated she was unaware there were concerns for maggots in the wound on 09/07/25. Interview on 10/21/25 at 3:27 P.M. with LPN #807 revealed she had cared for Resident #150 on 09/07/25. LPN #807 stated Resident #150 had very complex wounds. LPN #807 stated she was notified by the aide there were maggots in Resident #150's wound on this date. LPN #807 stated she did not believe the agency night nurse from the shift prior had provided wound care as ordered. LPN #807 stated she and Registered Nurse (RN) #800 assessed the resident's wound and cleansed the wound with normal saline. LPN #807 estimated there were approximately 20 maggots seen in the right heel wound. LPN #807 stated she notified the Director of Nursing (DON) and NP she was going to call 911. Interview on 10/21/25 at 4:06 P.M. with CNA #818 revealed she had cared for Resident #150 on 09/07/25. CNA #818 stated Resident #150 was dependent on staff for all care needs. CNA #818 stated during care it was noted Resident #150's dressing (to the right foot) was discolored and coming off. CNA #818 stated the dressing was dated 09/05/25 and was usually done by night shift. CNA #818 noted there was a pungent odor to the wound. CNA #818 stated she notified LPN #807 about the concerns with Resident #150's wound. Interview on 10/21/25 at 4:40 P.M. with Podiatrist #705 revealed Resident #150 had very complicated wounds. Podiatrist #705 stated he had discussed amputation multiple times with Resident #150. Podiatrist #705 stated Resident #150 was unable to care for his own wounds and relied on caregivers. Podiatrist #705 stated he generally does not trust nursing facilities to provide wound care in an appropriate manner and would prefer to provide the care for his patients himself. Podiatrist #705 stated he had been caring for Resident #150's dressings in office since an operation in September 2025. Podiatrist #705 stated he was consulted while Resident #150 was in the hospital on [DATE] but did not visualize any maggots in the wound at that time. Interview on 10/22/25 at 7:34 A.M. with ADON #829 confirmed she was unable to locate any evidence Resident #150 had an order for wound care between 07/24/25 to 08/20/25. ADON #829 stated the Wound NP #706 had seen Resident #150 weekly during that time but was unable to locate any evidence of additional treatments provided in Resident #150's medical record. Interview on 10/22/25 at 8:22 A.M. with the DON denied any knowledge of missing orders or declining wounds for Resident #150. The DON indicated she was notified by LPN #807 staff saw maggots in the resident's wound on 09/07/25. The DON stated she would expect staff to clean the wound if they observed something in the wound. Interview on 10/22/25 at 11:51 A.M. with CNA #857 revealed she had cared for Resident #150 on 09/07/25. CNA #857 confirmed she had observed maggots crawling out from his right foot wound. CNA #857 stated she stayed with Resident #150 while CNA #818 went to get LPN #807. CNA #857 stated Resident #150 was very compliant with care and would ask caregivers for extra clean ups at times. Interview on 10/22/25 at 3:51 P.M. with former Wound NP #706 revealed she had been caring for Resident #150's wounds for approximately five months at the facility. Wound NP #706 stated Resident #150 had a stable necrotic area to right heel. Wound NP #706 stated the ulcer was a diabetic foot ulcer, and she was treating with Betadine. Wound NP #706 verified the wound then presented as a pressure injury (unable to recall date). Wound NP #706 stated she had noted some decline in his right heel. Wound NP #706 stated there were some incidents when the wrong dressing was applied or the wound was not padded and protected. Wound NP #706 stated Resident #150's wound was larger, so it was documented it was deteriorating. Wound NP #706 stated she was unable to recall any additional information as she was no longer employed with the company and did not have access to her notes for this resident. Interview on 10/22/25 at 4:01 P.M. with RN #800 revealed an aide had come to get her on 09/07/25 and stated Resident #150's wound dressing had come off. They stated there were maggots in the wound. RN #800 stated she and LPN #807 went in to assess the situation. RN #800 stated she cleansed the area as much as she could and told LPN #807 to work on getting Resident #150 sent out [to the hospital]. RN #800 stated there were approximately 20 maggots in the wound and stated it was disgusting. RN #800 stated the maggots were moving within the wound. RN #800 stated she ensured Resident #150 was sent out to the hospital and then went back to her assignment. Review of facility policy on wound care dated September 2021 revealed prior to providing wound care physician's orders should be verified. Documentation of the wound care procedure would be completed in the resident's medical record. This deficiency represents non-compliance investigated under Complaint Number 2642458 and is a recite to the complaint survey completed on 10/14/25.

Based on interview and medical record review, the facility failed to ensure residents were notified in writing of a room move. This affected three residents (#110, #115, #117) of three residents reviewed for room moves. The facility census was 50.Findings include:1. Review of the medical record for Resident #110 revealed an admission date of 06/07/24 and diagnoses including dementia, congestive heart failure (CHF), and hypertension.Review of the clinical census revealed Resident #110 had a room move on 12/31/24.Review of the progress note dated 12/31/24 revealed Resident #110 requested a room move.Review of the medical record revealed no evidence of a written room move notification was issued.2. Review of the medical record for Resident #115 revealed an admission date of 03/11/25 and diagnoses including Parkinson's disease, chronic obstructive pulmonary disease (COPD), and dementia.Review of the clinical census revealed Resident #115 had a room move on 04/22/25.Review of the progress note dated 04/22/25 revealed social services discussed a room move with Resident #115. Resident #115 was agreeable to move rooms.Review of the medical record revealed no evidence of a written room move notification was issued.3. Review of the medical record for Resident #117 revealed an admission date of 07/09/21 and diagnoses including chronic kidney disease (CKD), osteoporosis, and atrial fibrillation.Review of the clinical census revealed Resident #117 had a room move on 05/13/25.Review of the progress note dated 05/13/25 revealed social services contacted Resident #117's emergency contact. The facility needed a private room for another resident who required isolation. Resident #117's emergency contact agreed to the room move.Review of the medical record revealed no evidence of a written room move notification was issued.Interview on 10/22/25 at 10:12 A.M. with Social Service Designee (SSD) #860 revealed when a resident was set to move rooms, they had a verbal discussion to get confirmation. SSD #860 confirmed there was no written notice for room moves for Residents #110, #115, or #117.Interview on 10/22/25 at 2:57 P.M. with Regional Nurse #703 revealed the facility did not have a policy on room moves.This deficiency represents non-compliance investigated under Complaint Number 2642458.

Based on observation, staff interview, and facility policy review, the facility failed to maintain the shower on the [NAME] hallway in good working condition. This had the potential to affect 11 residents (#7, #15, #22, #24, #33, #35, #38, #40, #43, #45, and #47) who used the [NAME] Hallway shower. The facility census was 48. Findings include: On 10/08/25 at 8:55 A.M., an interview with Family Member #263 revealed the shower on the [NAME] Hallway had several titles falling off the wall and they have been like that for about a year now.Observation of the [NAME] hallway shower room with Licensed Practical Nurse (LPN) #300 on 10/08/25 at 9:17 A.M. revealed the toilet broken off the seal in the floor, there was feces smeared on the outside of the toilet, there were six tiles pulled off the shower stall wall around the floor exposing a very large hole in the wall. There were two tiles missing from the bottom corner of the shower stall with a hole in the wall exposed. There was a pile of broken tile in the corner of the shower stall. An interview at this with LPN #300 confirmed the tiles were off the wall and were lying on the floor in a pile. She also verified the toilet was broken and there was feces on the toilet. On 10/08/25 at 9:31 A.M., an interview with Certified Nursing Assistant (CNA) #249 stated the tiles in the [NAME] Hallway bathroom have been broken for a while but she was not sure for how long. Review of the facility policy titled, Resident Environmental Quality, dated 08/23 revealed it was the policy of the facility to be designed, constructed, equipped and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public.

Based on review of the medical record, staff interview, and facility policy review, the facility failed to ensure a treatment was timely initiated for treatment of Resident #36's yeast infection. This affected one resident (#36) of three residents reviewed prompt and adequate care. The facility census was 48. Findings include:Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included infection of the skin, cognitive communication deficit, personality disorder, Parkinson's disease, chronic obstructive pulmonary disease, hyperlipidemia, anemia, major depressive disorder, disorder of adult personality and behavior, hypothyroidism, and dementia.Review of the Health Status note dated 03/12/25 at 5:54 A.M. revealed Resident #36 was awake most of the night complaining about a pain and burning sensation in her vaginal area. There was no further documentation or evidence the physician being notified. Review of the Nursing Note dated 03/24/25 at 10:51 A.M revealed the facility's Nurse Practitioner (NP) was in at around 10:00 A.M. and was notified of residents' concerns and she went to visit the resident. The NP ordered doxycycline (an antibiotic) 100 milligrams twice daily for redness in her right leg, consult an endocrinologist for hyperthyroidism, vitamin D 50, 000 units once a week for vitamin D deficiency, and miconazole (an antifungal) cream for seven days for vaginal itching. Resident #36 was recorded as being her own responsible party. Review of the Medication Administration Record dated March 2025 revealed Resident #36 was not administered her miconazole vaginal cream on 03/24/35, 03/26/25, 03/27/25 and 03/29/25 because it was not available. Review of the pharmacy delivery sheets dated from 03/01/25 through 03/31/25 revealed no evidence that the miconazole vaginal cream for Resident #36 was delivered to the facility. Review of the Health Status note dated 04/04/25 at 10:40 A.M. revealed Resident #36 complained of vaginal discomfort, she stated she had a yeast infection. The NP ordered for her to receive one dose of Diflucan (an oral antifungal medication) and Monistat vaginal cream daily for seven days. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #36 had intact cognition. On 10/08/25 at 10:07 A.M., an interview with Resident #36 revealed she had told the nurses several times she had vaginal itching and it was from the antibiotic. She stated she got a yeast infection every time she was on an antibiotic, but they did not do anything so she called her doctor and that was when they had the doctor at the facility to see her. Resident #36 stated she never got the cream because the staff could never find it. On 10/08/25 at 3:33 P.M. an interview with Licensed Practical Nurse (LPN) #300 revealed she was not sure why Resident #36 did not get her vaginal cream but she would investigate it. LPN #300 verified the documentation indicated she had first complained about itching on 03/12/25 and the physician was not notified until 03/24/25 by the resident herself. She stated she would have to find out why the cream was not delivered. On 10/09/25 at 1:25 P.M. an interview with the Administrator revealed the medication for Resident #36 was over the counter so they went out and purchased it for her use. She stated the previous Administrator went out and purchased it. On 10/09/25 at 1:48 P.M. an interview with the Administrator verified there was no documentation the medication was given on 03/24/35, 03/26/25, 03/27/25, and 03/29/25. Review of the facility policy titled, Administering Medications, dated 04/28/25 revealed medications would be administered in a safe and timely manner and as prescribed.

Based on observation, review of the medical record, review of manufacturer's instructions, and staff interview, the facility failed to ensure the air mattress for Resident #10 was set at the appropriate weight for him. This affected one resident (Resident #10) of three residents reviewed for preventative interventions in place. The facility census was 48.Findings include:Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, systemic inflammatory response syndrome (SIRS), diabetes, hemiplegia of the left side, anoxic brain damage, aphasia, dysphagia, anemia, osteoarthritis, traumatic brain injury, anxiety disorder, neuromuscular disfunction of the bladder, adult failure to thrive, peripheral vascular disease and bed confinement. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #10 had severely impaired cognition, was dependent on staff for all activities of daily living (ADLs) and had an indwelling urinary catheter. Resident #10 received a mechanically altered diet and had a feeding tube. Review of Resident #10's physician's orders for October 2025 revealed Resident #10 had an order dated 05/08/25 for an air mattress with bolsters dated 05/08/25 and an order for wound care dated 10/02/25 which stated to cleanse the sacrum with normal saline, pat dry, apply barrier cream and dry dressing for pad and protection every three days and as needed.Observation with the Director of Nursing (DON) on 10/07/25 at 1:55 P.M. revealed the air mattress was set at 610 pounds. The DON verified at the time of observation the mattress was set at 610 pounds but stated the resident was comfortable. Observation on 10/08/25 at 11:30 A.M. revealed the air mattress for Resident #10 was still set at 610 pounds. Observation with Licensed Practical Nurse (LPN) #226 on 10/08/25 at 2:00 P.M. revealed the air mattress for Resident #10 was set at 610 pounds. An interview at the time of observation with LPN #226 revealed Resident #10 only weighted 165 pounds. She stated she was told he was care planned for it to be at 610 pounds so he could elevated higher to see the television. On 10/08/25 at 4:15 P.M. an interview with the DON verified there was no documentation in the plan of care for Resident #10 to have his air mattress at 610 pounds per his preference. Review of the operation manual for the Proactive Protek Aire Mattress revealed the Press Pressure Range was 20-65 millimeters of mercury adjustable by the residents weight. The mattress weight settings were adjustable between 90 and 650 pounds.

Based on medical record review, review of Self-Reported Incidents (SRI), staff interview, and facility policy review, the facility failed to thoroughly investigate an allegation of abuse for Resident #51. This affected one resident (#51) of three residents reviewed for abuse. The facility census was 48.Findings include:Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, adjustment disorder with depressed mood, severe protein-calorie malnutrition, atrial fibrillation, abdominal aortic aneurysm, hypertension, benign prostatic hyperplasia, pacemaker, cystic disease of the liver, bradycardia, transient ischemic attack, and cognitive communication deficit. Review of the Discharge Minimum Data Set, dated [DATE] revealed Resident #10 had moderately impaired cognition with no behaviors. Review of the progress notes from 04/01/25 to 04/10/25 revealed no documentation of allegation of mistreatment being investigated. Review of the Self-Reported Incident dated 04/09/25 revealed Resident #51 told the social worker at the hospital he felt mistreated at the facility. The resident was currently at the hospital. Summary of the incident revealed the Administrator interviewed the resident when he returned from the hospital and felt safe at the facility and did not feel mistreated. Further review of the SRI revealed no facility investigation was completed. There were no interviews with staff or residents and no skin assessments completed. On 10/08/25 at 3:15 P.M. an interview with Regional Director of Clinical Services #262 verified there was no investigation found for the SRI dated 04/09/25. She stated it was the former Administrator who completed the investigation and they could not find the investigation anywhere. Review of the undated facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Residents Property, revealed residents had the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This included, but was not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint that was not required to treat the resident's medical symptoms. It was the Facility's policy to investigate all alleged violations involving Abuse, Neglect, Misappropriation of Resident Property, Exploitation or Mistreatment, including Injuries of Unknown Source, in accordance with this policy and to ensure that all individuals who report such incidents and allegations are free from retaliation or reprisal for reporting the incident.This deficiency represents non-compliance investigated under Complaint Number 1387795.

Based on review of the medical record, review of the hospital records, staff interview, and facility policy review, the facility failed to properly care for the feeding tube for Resident #10 to prevent mold from forming within the tube. This affected one resident (#10) of three residents reviewed for feeding tubes. The facility census was 48.Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, systemic inflammatory response syndrome (SIRS), diabetes, hemiplegia of the left side, anoxic brain damage, aphasia, dysphagia, anemia, osteoarthritis, traumatic brain injury, anxiety disorder, neuromuscular disfunction of the bladder, adult failure to thrive, peripheral vascular disease, and bed confinement.Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #10 had severely impaired cognition, was dependent on staff for all activities of daily living (ADLs) and had an indwelling urinary catheter. Resident #10 received a mechanically altered diet and had a feeding tube. Review of Resident #10's physician's orders for August 2025 revealed Resident #10 had an order dated 04/20/24 for hydration flushes every four hours with 300 milliliters of water, an order dated 08/27/25 for bolus tube feedings using IsoSource 1.5 (tube feeding formula) 237 milliliters routinely at 12:00 A.M., 3:00 A.M., 6:00 A.M., and 9:00 P.M., an order dated 04/03/24 to cleanse Resident #10's Percutaneous Endoscopic Gastrostomy (PEG) tube site daily with soap and water, apply a T-drain (split dry gauze) dressing daily and as needed, and an order dated 04/05/24 noting that Resident #10 was ordered a regular diet with pureed texture with small portions and was able to be administered his medication by mouth.Review of the Health Status notes dated 08/25/25 at 3:11 P.M. revealed Resident #10 was sent out to the hospital for evaluation of a discolored PEG tube. Upon initial assessment, the PEG tube site appeared intact but with dark discoloration of the tubing, with no visible leakage or bleeding from the insertion site. The site surrounding the PEG tube was clean and dry with minimal erythema (redness), however, the tubing showed brownish discoloration internally, which raised concerns for possible infection or internal bleeding. Resident #10 denied abdominal pain, nausea, or vomiting but reported mild discomfort at the peg tube site. Resident #10 had no sign of fever or hemodynamic instability noted. His vital signs were within normal limits at time of assessment. The physician was notified and gave order to send him to the hospital for further evaluation and possible replacement. Resident #10 was transported via ambulance in stable condition. The family was notified of his change in condition and transfer to hospital. The PEG tube site was lightly dressed prior to transport. Review of the Case Management report from the hospital dated 08/25/25 revealed Resident #10 presented to the emergency room (ER) for tube feed assessment. It was reported by an unnamed Registered Nurse that the resident had a moldy peg tube with a large black and budging (moving) spots. Review of the Physician's emergency room report dated 08/26/25 at 12:33 A.M. revealed Resident #10 was in the ER with mold around his PEG tube which was replaced in the ER and he was discharged back to the facility. On 10/08/25 at 3:33 P.M. an interview with Nurse #300 verified there was mold in the PEG tube of Resident #10. She stated they sent him out to the hospital because she did not want to flush the tubing with the mold in the tube. She stated she interviewed the (unnamed) certified nursing assistants (CNA) about it and they all stated it had been like that for a while, however, they were not nurses and did not know what it was. Nurse #300 also stated none of the nurses remembered seeing discoloration or mold in the tubing and confirmed if they had been flushing the PEG tube as ordered they would have seen it.Review of the facility policy titled, G Tube/J Tube Care, dated 09/2021 revealed the licensed nurse would provide routine care to the gastrostomy and jejunostomy tubes to maintain patency of the tube and good skin integrity.This deficiency represents non-compliance investigated under Complaint Number 2603716.

Based on medical record review, staff interview, review of a self-reported incident (SRI), and policy review, the facility failed to timely investigate and report allegations of misappropriation to the State Survey Agency. This affected one (#5) of three residents reviewed for misappropriation. The facility census was 47. Findings included: Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included congestive heart failure, alcoholic cirrhosis of liver with ascites, and acute respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. Review of an SRI submitted to the State Survey Agency on 12/19/24 at 12:21:15 P.M. revealed an allegation of a staff member taking $40.00 from Resident #5. The SRI revealed Resident #5 alleged he gave Housekeeper #200 $40.00 on 12/10/24 to purchase vape (an electronic device that heats a liquid into an aerosol that is inhaled through a mouthpiece) supplies. Resident #5 reported to Activity Director (AD) #206 on 12/12/24 that Housekeeper #200 took his money and did not return the money or vaping supplies. Further review of the SRI revealed the facility indicated in the report the allegation occurred on 12/12/24 and the date of discovery was 12/16/24. Review of an attached document titled, Self-Reported Incident Initial Form, included with the SRI submitted to the State Survey Agency on 12/19/24, revealed an allegation category of misappropriation of property/exploitation was reported to AD #206 on 12/12/24 at approximately 2:15 P.M. and the Administrator was notified of the allegation on 12/12/24 at approximately 2:30 P.M. Further review of the document revealed a notation that the report was submitted on 12/13/24 at approximately 4:00 P.M. Interview on 12/24/24 at 8:56 A.M. with the Administrator confirmed he did not report Resident #5's allegation of misappropriation to the State Survey Agency within the required timeframe when it was reported to him on 12/12/24. Interview on 12/24/24 at 9:20 A.M. with Regional Director of Clinical Operations (RDCO) #300 confirmed the SRI for Resident #5's allegation of misappropriation was not timely reported to the State Survey Agency as it was not submitted until 12/19/24. Review of facility abuse policy, dated 10/06/22, revealed reporting for misappropriation of resident property will be reported to Ohio Department of Health (ODH) immediately, but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. This deficiency represents non-compliance investigated under Master Complaint Number OH00160955.

Based on observation, medical record review, hospital record review, facility policy review and interviews, the facility failed to ensure timely evaluation, physician notification and treatment following a fall with fracture for Resident #205. Actual Harm occurred for Resident #205 on 10/21/24 at 7:19 P.M. when the facility received results of a STAT (immediate) x-ray indicating the resident had a left elbow fracture but failed to seek medical intervention or treatment for the resident. The nurse practitioner (NP) was notified of the results on 10/22/24 at 8:42 A.M. at which time an order was obtained to transfer the resident to the hospital. The delay in treatment and lack of timely medical intervention resulted in Resident #205 experiencing increased pain and resulted in a delay in the facility identification of additional injuries (the hospital identified the resident also had a left acetabulum fracture, left iliac fossa (bone that is part of the hip) fracture and left retroperitoneal hemorrhage (bleeding in the space located behind the abdominal cavity). Resident #205 was transferred to a level 2 trauma hospital for further treatment. This affected one resident (#205) of one resident reviewed for change in condition. The facility census was 50. Findings include: Review of Resident #205's medical record revealed an admitted [DATE] with diagnoses including vascular dementia with behavioral disturbance, atrial fibrillation, hypotension, hyperlipidemia, alcohol abuse, anxiety, major depressive disorder and insomnia. Resident #205 was transferred to the hospital on 10/22/24. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #205 was minimally cognitively impaired, was able to ambulate with a wheeled walker and required minimal (staff) assistance for eating and oral hygiene, partial/moderate (staff) assistance for toileting and dressing and maximal (staff) assistance all other activities of daily living (ADLs.) Review of the care plan dated 10/19/24 revealed Resident #205 was at risk for falls related to impaired balance, hypotension, dementia, impaired judgement, incontinence and use of psychotropic medications. Interventions included to re-educate on the use of the call light for assistance with transfers/ambulation, notify therapy for evaluation if applicable, monitor for latent signs/symptoms of pain/injury, notify family/Power of Attorney (POA) of incidents and interventions and notify the physician of incidents. Review of the nursing progress note dated 10/21/24 at 2:00 P.M. revealed the State tested Nursing Assistant (STNA) reported Resident #205 was lying on his left side on the floor in his room. The resident stated he was getting clothes out of his closet, lost his balance and fell on his left elbow. Range of motion was within normal limits. Tylenol was given. STAT x-ray of the left elbow was ordered. The note revealed the resident was confused at times and ambulatory without assistance. Following the incident, the resident had a room change to be closer to the nurses' station. Vital signs were taken and were as follows: blood pressure 99/56, pulse 90, respirations 20, temperature 97.8 degrees Fahrenheit (F) and oxygen saturation per pulse oximetry at 97 percent on room air. The note documented NP updated. Review of a physician order dated 10/21/24 revealed an order for a STAT x-ray of the left elbow and acetaminophen 325 milligrams (mg), two tablets by mouth every six hours as needed for pain. Review of Medication Administration Record (MAR) for October 2024 revealed acetaminophen 650 mg was administered to Resident #205 by LPN #333 on 10/21/24 at 4:30 P.M. Review of the nursing progress note dated 10/21/24 at 3:22 P.M. revealed an order for a STAT x-ray of the left elbow was submitted to the radiology provider. Review of the pain assessment records revealed Resident #205 had consistent pain levels of 0 out of 10 (on a scale from 0-10) from admission on 10/04/24 until the date of injury on 10/21/24. Following the fall, Resident #205's pain levels increased to 5 out of 10. Observation on 10/22/24 at 8:19 A.M., during medication administration with Licensed Practical Nurse (LPN) #333, revealed Resident #205 was lying in bed with his left arm resting on his chest and bent at a 90-degree angle. The resident's left elbow was red and swollen. Concurrent interview with Resident #205 revealed his elbow hurt. Coinciding interview with LPN #333 revealed Resident #205 had a fractured elbow due to a fall the previous day. LPN #333 stated she was waiting for the NP to call back with an order to send the resident to the emergency room (ER) for further evaluation. LPN #333 stated the facility did not like to send residents to the ER unless there was an order from the NP. Review of the nursing progress note dated 10/22/24 at 8:46 A.M. revealed a return call was received from the NP and order given to send the resident to the ER for evaluation and treatment of the left elbow per STAT x-ray results. Review of the hospital ER Physician Report dated 10/22/24 at 11:14 A.M. revealed Resident #205 presented to the ER following a fall. The resident had an x-ray that showed an intra-articular fracture of the left ulna. Resident #205 could not provide the physician with specifics and denied pain but had pain when his left elbow was touched or moved and in the left hip with movement. Additional radiological imaging was completed and confirmed Resident #205 had a left olecranon (bony part of the elbow, allows the elbow to move) fracture. Furthermore, imaging indicated Resident #205 also had a left acetabular (socket part of the hip joint where the thigh bone sits) fracture and acute fracture of the posterior right 11th rib. Pre-operative diagnoses included left olecranon fracture, left acetabulum fracture, left iliac fossa (bone that is part of the hip) fracture and left retroperitoneal hemorrhage (bleeding in the space located behind the abdominal cavity). Resident #205 was transferred to a level 2 trauma hospital for further treatment. Interview on 10/24/24 at 4:50 P.M. with LPN #333 revealed she was notified of Resident #205's fall by Staffing Coordinator (SC) #304 after the resident's roommate heard the resident fall and called out for staff assistance. LPN #333 stated Resident #205 was assessed and complained of elbow pain, but no other pain at that time. LPN #333 stated Resident #205 had full range of motion and once he was back in bed, he was able to demonstrate full body mobility buy doing bicycles with his legs. LPN #333 stated the resident told her he tried to break his fall with his left elbow. LPN #333 stated she notified the NP, and an order was received for a STAT x-ray of the left elbow and acetaminophen for pain, which was administered to the resident. The radiology provider was contacted immediately for the x-ray. LPN #333 denied Resident #205 had any swelling at that time. LPN #333 stated she gave report to Registered Nurse (RN) #310, informing her of Resident #205's fall and pending x-ray results. When she arrived for her shift on 10/22/24 at 7:00 A.M., she found the x-ray results, which were faxed to the facility on [DATE] at 7:19 P.M., laying on the nurses' station desk. LPN #333 stated she immediately checked on Resident #205 and received report from RN #310, who indicated the resident's left elbow was swollen and discolored and had ballooned from the previous afternoon. RN #310 did not indicate whether or not he had contacted anyone regarding the x-ray results. LPN #333 stated she administered Tylenol to the resident, elevated his elbow on a pillow and stated that he needs to go (to the hospital). Review of the timeline provided by the Director of Nursing (DON) revealed the STAT left elbow x-ray was completed 10/21/24 at 6:38 P.M. and the results were faxed to the facility on [DATE] at 7:19 P.M. On 10/22/24 at 7:05 A.M., LPN #333 sent a message and the x-ray results to the NP. After receiving no response, LPN #333 called the NP at 7:44 A.M. (left a message) and again at 8:42 A.M. The NP responded with an order to send Resident #205 to the ER. The timeline provided no indication RN #310 notified the NP on 10/21/24 when the results were received. Interview 10/24/24 at 3:03 P.M. with the DON and Assistant Director of Nursing (ADON) #367 revealed Resident #205 was transferred to the ER via 911 emergency squad after receiving the order from the NP on 10/22/24 at 8:42 A.M. The DON indicated she left a message for RN #310 regarding physician notification when the x-ray results were received on 10/21/24 but she had not received a response. The DON verified the NP should have been notified of the x-ray results indicating a fracture immediately for further orders. Additionally, the DON confirmed Resident #205 was in pain and his injuries went untreated from the time of the fall on 10/21/24 at 2:00 P.M. until he was transferred to the ER at approximately 8:45 A.M. on 10/22/24. This deficiency represents noncompliance investigated under Complaint Number OH00158492.

Based on observation, staff interview and resident interview, the facility failed to maintain a clean, sanitary and safe environment. This had the potential to affected all 50 residents residing in the facility. The facility census 50. Findings include: 1. Observation on 10/22/24 at 3:50 P.M. of the west hall shower room with Certified Nursing Assistant (CNA) #374 revealed a spa tub that appeared to be nonfunctional. The bottom side of the tub had a cover that was pulled off exposing a pipe and wires. Coinciding interview with CNA # 374 verified the finding and stated the chair portion to the tub broke about a month ago and the facility was waiting on a new part. 2. Observation on 10/23/24 between 2:00 P.M. and 2:32 P.M., during an environmental tour with Housekeeping Supervisor (HSKP) #369 and Maintenance Director (MD) #321, revealed the following: - The ceiling fans that were in the dinning area were noted to be unclean and the blades full of dust. - One of the ceiling fans in the dinning room had no chain and was unable to be turned off. - The dinning room tables and chair were significantly dirty with numerous areas of chipped paint and other debris through out the tables and chairs. - The wooden doors to resident rooms and bathrooms throughout the facility had levels of significant chipping, scratching, scuffing and other damage. - The hallways of the facility revealed numerous water stained ceiling tiles. - The cover of the air conditioning unit in Resident #21 and Resident #38's room was completely off and exposed the coils of the unit, which were observed to be covered in a significant thick layer of dust. - The metal baseboard in the room occupied by Resident #20 and Resident #34 was on the floor. - The walls in the room occupied by Resident #10, Resident #22, Resident #41 and Resident #53 and had numerous areas of paint peeling off the wall. - The base of the tube feed poles utilized by Resident #1 and Resident #19 were coated in residual tube feed formula. -The plastic base of the west hall hoyer lift was cracked. The lift was also observed to be extremely dirty and full of visible dirt and debris. The north hall Hoyer lift was also noted to be extremely dirty. - The carpeting in the rooms occupied by Resident #8, Resident #25, Resident #32, Resident #33 and Resident #40 had areas of significant staining. -The rooms occupied by Resident #22, Resident #31, Resident #51 and Resident #53 had numerous water stained ceiling tiles. - The west unit shower room area had a significant area of an unknown red substance along with a mold-like substance around the drain. Interview with HSKP #369 and MD #321, at the time of the environmental tour, verified the above findings. Interviews on 10/24/24 at 11:00 A.M. with Residents #10, #11, #21, #22, #32, #37, #44 and #52, during Resident Council, revealed the residents expressed concerns related to the facility being unclean, dirty and not well maintained. The residents stated the facility had been in this state for a significant period of time.

Based on observations, staff interview and review of facility policy, the facility failed to maintain a clean and sanitary kitchen and further failed to ensure male staff with beards wore hair restraints while in the kitchen. This had the potential to affect all 50 residents. Findings include: 1. Observations on 10/21/24 from 8:36 A.M. to 8:56 A.M., during the initial kitchen tour with Dietary Manager (DM) #368, revealed various food splatter and stains on the outside of the steamer table and on the shelf underneath. The preparation (prep) table had three large, open bags of dried pasta stored on the shelf with clean pots and pans. Both shelves of the prep table were dirty with various dried food and debris. The stove and the flat grill were covered in black, dried, burnt-on grease and dust covered grease was observed under the flat grill area. The back wall and floor between the steamer and stove had various dried food splatters and debris, with dried food crumbs and debris on the pipe affixed to this wall. On the floor underneath the dish machine was a dark colored dried substance and a tan colored dried substance. Continued observation revealed a build-up of a tan colored substance on the dish machine. Lastly, the reach-in cooler near the dish machine, which stored milk and juice, had a dried white splatter along the inside walls and the bottom. Concurrent interview with DM #368 verified the findings. 2. Observation on 10/21/24 at 12:57 P.M. of meal service revealed two male dietary staff in the kitchen. Both male dietary staff had uncovered and unrestrained beards during the meal service. Interview on 10/21/24 at 1:10 P.M. with DM #368 verified the two male dietary staff were not wearing hair restraints over their beards. DM #368 stated she meant to have them put them on when they came in for their shift at 11:00 A.M. Review of the facility policy titled Sanitation, revised October 2008, revealed the food service area shall be maintained in a clean and sanitary manner.

Based on record review, staff interview, and facility policy review, the facility failed to develop and implement resident centered care plans for Residents #4, #19, #20, #40 and #51. This affected five residents (#4, #19, #20, #40 and #51) of seventeen sampled residents. The facility census was 50. Findings include: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses including dementia, syncope and collapse, and seizures. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 was severely cognitively impaired and required extensive assistance of two staff persons for completing her activities of daily living (ADL). Review of the physician's orders for October 2024 revealed an order dated 04/10/23 stating admit resident to (contracted hospice agency) with a diagnosis of dementia. Review of the care plan dated 04/24/24 revealed a care plan was developed for Resident #4's hospice care. Interventions included hospice aide visits, hospice nurse visits, hospice Chaplin visits, and hospice social worker visits. No specific number of visits were noted on each intervention and each intervention was noted to read specify frequency and did not contain any specific visit frequency information. Review of Article V Hospice Plan of Care subsection F of the hospice contract for services, dated 12/09/19, revealed Each Facility providing Hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent Hospice Plan of Care and a description of the services furnished by the Facility to attain maintain the resident's highest practicable physical, mental and psychosocial well-being as required by 42 C.F.R. 483.25. Interview with the Director of Nursing (DON) on 10/22/24 at 3:00 P.M. verified the facilities care plan did not reflect the frequency of visits and other specific information related to care and services provided by the contracted hospice to Resident #4. Review of the policy entitled Hospice Program, dated 07/01/17, revealed Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. 36307 2. Review of the record for Resident #19 revealed an admitted [DATE] with diagnoses including recurrent E. Coli, striatonigral degeneration, obstructive and reflux uropathy, type two diabetes, chronic obstructive pulmonary disease, hypothyroidism, atherosclerotic heart disease, occlusion and stenosis of carotid artery, aortic ectasia, generalized anxiety disorder, major depressive disorder, and panic disorder. Upon admission, Resident #19 presented with an indwelling urinary catheter related to the diagnoses of obstructive and reflux uropathy, a wound to her right lower extremity, and blanching in the perineal area. Review of the physician's order dated 09/10/24 indicated once daily wound care instructions for the right lower extremity wound and the open area at the intergluteal cleft. Review of the physician's orders dated 09/16/24 indicated Foley (indwelling urinary catheter) to continuous drainage for urinary retention along with orders for Foley care. Review of the comprehensive care plan for Resident #19 initiated on 09/01/24 revealed no care plan was initiated for the resident's indwelling urinary catheter or the existing wounds. Interview on 10/23/24 at 4:41 PM with MDS Coordinator Licensed Practical Nurse (LPN) #336 revealed that care plans for pressure wounds and Foley catheter were delayed due to weather/tornado and power outage in August 2024. The MDS Coordinator LPN #336 verified that the care plans were overdue and were currently in progress and would be placed in the resident's electronic medical record. 37096 3. Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including cerebral infarction, a stroke affecting the right dominant side, dementia, aphasia, contracture of the right hand, atrial fibrillation, and legionnaires disease. Review of the comprehensive MDS assessment, dated 09/13/24, revealed Resident #20 had impaired cognition and needed substantial to maximum assistance with showers and dressing. Review of the care plan dated 09/24/24 revealed Resident #20 had a self-care deficit related to hemiplegia, impaired balance, limited range of motion, and stroke. Interventions for showering/bathing included the resident required assistance from one staff member, avoid scrubbing, and pat dry sensitive skin. In addition, check and trim nails and report any changes to the nurse. The documentation did not reveal the resident refused showers. Review of the shower documentation from 09/01/24 through 10/21/24 revealed there was no documented evidence of shower/bed bath for the month of September 2024. The October documentation revealed that Resident refused shower/bed bath on 10/01/24, 10/04/24, 10/08/24, and 10/15/24. Resident #20 received one bed bath on 10/11/24. Observation on 10/21/24 at 11:21 A.M. revealed the Resident #20 looked disheveled and had not been shaven. Further observation on 10/23/24 at 10:00 A.M. revealed he was disheveled and unshaven. Interview on 10/24/24 at 5:33 P.M. with the DON verified the resident refused showers and verified the care plan did not reflect refusals of care. 39969 4. Review of the medical record for Resident #40 revealed an admitted [DATE]. Diagnoses included right femur fracture, muscle weakness, and cognitive communication deficit. Review of the smoking and safety assessment dated [DATE] revealed Resident #40 was a smoker and did not require any devices for smoking safety. Review of the admission MDS assessment dated [DATE] revealed Resident #40 had intact cognition and used tobacco. Review of the plan of care for Resident # 40 revealed there was no care plan for smoking. Interview on 10/23/24 at 4:28 P.M. with MDS Coordinator #336 revealed she does most of the care plans and verified there was no smoking care plan created for Resident #40. 5. Review of the medical record for Resident #51 revealed an admitted [DATE]. Diagnoses included sepsis, morbid (severe) obesity due to excess calories, cellulitis of abdominal wall and type two diabetes without complications. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #51 had intact cognition, required substantial/maximum staff assistance for toileting, hygiene and shower/bathing. The MDS indicated Resident #51 had three unhealed stage three pressure ulcers. Review of the progress note dated 10/03/24 at 10:37 A.M. revealed the interdisciplinary team (IDT) discussed skin alteration from 10/02/24, found on wound rounds. Resident #51 was observed with new pressure area to center midline sacro-coccyx during wound rounds. The area was cleansed and treatment order provided by Wound Nurse Practitioner (WNP) #800. Resident #51 was educated on the importance of getting out of bed and hygiene to decrease the risk of skin breakdown. Resident #51 verbalized understanding. Will be followed by wound WNP weekly. Resident #51's care plan was reviewed and interventions in place. A new intervention was added to educate Resident #51 on the importance of getting out of bed and hygiene to decrease the risk of skin breakdown. Review of Resident #51's care plan revealed no care plan goals or interventions related to wounds or skin impairments. Interview on 10/23/24 at 4:28 P.M. with MDS Coordinator #336 stated she does the majority of the care plans. MDS Coordinator #336 verified Resident #51 did not have a care plan related to wounds or skin impairments but she was working on her care plan today.

Based on record review and interview the facility failed to ensure grievances during resident council meetings related to evening snacks not being distributed were responded to timely and appropriately. This affected eight residents (#10, #11, #21, #22, #32 #37, #44 and #52) who attended the resident council group meeting, and one resident (#36) reviewed for food. The facility census was 50. Findings include: Interview on 10/21/24 at 11:54 A.M. with Resident #36 revealed snacks in the evening were not being passed. Review of the resident council meeting minutes dated 07/22/24, 08/21/24, and 09/18/24 revealed either snacks were not being distributed or brought to all the rooms in the evening. Completion of the resident council group meeting portion of the annual survey on 10/24/24 between 11:00 A.M. and 12:00 P.M. with Residents #10, #11, #21, #22, #32, #37, #44 and #52 revealed significant concerns related to snacks being unavailable before and after resident meals. Multiple residents commented that staff eat the majority and often times eat all of the snacks that are left at the nurse's station. The group also noted that snack availability was an ongoing issue and that any concerns brought up in the resident council meetings were ignored. Interview on 10/28/24 10:34 A.M. with Dietary Manager (DM) #368 verified there were resident complaints about snacks not being distributed in the evening in the last few resident council meetings. DM #368 stated she told the Director of Nursing (DON) and talked with Staff Coordinator (SC) #304 to remind the staff to pass the snacks in the evening. DM #368 stated there were three residents she knew that complained, and she started making their own bags of snacks to keep in their rooms. DM #368 stated last week she started making snack bags for Resident #32 and was about to start one for Resident #22. DM #368 stated she had been making snack bags for Resident #36 for months now. Interview on 10/28/24 at 10:53 A.M. with SC #304 stated she was informed that snacks were not being distributed in the evening and she spoke with the aides and nurses on evenings to ensure snacks were being distributed. SC #304 stated she didn't have anything documented but came in early to talk with them before they left after their shift.

Based on observation, resident interview, medical record review, staff interview and review of facility policy, the facility failed to ensure residents who required staff assistance with baths/showers received needed care. This affected two (#22 and #51) of five residents reviewed for activities of daily living (ADLs). The facility census was 50. Findings include: 1. Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses included left femur fracture, difficulty in walking, repeated falls, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/11/24, revealed Resident #22 had impaired cognition, had no behaviors and required partial/moderate assistance from staff for showers and bathing. Interview on 10/21/24 at 3:47 P.M. with Resident #22 revealed he has not had a shower or bath in the last two weeks and the water in the bathroom was cold. Concurrent observation revealed a strong odor in the resident's room. Observation on 10/22/24 at 3:44 P.M. of Resident #22 revealed the resident sitting on the side of his bed in the same clothing as the day prior. Interview on 10/24/24 at 8:57 A.M. with Resident #22 revealed staff occasionally offered showers and his scheduled days were on Wednesday and Sunday. Resident #22 stated staff came up with excuses or the aides did not show up. Resident #22 stated there was one aide who provided him a bed bath about one time per week but he would like one to two showers weekly. Review of the weekly shower schedule, updated 10/11/24, revealed Resident #22 scheduled shower days were Sundays and Wednesdays on the 3:00 P.M. to 11:00 P.M. shift. Review of the shower/bath sheets for the past two months revealed three sheets revealed on 08/14/24 and 08/21/24, Resident #22 refused a shower. A third shower sheet indicated the resident received a shower on 08/28/24. There was no shower documentation for September and October 2024. Interview on 10/24/24 at 9:56 A.M. with the Administrator revealed the Director of Nursing (DON) was unable to locate any additional documentation of showers for Resident #22 for the past two months. 2. Review of the medical record for Resident #51 revealed an admitted [DATE]. Diagnoses included sepsis, morbid (severe) obesity due to excess calories, cellulitis of abdominal wall and type two diabetes without complications. Review of the admission MDS assessment, dated 10/01/24, revealed Resident #51 had intact cognition and required substantial/maximum assistance from staff for shower/bathing. Review of the plan of care for Resident #51 revealed no care plans related to the resident refusing or resisting showers/baths. Further review of Resident #51's medical record revealed no documented refusals of showers/baths. Interview on 10/21/24 at 3:26 P.M. with Resident #51 revealed she had not had a shower since her admission to the facility but would like one. Concurrent observation of Resident #51 revealed she was dressed in a black, floral dress and had hair on her chin. Resident #51 stated sometimes she would ask the staff to shave her, but no one had offered a shower. Observations on 10/22/24 at 3:40 P.M., 10/23/24 at 8:24 A.M. and on 10/23/24 at 3:27 P.M. of Resident #51 revealed the resident was wearing the same black, floral dress she was wearing on 10/21/24. Review of the weekly shower schedule, updated 10/11/24, revealed Resident #51's scheduled shower days were Mondays and Fridays on the 3:00 P.M. to 11:00 P.M. shift. Interview on 10/24/24 at 9:42 A.M. with the DON revealed she was unable to locate evidence of bath/showers for Resident #51. Observation on 10/24/24 at 10:50 A.M. of Resident #51 revealed she was in a pink and black flower dress. The resident had hair on her chin. Resident #51's room was odorous. Concurrent interview with Licensed Practical Nurse (LPN) #333 verified Resident #51's room was odorous. A telephone interview on 10/24/24 at 5:58 P.M. with Certified Nursing Assistant (CNA) #364 revealed she worked on Monday, 10/21/24, and was assigned to provide care for the resident until 7:00 P.M. CNA #364 stated she was unaware Monday was Resident #51's shower day and verified the resident was not offered or provided a shower. Review of the facility policy titled Activities of Daily Living (ADLs), Supporting, revised March 2018, revealed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). This deficiency represents noncompliance investigated under Complaint Number OH00158492.

Based on record review, staff interview, and facility policy review, the facility failed to complete a required Minimum Data Set (MDS) 3.0 assessment upon Resident #30's discharge from the facility. This affected one resident (#30) of two residents reviewed for discharge. The facility census was 50. Findings include: Resident #102 was admitted to the facility on [DATE] with diagnoses including Hepatitis C, cocaine abuse, chest pain, and kidney failure. Review of the census records and nursing progress notes, Resident #102 was discharged from the facility on 07/03/24. Review of the MDS records for Resident #102 revealed an initial MDS assessment was completed on 05/29/24. No other MDS assessments were completed for Resident #102 during his stay at the facility, including a required discharge assessment upon Resident #102 returning home from the facility. MDS Nurse #336 verified Resident #102's required discharge MDS assessment was not completed as required during an interview on 10/23/24 at 8:00 A.M. Review of the facility policy titled MDS Completion and Submission Timeframes, dated 07/01/17, revealed the facility would conduct and submit resident assessments in accordance with current federal and state submission time frames.

Based on record review, interview, and facility policy review the facility failed to ensure comprehensive assessments were implemented and completed for Residents #7 and #204. This affected two residents (#7 and #204) of 17 sample residents reviewed for assessments. The facility census was 50. Findings include: 1. Review of the medical record for Resident #7 revealed an admitted [DATE] with diagnoses including psychotic disorder, delusions, insomnia, and seizures. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had intact cognition and required partial to moderate assistance with rolling left and right. Review of the plan of care dated 09/24/24 revealed Resident #7 had a mobility deficit related to seizures, chronic obstructive pulmonary disease (COPD), asthma, and spinal stenosis. Interventions for bed mobility included supervision from one staff to turn and reposition in bed and bilateral grab bars to each side of the bed to assist with turning and repositioning. Review of the physician's orders dated October 2024 revealed Resident #7 had an order for bilateral grab bars to the bed to increase independence with bed mobility. Review of the assessments revealed the last bedrail assessment was completed on 09/22/21. There was no documented evidence of a current assessment. Interview on 10/23/24 at 3:09 P.M. with the Director of Nursing (DON) verified there was no current bed rail assessment completed. Review of the facility policy titled Assistive Devices and Equipment, revised July 2017, stated side rails, grab bars, specialized chairs, specialized mattress, specialized room arrangement will be assessed upon initiation, quarterly, and as needed for appropriateness. 36307 2. Review of the medical record for Resident #204 revealed an admitted [DATE] with diagnoses including polyneuropathy, subluxation of C3/C4 cervical vertebrae, mid-cervical region cervical disc disorder with myelopathy, cervical spine fusion, adult failure to thrive, bradycardia, generalized anxiety, history of alcohol abuse, and chronic post-traumatic stress disorder. Review of the comprehensive care plan for Resident #204 initiated on 10/01/24 revealed no care plan was initiated for the resident's risk of pain due to his diagnosis of polyneuropathy and spinal issues. Review of the MDS assessment dated [DATE] revealed Resident #204 was cognitively intact, used a wheelchair for mobility, and required minimal staff assistance for all activities of daily living (ADL). Review of the physician's orders for Resident #204 dated 9/30/24 revealed an order to monitor pain every shift. Review of the physician's orders for Resident #204 dated 09/30/24 revealed orders for acetaminophen 500 milligrams (mg) (pain reliever) give two tablets by mouth every six hours as needed for pain and pregabalin (Lyrica) (medication to treat nerve pain) oral capsule 150 mg one capsule by mouth two times a day for pain for 30 days. Review of the medical record for Resident #204 revealed no pain risk evaluation was conducted upon admission. Review of the medication administration record (MAR) for October 2024 revealed pain levels marked as zero out of ten for each shift from the date of admission to the date of the survey. During interview with Resident #204 on 10/21/24 at 12:10 P.M. revealed the resident complained of constant pain in his hands making it difficult for him to maintain his grip on things. He stated he told the nursing staff on multiple occasions, and they say they will contact the physician. During follow up interview on 10/24/24 at 10:27 A.M. with Resident #204, he indicated continued pain at a seven on a pain scale of zero to ten, ten being the worst. He stated the pain goes up his arms almost to his elbows and although he gets Lyrica, it is not sufficient to help decrease the pain. Resident #204 stated that the nurses say that they will call the physician, but no changes were ever made. Resident #204 stated he contacted the physician at the hospital but was told the nurse at the facility had to contact the physician to advise about medications. Resident #204 stated he continued to report pain to the nurses. Interview on 10/23/24 at 4:41 PM with MDS Coordinator Licensed Practical Nurse (LPN) #336 confirmed that the care plans had not been initiated for Resident #204 due to a prolonged power outage which caused a delay in developing appropriate care plans for residents in the facility. MDS Coordinator LPN #336 indicated care plans were currently in progress for all that had been delayed.

Based on record review, interview, and facility policy review, the facility failed to timely notify emergency contacts/guardians of a change of condition in a timely manner for Residents #205 and #20. This affected two residents (#205, #20) of two residents reviewed for change of condition. The facility census was 50. Findings include: 1. Review of the medical record for Resident #205 revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses of vascular dementia with behavioral disturbance, atrial fibrillation, hypotension, hyperlipidemia, alcohol abuse, anxiety, major depressive disorder, and insomnia. Review of the care plan dated 10/19/24 revealed Resident #205 was at fall risk related to impaired balance, hypotension, dementia, impaired judgement, incontinence, and use of psychotropic medications. Interventions included re-education of use of call light for assistance with transfers/ambulation, notify therapy for evaluation if applicable, monitor for latent signs/symptoms of pain/injury, notify family/power of attorney (POA) of incident and intervention, and notify the physician of incident. Review of a late entry nurse progress note dated 10/18/24 revealed Resident #205's roommate let staff know that the resident was on the floor. Resident #205 did have some confusion when located at his bedside. The resident was evaluated for injuries and vital signs were obtained. Resident #205 was assisted back to bed by the certified nurse aide (CNA). Resident #205 was able to perform range of motion (ROM) and had no complaints of pain or discomfort at this time. No visible injuries were noted. Review of the nurse progress note dated 10/21/24 at 2:00 P.M. revealed the CNA reported Resident #205 lying on his left side on the floor in his room. He stated he was getting clothes out of his closet, lost his balance, and fell on his left elbow. ROM was within normal limits (WNL). Tylenol was administered. An order was obtained for a STAT (immediate) left elbow x-ray. Resident #205 had confusion at times and was ambulatory without assistance. Resident #205 was to have a room change to be closer to the nurse's station. Vital signs 99/56, pulse 90, respirations 20, temperature 97.8 degrees Fahrenheit and oxygen saturation per pulse oximetry at 97 percent on room air. The certified nurse practitioner (CNP) was updated. Review of the nurse progress note for Resident #205 dated 10/21/24 at 3:22 P.M. revealed an order for STAT x-ray of the left elbow was submitted to the radiology provider. Review of the nurse progress note for Resident #205 dated 10/22/24 at 8:46 A.M. revealed the CNP returned the call and said it was okay to send the resident to the emergency room (ER) for treatment and evaluation of the left elbow due to the STAT x-ray results. Review of the hospital ER documentation dated 10/22/24 revealed Resident #205 arrived at the ER at approximately 9:00 A.M. with a left elbow fracture as well as a left pelvic fracture. Review of the nurse progress note dated 10/22/24 at 9:53 A.M. revealed that a call was placed to Resident #205's daughter and a message left on the home phone to return call to facility. Review of the nurse progress note dated 10/22/2024 at 10:02 A.M. revealed Resident #205's daughter returned the call and was updated on the x-ray results of the left elbow fracture from the fall. Interview on 10/23/24 at 12:27 P.M. with Resident #205's daughter confirmed that facility informed her that her father was hospitalized after a fall and fractured elbow. She indicated that the resident was found to also have a fracture of hip while in the ER. Resident #205 was transferred to another hospital due to trauma for surgery. The facility stated that the resident was in good spirits. The daughter stated his mental state was okay and had good days and bad days, but due to his fluctuating mental status the surgeon wanted her okay for surgery. She also stated the resident had a diagnosis of low blood pressure and needed to stay hydrated. Resident #205's daughter said she was notified of the hospitalization the morning of 10/22/24. She was told that he had mobility in the elbow, and it was not swollen or bruised immediately after the fall. She stated she was not notified of the residents' fall at 2:00 P.M. the prior afternoon. The daughter also stated she was not notified of the resident's previous fall on 10/18/24. Interview on 10/24/24 at 3:03 P.M. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that there was no documented evidence to support that Resident #205's emergency contact/daughter, was notified of the residents falls on 10/18/24 and 10/21/24 nor his elbow fracture confirmed by x-ray, until 10:02 A.M. on 10/22/24. Review of the policy titled Change in a Resident's Condition, reviewed on 8/2023, revealed the facility shall notify the resident, his or her Attending Physician and representative (sponsor) of changes in the resident's medical/mental condition. 37096 2. Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including cerebral infraction, a stroke affecting the right dominant side, dementia, aphasia, contracture of the right hand, atrial fibrillation, and legionnaires disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had impaired cognition and required substantial to maximum assistance with showers and dressing. Review of the plan of care dated 09/24/24 revealed Resident #20 was recovering from legionnaires disease. Interventions included notifying the guardian and physician. In addition to assessing the resident's respiratory status. Review of the progress note dated 08/23/24 at 4:15 P.M. revealed Resident #20 was sent out to the hospital by emergency medical services (911) per physician order. Note dated 08/31/24 at 6:30 P.M. stated Resident #20 arrived by stretcher to the facility. The resident was alert and oriented and on two liters of oxygen. The resident presented with no distress or pain. There was no documented evidence that Resident #20's guardian was notified he was back from the hospital. Interview on 10/22/24 at 11:56 A.M. with Resident #20's guardian stated he did not know Resident #20 was back from the hospital. Interview on 10/28/24 at 2:33 P.M. with the Administrator verified there was no documented evidence that Resident #20's guardian was notified the resident returned to the facility. Review of the policy titled Change in a Resident's Condition' reviewed on 8/2023, revealed the facility shall notify the resident, his or her Attending Physician and representative (sponsor) of changes in the resident's medical/mental condition. This deficiency represents non-compliance investigated under Complaint Number OH00158492.

Based on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon a discharge or death. This affected one resident (#102) of one resident reviewed for personal funds conveyance upon death or discharge. The facility census was 50. Findings include: Resident #102 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, heart failure, and anxiety disorder. Review of census records revealed Resident #102 expired at the facility on [DATE]. Review of the account records revealed Resident #102's account was closed on [DATE], and $160.21 was disbursed to Resident #102's estate. Interview with Business Manager (BM) #301 on [DATE] at 4:30 P.M. revealed Resident #102's personal funds were not dispersed with in required time frames (30 days upon on a resident's death or discharge).

Based on medical record review, review of hospital documents, staff documents and review of facility policy, the facility failed to ensure an accurate weight was obtained to monitor nutritional status for a resident at risk for significant weight loss. This affected one (#201) of two residents reviewed for nutrition. The facility census was 50. Findings include: Review of the medical record for Resident #201 revealed an admitted [DATE] with diagnoses including dementia with behavioral disturbance, Meniere's disease, hypertension, osteoarthritis, anemia, rheumatoid arthritis and major depressive disorder, severe, with psychotic features. Review of the care plan dated 10/15/24 revealed Resident #201 had a nutritional problem related to diagnoses, psychotropic medications, weight loss, underweight related to body mass index (BMI) and mechanically altered diet. Interventions included the following: weight per facility protocol; monitor, record and report to the physician signs/symptoms of malnutrition; and monitor, document and report to the physician signs/symptoms of dysphagia. Review of physician's order dated 10/11/24 revealed weekly weights times four weeks upon admission, then monthly. If gain or loss greater than three pounds (lbs.), reweigh and notify the physician. Review of hospital records revealed Resident #201 had a hospital weight of 95.7 lbs. and a BMI of 14.2 and stated the resident was severely underweight for advanced age. Further review of the medical record revealed there was no documented facility admission weight. Review of nutritional assessment note dated 10/15/24 revealed a review of Resident #201's hospital records indicated weight loss prior to admission to the hospital. Resident #201 was at risk for weight loss related to acute infection and recent hospitalization and at risk for malnutrition related to a BMI less than 18.5, mechanically altered diet and chronic disease. The recommendations included: house supplement eight ounces two times daily, obtain admission weight, weigh weekly for four weeks and to monitor weight, meal intakes, skin and labs. Interview on 10/23/24 at 3:37 PM with Nutrition Consultant Diet Tech (NCDT) #381 revealed she liked to see an admission weight due to hospital weights being estimated. NCDT #381 stated due to Resident #201 being severely underweight, any weight loss would be significant so an accurate baseline weight was needed. Review of a weight obtained for Resident #201 on 10/17/24 revealed a weight of 83.6 lbs. Based on the hospital's estimated weight of 95.7 during her hospital admission from 9/26/24 to 10/08/24, Resident #201 experienced a 12.1 lbs. significant weight loss. Interview on 10/24/24 at 3:03 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #367 verified an admission weight was not obtained for Resident #201 until 10/17/24, which was nine days after admission and two days after the nutritional assessment was completed, resulting in no current weight to compare the resident's nutritional status and needs to. Review of the the facility policy titled Weight Policy & Procedure, dated August 2024, revealed weights will be reviewed routinely by nursing and dietary services to identify those residents who are experiencing weight changes.

Based on resident and staff interview, medical record review and review of facility policy, the facility failed to accurately document and effectively manage resident's pain. This affected one (#204) of two residents reviewed for pain management. The facility census was 50. Findings include: Review of the record for Resident #204 revealed an admitted [DATE] with diagnoses including polyneuropathy, subluxation of C3/C4 cervical vertebrae, mid-cervical region cervical disc disorder with myelopathy, cervical spine fusion, adult failure to thrive, bradycardia, generalized anxiety, history of alcohol abuse and chronic post-traumatic stress disorder. Review of the Minimum Data Set (MDS) assessment, dated 10/07/24, revealed Resident #204 was cognitively intact, used a wheelchair for mobility and required minimal staff assistance for all activities of daily living (ADLs.) Review of the comprehensive care plan initiated, 10/01/24, revealed no care plan was initiated for Resident #204's risk for pain due to his diagnosis of polyneuropathy and spinal issues. Review of Resident #204's current physician's orders revealed to monitor for pain every shift. Additionally, Resident #204 had orders for acetaminophen 500 milligrams (mg), two tablets by mouth every six hours as needed for pain and pregabalin (Lyrica) oral capsule 150 mg, one capsule by mouth two times a day for pain for 30 days. Review of Medication Administration Record (MAR) for October 2024 revealed Resident #204's pain levels were marked as 0 out of 10 (on a scale of one to 10) for each shift from the date of admission. Further review of Resident #204's medical record revealed no pain risk assessment was completed upon admission. Interview on 10/21/24 at 12:10 P.M. with Resident #204 revealed he had constant pain in his hands, making it difficult for him to maintain his grip on things. Resident #204 stated he has told the nursing staff on multiple occasions about his pain and they say they will contact the physician. A follow-up interview on 10/24/24 at 10:27 A.M. with Resident #204 revealed he continued to have pain at a 7 out of 10. Resident #204 stated the pain went up his arms, almost to his elbows, and although he gets Lyrica, it is not sufficient to help decrease the pain. Resident #204 stated the nurses say that they will call the physician but no changes are ever made. Resident #204 stated he contacted the physician at the hospital but was told the facility nurse had to contact the physician to advise about medications. Resident #204 stated he continued to report pain to the nurses. Interview on 10/24/24 at 3:30 P.M. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #367 confirmed they were unaware of Resident #204's ineffective pain management and would follow up with the physician. A follow-up interview on 10/24/24 at 4:00 PM. with the DON revealed she spoke with the physician and, due to Resident #204's history of alcohol abuse, they were hesitant to administer more pain medication. The DON stated the physician would arrange for a pain management evaluation for Resident #204. Review of the facility policy titled Assessment, Intervention and Management of Pain, dated October 2020, revealed to contact the physician if the current pain management regimen, including nonpharmacological and pharmalogical intervention, is ineffective at managing resident pain at a satisfactory level.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, facility policy review and interview, the facility failed to ensure Resident #99's received assistance with activities daily living (ADLs) to maintain adequate and necessary personal and oral hygiene. Actual harm occurred on 06/21/24 when Resident #99, who was totally dependent on staff assistance for ADLs, did not receive sufficient hygienic care and developed maggots in her mouth and nose, requiring hospitalization . This affected one resident (#99) of three residents reviewed for ADL care. The facility census was 47. Findings include: Review of Resident #99's closed medical record revealed the resident was admitted on [DATE] and discharged to the hospice house on 06/21/24 with diagnoses including amyotrophic lateral sclerosis (ALS), dysphagia and gastrostomy status. Review of Resident #99's ADL Self-Care Performance Deficit Care Plans with an admitted [DATE] revealed the resident required one staff participation with personal hygiene and oral care. Review of Resident #99's Admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem and was dependent (helper completed all effort and resident did none of the effort to complete the activity). Review of Resident #99's hospice Visit Summary forms from 05/03/24 to 06/21/24 revealed the resident received mouth care and a bed bath on 06/14/24 and on 06/21/24 by hospice staff. No visits from hospice services were conducted between 06/15/24 to 06/20/24. Review of Resident #99's ADL Look Back Report form from 06/14/24 to 06/21/24 revealed the resident was provided oral care on 06/15/24 at 3:56 A.M.; on 06/16/24 at 12:51 A.M.; on 06/17/24 at 12:09 A.M.; and on 06/18/24 at 1:06 P.M. The documentation did not reveal evidence the resident was provided any oral care on 06/19/24 or 06/20/24. The documentation also did not reveal evidence the resident was provided oral care for first and second shifts on 06/15/24; first and second shifts on 06/16/24; first and second shifts on 06/17/24; or second or third shifts on 06/18/24. Review of Resident #99's progress note dated 06/21/24 at 11:00 A.M. authored by Licensed Practical Nurse (LPN) #821 revealed a full body assessment was completed by the nurse and two staff members. Tiny white worms were noted on top of the resident's tongue when mouth care was provided. The resident sneezed and more tiny white worms came out of her nostrils. The concern was reported to the administration and the physician. A call was placed to the hospice nurse who was asked to return to the facility to address. Review of Resident #99's progress note dated 06/21/24 at 12:30 P.M. authored by LPN #821 indicated the hospice nurse returned to the facility to assess the resident. Review of Resident #99's progress note dated 06/21/24 at 2:00 P.M. authored by LPN #821 indicated the hospice nurse collected a tiny white worm specimen to send with the resident to the ER. A call was placed to 911 per hospice and the resident's son was notified via the phone by the hospice nurse and updated on the resident's condition. Review of Resident #99's progress note dated 06/21/24 at 5:17 P.M. authored by the Administrator indicated the hospice nurse informed him that she spoke with the resident's family, and they were aware of the reason for hospitalization and in agreement with the plan. The hospice nurse stated they were going to ensure a head CAT scan (CAT or CT which was a computed tomography scan or medical imaging technique that uses X-rays and computers to create detailed cross-sectional images of the inside of the body) and a chest X-ray were completed, and that the family had already asked about an in-patient hospice house. Review of Resident #99's progress note dated 06/21/24 at 11:27 P.M. authored by LPN #822 indicated a call was placed to the ER to obtain an update on the resident. The resident had been transported by a private ambulance to the hospice center. Review of Resident #99's hospital documentation dated 06/21/24 indicated the resident presented from the skilled nursing facility (SNF) for concerns of larvae in the resident's nose. Nursing was completing oral and mouth care and noted larvae in the nose. The resident had ALS and was nonverbal. She had a percutaneous endoscopic gastrostomy tube (PEG tube which was passed into a resident's stomach through the abdominal wall to provide a means of feeding when oral intake was not adequate). The resident was on hospice services, and they provided care as well. The hospice team was worried about the resident's airway and sent the resident in for an airway assessment. A CAT of the facial area was ordered to evaluate the extent of an intraoral involvement or airway involvement. The CAT of the facial without contrast was obtained per the request of hospice services and there was no evidence of an erosive abnormality noted in the facial region. A reassessment of the resident did not reveal evidence of intraoral larvae or maggots. The resident did have a dry tongue and received all nutrition through the PEG tube. The resident was moved to the hospice care center and would be discharged from the ED for hospice ongoing care. The larvae were sent for an analysis but were most likely consistent with a fly. Review of the Timeline of Events (facility investigative report) for Resident #99 dated 06/21/24 indicated at 9:30 A.M. the facility notified hospice of an intolerance to the current tube feeding regimen and the hospice nurse reported that a tiny white worm was found on the resident's chest when providing a bed bath. At 9:50 A.M., the facility nurse and two staff members completed a full body assessment and noted that white worms were on top of the resident's tongue during oral care. The resident sneezed and more came out of the nasal passages. The Administrator, physician and hospice were notified. At 11:30 A.M., the hospice nurse returned to the facility and obtained a specimen to send to the emergency room (ER). The family was notified at this time. At 2:37 P.M., the facility completed oral assessments on all residents to ensure no other residents were affected. No other concerns were identified. Housekeeping did an audit of rooms and the building, and no other flies were noted. Window screens were audited, and six screens were noted to have holes in them. Tape was applied to the holes until repairs could be made. Audits would be completed three times a week for oral care for five residents per the Director of Nursing (DON) and/or designee. The concern would be reviewed in the quality assurance perform improvement (QAPI) meeting. Information obtained from the resident's family as part of the complaint investigation revealed Resident #100 had been admitted to the facility since late April 2022 and had a diagnosis of ALS. The family revealed they had been contacted by a hospice nurse, (this nurse visited the resident weekly) on Friday 06/21/24 indicating she had some bad news. The family revealed what was reported to them left them horrified and speechless. The nurse informed the family that a nurse's aide found fly larvae in the resident's mouth. The family stated literal fly eggs that had hatched into larvae and were now feeding on my poor mother, while she laid in bed not being able to move or help herself. The resident was transferred to the hospital for a CT scan to determine how deep the bug infestation had made it into her sinuses and lungs. The family indicated the next 24 hours were very rough having to endure multiple bug larvae being extracted from her body. Interview on 07/29/24 at 8:15 A.M. with the Administrator indicated he was aware that the hospice nurse had observed a maggot on Resident #99's shirt/gown on 06/21/24. Interview on 07/29/24 at 8:23 A.M. with State tested Nursing Assistant (STNA) #814 indicated she assisted STNA #817 with Resident #99's ADL care when the hospice nurse had discovered a maggot crawling across the resident's gown. STNA #814 confirmed she had looked in Resident #99's mouth during oral care and had observed five maggots in the resident's mouth. She stated she also did see a maggot drop out of the resident's left nostril during care. She stated the resident always had her mouth open and could not move independently from the neck down. She stated the resident was dependent on all care. Telephone interview on 07/29/24 at 8:48 A.M. with Licensed Social Worker (LSW) for hospice house #816 revealed Resident #99 was admitted to their facility on 06/21/24 and discharged home on 06/28/24. She was aware of maggots in the resident's mouth and nose but unable to provide further details. Telephone interview on 07/29/24 at 9:22 A.M. with Hospice Registered Nurse (RN) #846 and Chief Quality Officer for Hospice #815 confirmed on 06/21/24, she had assessed Resident #99 in the morning and provided a bed bath with the hospice nurse. She stated at that time, a small fly larvae was discovered crawling across the resident's chest on top of the gown. Hospice RN #846 stated she did a body assessment and could not determine the cause of the fly larvae so she notified the shift nurse. She stated she was called by the facility later in the day and was informed by the facility that the resident had sneezed and found maggots in her nose. Hospice RN #846 confirmed she went back to the facility and assessed the resident and identified a maggot in her right nostril which she scooped out and placed in a plastic bag to be sent with the resident to the ER. Hospice RN #846 confirmed Resident #99 was discharged to the hospital and then to the hospice house before discharging home. Interview on 07/29/24 at 11:42 A.M. with the DON confirmed Resident #99's oral care should be completed every shift by the nursing staff and the facility had three shifts per day. The DON also confirmed the resident's oral care was not completed as required as evidenced by the documentation in the resident's medical record. A follow up interview on 07/29/24 at 1:40 P.M. with STNA #814 confirmed she had observed three or four flies flying around Resident #99's room on 06/21/24 when the maggots were discovered in the resident's nose and mouth. Review of the facility ADL policy, reviewed 08/2021, revealed residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADL care. Appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care). The deficient practice was corrected on 06/26/24 when the facility implemented the following corrective actions: Regional Support RN #551 completed staff inservices for ADLs and Oral Care Recommendations in person on 06/21/24 which included RN #810, LPNs #821, #902, #903, STNAs #805, #820, #825, #901. Regional Support RN #551 and STNA Scheduler #808 completed additional staff inservices for ADLs and Oral Care Recommendations via the telephone for all other nursing staff from 06/21/24 at 3:55 P.M. to 06/23/24 at 12:40 P.M. which included 3 RNs, 10 LPNs and 19 STNAs. LPN #821 completed Oral Cavity Assessment Audits of all residents on 06/21/24 with no negative findings. Director of Housekeeping #552 completed an audit of resident rooms for flies on 06/21/24 with no negative findings. Director of Housekeeping #552 completed an audit for intact window screens on 06/21/24. The facility identified six resident rooms with holes in the screen including rooms 104, 106,108, 111 and 115. Tape was placed over the holes in the screens. A QAPI Meeting was held on 06/24/24 at 3:45 P.M. with the Administrator, DON via phone and Medical Director via phone. No other staff had signed the form including the Infection Preventionist, Dietitian/Dietary Representative, Pharmacy Representative, Lab Representative, Life Enrichment Representative, Life Enrichment Representative, Environmental Services, Rehabilitation/Restorative Representative, MDS Representative, Safety Representative, Medical Records Representative and Human Resources. The DON completed Oral Care Audits beginning 06/26/24 for three times a week for five weeks. Pest control services were provided for flies in the facility with fly baits on 06/17/24, 06/24/24, 07/15/24 and 07/17/24. The facility maintained the use of a contracted company for pest control. This deficiency represents non-compliance investigated under Complaint Number OH00155328.