Every finding on record at Edgewood Manor of Lucasville II

Based on resident record review, staff interview, review of the facility Self-Reported Incident (SRI) and investigation, and review of facility policy, the facility failed to timely report an Injury of Unknown Origin (IUO). This affected one resident (#14) out of the three residents reviewed for abuse. The facility census was 70. Findings include:Record review for Resident #14 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included paranoid schizophrenia, need for assistance with personal care, and cognitive communication deficit.Review of the annual Minimum Data Set (MDS) assessment, dated 04/30/26, revealed the resident was assessed to have impaired cognition, hallucinations, and delusions.Review of the facility Self-Reported Incident (SRI), dated 06/05/26 and timed 3:07 P.M., revealed on 06/05/26 Resident #14 was observed by staff to have discolored area on his left forearm. When asked what happened, he stated that a man with a beard hit him a while ago. When asked what man, Resident #14 stated the one from North Carolina. Review of the facility Staff Investigation Interview Form, dated 06/05/26, revealed Certified Nursing Assistant (CNA) #204 reported observing a bruise to Resident #14's left forearm on 05/29/26 which was reported to Licensed Practical Nurse (LPN) #207.Review of the facility Staff Investigation Interview Form, dated 06/05/26, revealed Housekeeper #212 reported bruising present to Resident #14 on 06/03/26 and the resident stated he was unaware of how it happened.Review of the facility Staff Investigation Interview Form, dated 06/05/26, revealed CNA #153 reported being made aware Resident #14 had a bruise during shift report.Review of the facility Staff Investigation Interview Form, dated 06/05/26, revealed Occupational Therapy Employee (OTE) #220 noted an area of bruising to Resident #14 on 05/28/26 and reported it to LPN #115.Interview on 07/06/26 at 11:17 A.M. with Housekeeper #212 confirmed on 06/03/26, around breakfast time, she observed an area of bruising to Resident #14's left hand and arm which she reported to CNA #153 who was providing care to the resident on that day.Interview on 07/06/26 at 11:55 A.M. with CNA #153 confirmed on 06/03/26, around change of shift, she was speaking with Resident #14 and saw a bruise on his arm and hand which she reported to LPN #207. CNA #153 confirmed when she questioned Resident #14 as to what had happened, he stated he went into another residents room to get crackers and they slammed him on the ground.Interview on 07/06/26 at 12:21 P.M. with Assistant Director of Nursing (ADON) #154 confirmed facility management staff was not made aware of the bruise to Resident #14's arm until 06/05/26. ADON #154 confirmed staff interviews completed during the investigation of the injury of unknown origin for Resident #14 revealed staff reported seeing the area of bruising as early as 05/28/26, eight days before facility management were notified and an investigation was initiated.Interview on 07/06/26 at 12:50 P.M. with OTE #220 confirmed she reported an area of bruising and swelling to Resident #14's arm to LPN #115 on 05/28/26.Interview on 07/06/26 at 1:47 P.M. with LPN #115 confirmed she could not recall any reports of bruising to Resident #14's arm until 06/05/26.Interview on 07/06/26 at 2:15 P.M. with LPN #207 confirmed she was not aware of bruising to Resident #14's arm until 06/05/26. Interview on 07/06/26 at 2:40 P.M. with the Administrator and Director of Nursing (DON) confirmed facility management staff were not made aware of the area of bruising to Resident #14's left arm and hand until 06/05/26 despite staff interviews stating they had seen bruises on the residents arm as early as 05/28/26. They confirmed injury of unknown origin SRI and investigation were not initiated until 06/05/26 when they became aware. Review of the facility policy titled Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedures, dated 2022, revealed the facility will report the alleged violation and investigation within required timeframes pursuant to Federal and State statutes and regulations. This deficiency represents non-compliance identified under Complaint Number 3043103.

Based on closed record review, interview and policy review, the facility failed to allow Resident #22 to return to the facility following a discharge to jail and subsequent hospitalization due to the inability to find a safe discharge location. The facility also failed to assist the resident with appropriate and necessary discharge planning to ensure the resident's total care needs were met. This affected one resident (#22) of three residents reviewed for discharge and transfers. The facility census was 68.Findings include: Closed record review revealed Resident #22 admitted to the facility on [DATE] with diagnoses including bipolar disorder, traumatic brain injury, and schizoaffective disorder bipolar type. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22's cognition was moderately impaired. The MDS assessment noted the goal for the resident was to remain in the facility for long term care. The MDS also reflected the resident had physical behaviors directed towards others (examples: hitting, kicking, pushing, scratching, grabbing, abusing others sexually); verbal behavioral symptoms directed towards others (examples: threatening others, screaming at others, cursing at others); and other behaviors not directed towards others (examples: physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, vocal symptoms like screaming, disruptive sounds) all occurring four to six days but less than daily. The behaviors did not put the resident at risk for significant risk for physical illness or injury, did not significantly interfere with the resident's care and did not interfere with the resident's participation in activities or social interactions. The resident's behavioral symptoms did not place other residents at risk for physical injury but did significantly intrude on the privacy or activity of others and significantly disrupted the care or living environment. Review of a facility self-reported incident dated 03/31/26 revealed Resident #22 was involved in a resident-to-resident altercation where Resident #22 was noted to hit the other resident. There was no injury to either resident. The facility concluded the incident was isolated in nature due to delusions/hallucinations Resident #22 was having and noted Resident #22 would be seen by the facility psychologist on the psychologist's next visit. Review of a facility self-reported incident dated 04/24/26 revealed Resident #22 was involved in a resident-to-resident altercation. The report indicated another resident had walked in on Resident #22 while using the bathroom (the privacy curtain had been pulled). This surprised Resident #22 causing him to yell and hit the resident. As a result of the incident, the facility indicated social services would provide Resident #22 with psychosocial support as needed. Review of a nursing note dated 06/02/26 at 10:42 A.M. authored by Licensed Practical Nurse (LPN) #100 revealed Resident #22 had been in an altercation with another resident which was reported to the police. The note included Resident #22 was placed under arrest and left the building with the police.Review of a facility self-reported incident, tracking number 275225 revealed the facility reported an allegation of physical abuse involving two residents (one of which was Resident #22) that occurred on 06/02/26 at 8:45 A.M. Neither resident involved in the incident was documented as the perpetrator of the incident. Based on the facility report of the incident, it did not appear as though any staff had actually witnessed the incident. A brief description of the incident revealed Resident #22 and the other resident were having a conversation when Resident #22 allegedly reached out and touched the other resident. There were no identified injuries to the other resident. Resident #22 stated the resident had been running his mouth and he knew he should not have hit him. The other resident denied talking about Resident #22. The police were contacted and after speaking with both residents, Resident #22 was placed under arrest for assault. Review of a Discharge Notice dated 06/03/26 revealed Resident #22 was being immediately discharged from the facility to the local jail due to an emergency existing in which the safety of individuals in the home would be endangered. The notice included the facility would offer assistance in arranging a location for the resident to reside and if assistance was needed, the facility should be contacted. Notification of the right to appeal to the discharge was included along with information on the local ombudsman. Per the Discharge Notice information, this notice was sent to the resident at the local jail.Interview on 06/12/26 at 9:22 A.M. with the Ombudsman revealed she currently had a case open for Resident #22. She was aware the resident had conflict with another resident and the facility was to have interventions in place. She stated Resident #22 and the other resident went outside to smoke and Resident #22 attacked the other resident and the facility called the police and Resident #22 was arrested. The following day, the resident was issued an emergency discharge notice. The Administrator informed the Ombudsman she spoke with corporate and they were willing to take the hit on it. The Administrator stated she needed to keep residents safe and the Ombudsman stated she told the Administrator she agreed and Resident #22 was the facility's resident. The Ombudsman stated discharge to jail was not safe, the hospital was not appropriate and the administrator stated we will take the cite. The Ombudsman said she had called the hospital and the resident's niece for a location update but she had been unable to find out. But she left messages.Interview on 06/12/26 at 11:11 A.M. with the Director of Nursing (DON) revealed there had been incidents of Resident #22 hitting other residents in the facility (03/31/26, 04/24/26 and 06/02/26) with investigations completed and interventions implemented. The DON verified as a result of the incident on 06/02/26 the resident was issued an immediate/emergency discharge and the facility refused to allow the resident to return. During the interview, the DON stated she was not sure why an immediate discharge was issued instead of giving the resident a 30-day discharge notice, considering Resident #22 barely had any incidents according to the facility incident log but stated she just did what she was told. Interview with the Administrator on 06/12/26 at 11:11 A.M. verified the resident was transferred to jail on 06/02/26 and when the judge ordered to release the resident, the facility refused to take the resident back. The Administrator verified the facility issued an emergency discharge notice with the discharge location as jail.Interview on 06/12/26 at 1:16 P.M. with Deputy Clerk (DC) #131 revealed Resident #22 was arrested and his release information stated to contact the facility, but she was unsure if that happened. She stated she did not know the resident's current location because she was not present when he was released from the jail.Interview on 06/12/26 at 1:34 P.M. with the Hospital Case Manager revealed on 06/02/26 Resident #22 had been arrested but was released by the judge (on 06/03/26) so the police wanted him to return to the facility; however, he was not allowed to return per the facility. So, the local police brought Resident #22 to the hospital where he was admitted to wait for nursing home placement. The case manager revealed Resident #22 had told hospital staff that he knew it wasn't right how the facility kicked him out. The Hospital Case Manager also shared the resident said he knew what he did was wrong but he called the other resident that he hit, a bully and the other resident picked on everyone and I had enough. Further interview revealed the resident had remained hospitalized because the facility would not let him return and due to the hospital's inability to find alternate placement for the resident. The case manager indicated the resident had no current medical needs requiring hospital treatment/monitoring.Information obtained as part of the complaint investigation revealed on 06/03/26 (in the A.M.), an Emergency Department Social Worker was contacted by a Sheriff Deputy at the jail stating the Judge had released a patient (Resident #22) who lived at Edgewood Manor of Lucasville. However, Edgewood was refusing to take the patient back and advised that he be taken to (named) hospital. The deputy stated the resident had initially been arrested on 06/02/2026 after assaulting another resident while on a smoke break at the nursing home.Upon his arrival at the emergency department, another social worker (SW) spoke with facility admissions personnel. The facility admissions personnel reported to the SW this was the second time Resident #22 had assaulted the other resident. She stated on 06/03/26 the facility (Edgewood Manor) sent the jail the letter to be given to the resident stating he could not return to the nursing home. The Hospital SW Manager and Director contacted the Area Agency on Aging Ombudsman. The Ombudsman stated she advised the facility to accept the resident back and noted the assault had occurred when the residents were on a smoke break together and indicated since there was a history of a previous assault (while on smoke break both times), the facility should not have permitted the residents to be on smoke break together. The SW Director contacted the facility Administrator who stated the decision was made by corporate leadership to deny the resident re-admission to the facility. The Administrator acknowledged awareness of potential regulatory consequences and stated the facility would accept any resulting citation. The SW wanted it noted that Edgewood Manor did accept behaviorally challenged patients and the resident (Resident #22) had schizophrenia, bipolar disorder and a traumatic brain injury.There were no additional notes in the resident's medical record to reflect communication from the jail, hospital or ombudsman related to the resident's discharge and/or desire for the resident to return to the facility pending adequate and necessary discharge planning or appeal process related to the 06/03/26 discharge notice. In addition, there was no evidence the facility provided any assistance in arranging for an adequate and alternate location for the resident to reside after they refused to allow him to return. Review of a policy titled Resident Transfer and Discharge Policy and Procedure dated 2026 revealed the facility permits each resident to remain in the facility unless the conditions that allow for a transfer or discharge were met; transfers and discharges were properly documented; and transfers or discharges were in a safe manner. Discharging a resident was a violation of their right unless the facility could demonstrate the conditions that allow for discharge were met. Conditions include the transfer or discharge was necessary for the resident's welfare and resident's needs could not be met in the facility; it is appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility; the safety of individuals in the facility was endangered due to the clinical or behavioral status of the resident; the health of individuals in the facility would be otherwise endangered; the resident had failed after reasonable notice to pay for stay at the facility.This deficiency represents non-compliance investigated under Complaint Number 3035518.

Based on observations, staff interviews, and review of facility policy, the facility failed to ensure privacy curtains were in place around commodes in the communal bathroom for residents to utilize for privacy when toileting. This had the potential to affect the 22 residents (#1, #2, #5, #6, #9, #14, #17, #18, #19, #22, #26, #27, #33, #34, #35, #36, #38, #39, #45, #54, #59, and #64) who resided on the 300 hall and 400 hall and were identified by the facility as utilizing the communal bathrooms. The facility census was 67. Findings include: Observation on 06/17/25 at 10:30 A.M. revealed residents residing on the 300 hall did not have private bathrooms present in their rooms and had to utilize a communal bathroom for toileting. The bathroom contained two commodes which had tracks on the ceiling to place a curtain to pull around the commodes for privacy when in use. No curtains were in place on the tracks to pull for privacy. Interview with Certified Nursing Assistant (CNA) #241 at the time of the observation confirmed the residents residing on the 300 hall had to utilize the communal bathroom for toileting. CNA #241 confirmed the door to the bathroom did not lock and there were not any curtains in place on the tracks above the commodes for residents to pull for privacy when using the bathroom. Observation on 06/18/25 at 2:20 P.M. revealed residents residing on the 400 hall did not have private bathrooms present in their rooms and had to utilize a communal bathroom for toileting. The bathroom contained two commodes which had tracks on the ceiling to place a curtain to pull around the commodes for privacy when in use. One curtain was hanging from one of the tracks but the curtain on the second track was not present. Interview with the Director of Nursing (DON) at the time of the observation confirmed the residents on the 400 hall had to utilize the communal bathroom for toileting. The DON confirmed the door to the bathroom did not lock and one of the curtains was not in place on the track for residents to pull for privacy when using the bathroom. The DON confirmed curtains should be present on the tracks around all commodes in common bathrooms. Review of the facility policy titled Resident Rights, revised 12/2016, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality.

Based on record review and staff interview, the facility failed to complete a gradual dose reduction (GDR) or documentation of a clinical contraindication for not attempting a GDR for a resident on two antipsychotics. This affected one (Resident #16) of five residents reviewed for unnecessary medications. The facility census was 67. Findings include: Record review of Resident #16 revealed this resident was admitted to the facility on [DATE]. Diagnoses included paranoid schizophrenia. Review of the Minimum Data Set (MDS) assessment completed on 04/02/25 revealed Resident #16 had cognitive impairments. Review of the physician orders revealed Resident #16 was on the following medications: on 02/11/23, Perphenazine (antipsychotic) 8.0 milligrams (mg) one tablet by mouth four times a day for paranoid schizophrenia. On 02/21/24, Ziprasidone (antipsychotic) 80 mg one tablet by mouth twice daily for paranoid schizophrenia, Resident #16's medical record did not have evidence have a GDR attempt for the two antipsychotic medications (Perphenazine and Ziprasidone) nor rationales why a GDR would be contraindicated. Interview with the Director of Nursing (DON) on 06/18/25 at 3:10 P.M. verified there were no attempts a GDR was attempted for the use of the two antipsychotic medications (Perphenazine and Ziprasidone) nor was there rationale why a GDR would be contraindicated for Resident #16

Based on medical record review and staff interview, the facility failed to ensure a resident who had abnormal heart rate received timely care and services. This affected one (Resident #37) of two residents reviewed for change of condition. The facility census was 67. Findings include: Review of the medical record for Resident #37 revealed an admission date of 11/19/2020. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, and chronic pain. Review of the nursing progress note dated 04/19/25 at 1:09 P.M. created by Licensed Practical Nurse (LPN) #202 revealed the nurse was putting the vital signs in the medical record for Resident #37 when noticing a heart rate was documented on the paper as 23 beats per minute (bpm) (normal was 60 to 100 bpm). LPN #202 went to recheck the resident's pulse to make sure it was not actually 23 bpm. The resident's heart rate was fluctuating back and forth from 23 to 25 bmp. LPN #202 called the physician to report the findings and the physician instructed to send Resident #37 to the emergency room. Interview on 06/18/25 at 3:30 P.M. with the Director of Nursing (DON) confirmed any abnormal vital sign results including a pulse of 23 should be reported to the nurse immediately for immediate assessment. The DON confirmed Resident #37's low heart rate was not reported to the nurse in a timely manner.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to timely report an allegation of staff to resident physical abuse. This affected one (Resident #9) of three residents reviewed for abuse. The facility census was 65 residents. Findings include: Review of the medical record for Resident #9 revealed an admitted [DATE] with diagnoses including muscle weakness, unsteadiness on feet, difficulty walking, paranoid schizophrenia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 09/04/24 revealed the resident was moderately cognitively impaired. Review of the facility SRI form for Resident #9 dated 10/11/24 timed at 8:38 A.M. revealed the facility reported an allegation of physical abuse per Licensed Practical Nurse (LPN) #205 towards Resident #9. Review of witness statements per Certified Nursing Assistants (CNAs) # 163 and #166 obtained by the Director of Nursing (DON) on 10/11/24 revealed between approximately 4:00 A.M. to 4:30 A.M. on 10/11/24 the two CNAs witnessed LPN #205 place his hands on the chest of Resident #9 and push him backwards, causing the resident to fall. CNA#163 reported sending a text message to Facility Scheduler (FS) #200 at 4:20 A.M. on 10/11/24 stating they had a serious issue at the facility and a second text message at 4:38 A.M. on 10/11/24 asking to speak to FS #200 privately when FS #200 arrived at the facility. CNA #163 reported FS #200 responded to the text messages at 4:43 A.M. on 10/11/24 by replying with the word okay. Interview on 10/25/24 at 10:20 A.M. with Assistant Director of Nursing (ADON) #156 confirmed FS #200 called her at 6:54 A.M. on 10/11/24 to report an allegation of abuse per LPN #205 towards Resident #9 which had allegedly occurred sometime between 4:00 A.M. and 4:30 A.M. on 10/11/24. ADON #156 confirmed she immediately called the DON and reported the allegation to the DON because the DON was closer to the facility. The ADON confirmed all allegations of abuse should be reported to administration immediately. Telephone interview on 10/25/24 at 11:52 A.M. with FS #200 confirmed on 10/11/24 at 6:30 A.M. CNAs #163 and #166 reported an allegation of physical abuse per LPN #205 towards Resident #9 which they witnessed on 10/11/24 around 4:00 A.M. to 4:30 A.M. FS #200 stated the CNAs said they did not report the allegation at the time of occurrence because the only other nurse in the building was LPN #205's (the alleged perpetratror's) spouse. Interview on 10/25/24 at 12:15 P.M. with the Administrator confirmed CNAs #163 and #166 did not report the allegation of abuse per LPN #205 towards Resident #9 in a timely manner. The Administrator further confirmed the facility SRI was not initiated in a timely manner with the SRI timed on 10/11/24 at 8:38 A.M. which was approximately four hours after the alleged incident. Telephone interview on 10/25/24 at 12:31 P.M. with the DON confirmed CNAs #163 and #166 should have reported the allegation of abuse per LPN #205 towards Resident #9 at the time of occurrence which was 10/11/24 between 4:00 A.M. and 4:30 P.M. The DON confirmed the CNAs stated they did not report the incident when it occurred due to fear of retaliation by LPN #205 and his spouse who were the only nurses working at the time of the incident. Review of the facility policy titled Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure undated revealed the facility staff should report allegations of abuse to administration immediately and the facility would report allegations of physical abuse to the state agency immediately. This deficiency represents noncompliance investigated under Complaint Number OH00158949.

Based on medical record review, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to ensure residents were protected from further possible abuse during an abuse investigation. This affected one (Resident #9) of three residents reviewed for abuse. The facility census was 65 residents. Findings include: Review of the medical record for Resident #9 revealed an admitted [DATE] with diagnoses including muscle weakness, unsteadiness on feet, difficulty walking, paranoid schizophrenia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 09/04/24 revealed the resident was moderately cognitively impaired. Review of the facility SRI form for Resident #9 dated 10/11/24 timed at 8:38 A.M. revealed the facility reported an allegation of physical abuse per Licensed Practical Nurse (LPN) #205 towards Resident #9. Review of witness statements per Certified Nursing Assistants (CNAs) # 163 and #166 obtained by the Director of Nursing (DON) on 10/11/24 revealed at approximately 4:00 A.M. to 4:30 A.M. on 10/11/24 the two CNAs witnessed LPN #205 place his hands on the chest of Resident #9 and push him backwards, causing the resident to fall. CNA#163 reported sending a text message to Facility Scheduler (FS) #200 at 4:20 A.M. on 10/11/24 stating they had a serious issue at the facility and a second text message at 4:38 A.M. on 10/11/24 asking to speak to FS #200 privately when FS #200 arrived at the facility. CNA #163 reported FS #200 responded to the text messages at 4:43 A.M. on 10/11/24 by replying with the word okay. Interview on 10/25/24 at 10:20 A.M. with Assistant Director of Nursing (ADON) #156 confirmed FS #200 called her at 6:54 A.M. on 10/11/24 to report an allegation of abuse per LPN #205 towards Resident #9 which had allegedly occurred sometime between 4:00 A.M. and 4:30 A.M. on 10/11/24. ADON #156 confirmed she immediately called the DON and reported the allegation to the DON because the DON was closer to the facility. The ADON confirmed all allegations of abuse should be reported to administration immediately. Telephone interview on 10/25/24 at 11:52 A.M. with FS #200 confirmed on 10/11/24 at 6:30 A.M. CNAs #163 and #166 reported an allegation of physical abuse per LPN #205 towards Resident #9 which they witnessed on 10/11/24 around 4:00 A.M. to 4:30 A.M. FS #200 stated the CNAs said they did not report the allegation at the time of occurrence because the only other nurse in the building was LPN #205's (the alleged perpetratror's) spouse. Interview on 10/25/24 at 12:15 P.M. with the Administrator confirmed CNAs #163 and #166 did not report the allegation of abuse per LPN #205 towards Resident #9 in a timely manner. The Administrator confirmed LPN #205 was permitted to work till 7:30 A.M. on 10/11/24 and alleged abuse had occurred between 4:00 A.M. to 4:30 A.M. on 10/11/24 Telephone interview on 10/25/24 at 12:31 P.M. with the DON confirmed CNAs #163 and #166 should have reported the allegation of abuse per LPN #205 towards Resident #9 at the time of occurrence, which was 10/11/24 between 4:00 A.M. and 4:30 P.M. The DON confirmed the CNAs stated they did not report the incident when it occurred due to fear of retaliation by LPN #205 and his spouse who were the only nurses working at the time of the incident. The DON further confirmed LPN #205 was permitted to work till 7:30 A.M. on 10/11/24 and alleged abuse had occurred between 4:00 A.M. to 4:30 A.M. on 10/11/24. Review of the facility policy titled Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure undated revealed when the facility had identified abuse, the facility would take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. This deficiency represents noncompliance investigated under Complaint Number OH00158949.

Based on staff interview and record review the facility failed to have accurate advance directives in the electronic and medical record. This affected one (Resident #14) of one resident reviewed for advanced directives. The facility census was 64. Findings include: Record review of Resident #14 revealed an admitted [DATE] with pertinent diagnoses of: Alzheimer's disease, hypertensive heart disease with heart failure, hypertension, type two diabetes mellitus, and chronic obstructive pulmonary disease. Review of the 07/24/23 quarterly Minimum Data Set (MDS) assessment revealed the resident was moderately cognitively impaired and required extensive assistance for dressing, personal hygiene, and limited assistance for walk in room and transfer. The resident needed supervision for bed mobility, eating, and toilet use. Review of the paper medical record on 08/15/23 at 8:45 A.M. revealed Resident #14 had a do not resuscitate comfort care (DNR-CC) paper that was not dated but had a signature of a doctor on it. Review of the electronic medical record on 08/15/23 at 8:50 A.M. revealed Resident #14 had an active Physician's Order to be Full Code from 05/19/22. Interview with Licensed Practical Nurse (LPN) #305 on 08/15/23 at 2:30 P.M. verified there was an active full code order in the electronic health record and an undated paper DNR-CC form in the paper chart.

Based on record review and interview, the facility failed to notify one resident's (#218) physician of a change in condition. This affected one (Resident #218) of four residents reviewed for accidents. The census was 64. Findings Include: Review of the medical record for Resident #218 revealed an initial admitted [DATE] with the latest readmission of 07/13/23 with diagnoses including paranoid schizophrenia, chronic obstructive pulmonary disease, repeated falls, difficulty in walking, unsteadiness on feet, generalized muscle weakness, extrapyramidal and movement disorder, bipolar II disorder, anxiety disorder, legal blindness , atrial fibrillation, ocular manifestations of vitamin A deficiency, disorder of urea cycle metabolism, dizziness and giddiness, benign prostatic hyperplasia, dysphagia, bullous keratopathy right eye, open angle glaucoma both eyes, acquired absence of eye, hyperlipidemia, constipation, speech disturbances, history of falling, pain, manic episodes, gastro-esophageal reflux disease, dry eye syndrome, obstructive and reflux uropathy, functional dyspepsia, hypertension, retention of urine, allergic rhinitis and psychosis. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had delusions. The resident required extensive assistance of one staff with bed mobility, transfers and ambulation. The assessment indicated the resident was occasionally incontinent of both bowel and bladder. The assessment indicated the resident had no falls since prior assessment completion. Review of the plan of care dated 03/03/23 revealed the resident was at risk for falls related to confusion, gait/balance problems, unaware of safety needs, vision/hearing problems, history of fall, difficulty walking, muscle weakness and lack of coordination. Interventions included anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure resident's environment is safe at all times, ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, floor mat at bedsides, follow facility fall protocol, left side assist bar to bed to serve as enabler, perimeter mattress to bed, therapy to evaluation and treat if indicated status post fall. Review of the resident's progress note dated 11/12/22 at 7:46 A.M. revealed the resident had complained to staff members early this morning about his left ankle was hurting. When observing left ankle, the ankle appeared swollen, little discoloration, compared to right ankle. The resident reported he did not remember how or when his ankle started bothering him. The resident was also observed lying on the floor after breakfast because he was unable to walk on left ankle. The resident stated he had been getting on the floor because he was unable to stand on foot. Review of the resident's progress note dated 11/12/22 at 10:22 A.M. revealed the resident was found on the floor at 10:00 A.M. lying on his left side with head against the bedroom door. The resident was noted to not have his shoes on properly. The resident stated he was okay and did not fall and hit the floor but tried to crawl because his ankle was hurting. The resident was assisted to bed. The resident's physician was then notified of the resident's inability to bear weight on the resident's left ankle as well as the pain. New orders were given to obtain an X-ray of the left ankle. On 08/17/23 at 12:30 P.M., interview with the Director of Clinical Services (DCS) verified the nurse should have notified the resident's physician of the resident's inability to bear weight on the left ankle due to pain when first discovered.

Based on observation, record review and interview, the facility failed to ensure one resident (#55) was free from physical restraints. This affected one (Resident #55) of three residents reviewed for restraints. The facility census was 64. Findings Include Review of the medical record for Resident #55 revealed an initial admitted [DATE] with the latest readmission of 05/13/23 with diagnoses including sepsis, anterior displaced type II dens fracture with delayed healing, chronic viral hepatitis, insomnia, tobacco use, Alzheimer's disease, generalized muscle weakness, shortness of breath, difficulty in walking, unsteadiness, dysphagia, dementia with behavioral disturbances, disorders of bladder, neurogenic bladder, hypertension and atrial fibrillation. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident had both hallucinations and delusions. The assessment indicated the resident required extensive assistance of one for bed mobility, transfers and ambulation. The assessment indicated the resident had and indwelling urinary catheter and was frequently incontinent of bowel. The assessment indicated the resident had not had any falls since the completion of the prior assessment. The assessment indicated a chair and bed alarm was used on a daily basis. Review of the medical record revealed no assessment for the use of the bed and chair sensor alarm. Review of the monthly physician orders for August 2023 identified orders dated 05/15/23 pressure sensor alarm to bed at all times, check placement and function every shift. Further review of the physician orders revealed no order for the pressure sensor alarm to wheelchair. Review of the resident's plan of care revealed no care plan for the pressure sensor alarm to the resident's wheelchair. On 08/16/23 at 2:15 P.M., observation of the resident revealed he was sitting in his wheelchair in his room with a pressure sensor alarm. On 08/16/23 at 2: 25 P.M., interview with State tested Nursing Assistant (STNA) #500 revealed the resident has always had a chair alarm and when a resident has a bed alarm, they have a chair alarm. The STNA revealed the chair alarm is used on a daily basis to alert staff of attempts of unassisted ambulation. On 08/16/23 03:18 PM, interview with Director of Clinical Services (DCS) verified the resident had a pressure sensor alarm in place with no order or assessment of the alarms.

Based on record review, review of facilities Self Reported Incident (SRI), review of facility policy titled Abuse, Investigation and Reporting and interviews the facility failed to appropriately identify and report a resident to resident abuse. This affected one resident (Resident #39) out of four residents screened for abuse. The facility policy was 64. Findings include: Record review of Resident #39 revealed an admitted [DATE] with pertinent diagnoses of: Bipolar disorder, depression, hypertension, seizures, muscle weakness, falls, COVID-19, lack of coordination, dementia, traumatic brain injury, and alcohol abuse. Review of the 07/11/23 annual Minimum Data Set (MDS) revealed the resident has severe cognitive impairment and is rarely/never understood. The resident required one person limited assistance for personal hygiene and physical help in part of bathing. The resident uses a wheelchair to aid in mobility. Review of progress note from 08/01/23 revealed another resident went into this resident's room and Resident #39 threw his water cup at the other resident, striking him on the cheekbone under his left eye. This caused a small laceration to the resident who walked into the room of Resident #39. Review of Self-Reported Incident revealed a staff member checked the room of Resident #39 after hearing a noise on 08/01/23. Resident #33 was observed leaving the room with a wet shirt with a cup of ice water everywhere on the floor. Approximately 5 minutes later, Resident #33 was observed with a small laceration below his left eye. The incident was unwitnessed by staff at the time of occurrence. Care was provided to both residents. During investigation, discovery was made that the incident was unwitnessed and the staff member was adding details to what they thought might have happened. All staff were reeducated on abuse and neglect policy. Skin assessments were completed for all residents. This report was initiated two days after the incident had occurred on 08/03/23. Interview with Registered Nurse #300 on 08/17/23 at 12:48 P.M. verified delay in reporting to the State Agency of 2 days and not following facility policy as this event occurred on 08/01/23 and was not reported to state agency until 08/03/23. Also verified the facility did not follow policy on reporting of possible abuse as this incident should have been reported on 08/01/23 when it occurred. Review of Facility Abuse Investigation and Reporting Policy revised in July 2017. It states under reporting that all alleged violations of abuse, neglect, exploitation, mistreatment, or injuries of unknown origin will be reported immediately but not later than 2 hours if the allegation involves abuse or resulted in bodily injury; or 24 hours if the incident does not involve abuse and has not resulted in serious bodily injury.

Based on record review, review of facilities Self Reported Incident (SRI), review of facility policy titled Abuse, Investigation and Reporting and interviews, the facility failed to appropriately report a resident to resident abuse. This affected one resident (Resident #39) out of four residents screened for abuse. The facility policy was 64. Findings include: Record review of Resident #39 revealed an admitted [DATE] with pertinent diagnoses of: Bipolar disorder, depression, hypertension, seizures, muscle weakness, falls, COVID-19, lack of coordination, dementia, traumatic brain injury, and alcohol abuse. Review of the 07/11/23 annual Minimum Data Set (MDS) revealed the resident has severe cognitive impairment and is rarely/never understood. The resident required one person limited assistance for personal hygiene and physical help in part of bathing. The resident uses a wheelchair to aid in mobility. Review of progress note from 08/01/23 revealed another resident went into this resident's room and Resident #39 threw his water cup at the other resident, striking him on the cheekbone under his left eye. This caused a small laceration to the resident who walked into the room of Resident #39. Review of Self-Reported Incident revealed a staff member checked the room of Resident #39 after hearing a noise on 08/01/23. Resident #33 was observed leaving the room with a wet shirt with a cup of ice water everywhere on the floor. Approximately 5 minutes later, Resident #33 was observed with a small laceration below his left eye. The incident was unwitnessed by staff at the time of occurrence. Care was provided to both residents. During investigation, discovery was made that the incident was unwitnessed and the staff member was adding details to what they thought might have happened. All staff were reeducated on abuse and neglect policy. Skin assessments were completed for all residents. This report was initiated two days after the incident had occurred on 08/03/23. Interview with Registered Nurse #300 on 08/17/23 at 12:48 P.M. verified delay in reporting to the State Agency of 2 days and not following facility policy as this event occurred on 8/1/23 and was not reported to state agency until 08/03/23. Also verified the facility did not follow policy on reporting of possible abuse as this incident should have been reported on 08/01/23 when it occurred. Review of Facility Abuse Investigation and Reporting Policy revised in July 2017. It states under reporting that all alleged violations of abuse, neglect, exploitation, mistreatment, or injuries of unknown origin will be reported immediately but not later than 2 hours if the allegation involves abuse or resulted in bodily injury; or 24 hours if the incident does not involve abuse and has not resulted in serious bodily injury.

Based on record review, and staff interview the facility failed to ensure a new Pre-Admission Screen and Resident Review (PASARR) was completed following a new mental health diagnosis. This affected two (Resident #1 and #42) residents of four residents reviewed for PASARR. The facility census was 64. Findings include: 1. Record review of Resident #1 revealed an admitted [DATE] with pertinent diagnoses of: alcoholic cirrhosis of liver without ascites, schizophrenia, obsessive-compulsive personality disorder, and hypertension. Review of the 07/03/23 annual Minimum Data Set (MDS) revealed the resident is cognitively intact and requires extensive assistance for bed mobility, transfer, dressing, and toilet use. The resident requires one person limited assistance for personal hygiene and physical help in part of bathing. The resident uses a wheelchair to aid in mobility and is always continent of bowel and bladder. Review of the medical record on 08/15/23 at 8:44 A.M. revealed Resident #1 had a diagnosis of schizophrenia from 10/01/16. Review of the medical record on 08/15/23 at 8:50 A.M. revealed there was never updated an PASARR since 07/09/10 to include the new diagnosis of schizophrenia. Interview with Registered Nurse (RN) #300 on 08/16/23 at 2:45 P.M. verified there was never an updated PASARR completed when the resident had a new diagnosis of schizophrenia. 33023 2. Record review of Resident #42 revealed an admitted [DATE] with pertinent diagnoses of: dementia, diabetes mellitus type II, muscle weakness, acute kidney failure, hypokalemia, anxiety, depression, and unspecified psychosis. A diagnosis of mood disorder was also added on 09/30/20. Review of the 07/01/23 annual Minimum Data Set (MDS) revealed the Resident has severe cognitive impairment and requires extensive assistance for bed mobility, transfer, dressing, and toilet use. The resident requires one person limited assistance for personal hygiene and physical help in part of bathing. The resident uses a wheelchair to aid in mobility and is always continent of bowel and bladder. Review of most recent PASARR completed on 08/16/23 revealed inaccurate indications of mental illness with an omission of mood disorder and Depakote not captured as a Mood Stabilizer in Section 6 of the PASARR documentation. Previous PASARR completed was on 05/13/20 with no indications of mental illness. Interview with RN #300 on 08/16/23 at 2:45 P.M. verified that the newly created documentation did not contain an accurate reflection of PASARR requirements.

Based on observation, record review, and interview, the facility failed to ensure Resident #15, #17, and #55 who required assistance with activities of daily living (ADL) received shaving assistance. This affected three (Resident #15,#17, and #55) of four residents reviewed for ADL. The facility census was 64. Findings Include: 1. Review of the medical record for Resident #15 revealed an initial admitted [DATE] with the latest readmission of 04/17/16 with the diagnoses including major depressive disorder, anxiety disorder, insomnia, palliative care, dementia with behavioral disturbance, undifferentiated schizophrenia, dysphagia, psychosis, hypertension, pain, contracture of right ankle, contracture of left ankle, anemia, restlessness and agitation, retention of urine, viral hepatitis C, convulsions, delusional disorder and personal history of traumatic brain injury. Review of the plan of care dated 03/20/23 revealed the resident had a self-care deficit related to activity intolerance, confusion, dementia, fatigue, impaired balance, limited mobility, pain, shortness of breath, depression, anxiety, schizophrenia, psychosis, cognitive deficits, hypertension, muscle weakness, contracture status, hepatitis C, convulsions, delusions, traumatic brain injury, fluctuation with activities of daily living expected with disease process, unable to educate on use of call light related to cognition, unable to use call light appropriately and unable to effectively make needs/wants known. Interventions included staff to anticipate and meet all needs and requires one staff assist with personal hygiene. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident had hallucination. The resident required limited assistance with personal hygiene including shaving. On 08/15/23 at 10:11 A.M., observation of Resident #15 revealed he had several days of facial hair growth. On 08/12/23 at 12:45 P.M., observation of Resident #15 revealed he had several days of facial hair growth. On 08/16/23 at 2:10 P.M., interview with State tested Nursing Assistant (STNA) #502 verified the resident had several days of facial hair growth and required staff assistance with shaving. 2. Review of the medical record for Resident #17 revealed an initial admitted [DATE] with the latest readmission of 07/20/22 with diagnoses including schizoaffective disorder bipolar type, hypertension, chronic obstructive pulmonary disease (COPD), abnormal posture, generalized muscle weakness, constipation, dependence on supplemental oxygen, sexual dysfunction, neuromuscular dysfunction of bladder, dementia, bipolar disorder, major depressive disorder, benign prostatic hyperplasia with lower tract symptoms, insomnia, palliative care, repeated falls, catatonic disorder, dysphagia, psychoactive substance abuse, anxiety disorder, psychosis and opioid dependence. Review of the plan of care dated 03/21/23 revealed the resident had a self-care deficit related to activity intolerance, confusion, dementia, fatigue, limited mobility, limited range of motion, shortness of breath, schizophrenia, hypertension, COPD, bipolar disorder, depression, pyelonephritis, muscle weakness, lack of coordination, encephalopathy, anxiety, psychosis, opioid dependence, fluctuations expected with activities of daily living (ADL) expected with disease process. Interventions included extensive assistance of one staff with personal hygiene. Review of the resident's MDS dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident had delusions, displayed verbal behaviors directed towards others and wandered. The resident required extensive assistance of one with bed mobility, transfers, toilet use and personal hygiene, including shaving. On 08/14/23 at 2:38 P.M., observation of Resident #17 revealed he had several days of facial hair growth. On 08/15/23 at 10:35 A.M., observation of Resident #17 revealed he had several days of facial hair growth. On 08/16 at 2:00 P.M., observation of Resident #17 revealed he had several days of facial hair growth. On 08/16/23 at 2:10 P.M., interview with STNA #502 verified the resident had several days of facial hair growth and required staff assistance with shaving. 3. Review of the medical record for Resident #55 revealed an initial admitted [DATE] with the latest readmission of 05/13/23 with diagnoses including sepsis, anterior displaced type II dens fracture with delayed healing, chronic viral hepatitis, insomnia, tobacco use, Alzheimer's disease, generalized muscle weakness, shortness of breath, difficulty in walking, unsteadiness, dysphagia, dementia with behavioral disturbances, disorders of bladder, neurogenic bladder, hypertension and atrial fibrillation. Review of the plan of care dated 03/03/23 revealed the resident had a self-care performance deficit related to activity intolerance, Alzheimer's, confusion, dementia, fatigue, impaired balance, limited mobility, atrial fibrillation, hypertension, behavioral disturbances, fluctuations in activities of daily living (ADL) performance expected with disease progression, unable to educate on use of call light related to cognition, unable to use call light appropriately and unable to effectively make needs known. Interventions included resident is dependent on one staff for personal hygiene. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident required extensive assistance of one for personal hygiene including shaving. On 08/14/23 at 1:31 P.M., observation of Resident #55 revealed he had several days of facial hair growth. On 08/15/23 at 10:37 A.M., observation of Resident #55 revealed he had several days of facial hair growth. On 08/16 at 2:05 P.M., observation of Resident #55 revealed he had several days of facial hair growth. On 08/16/23 at 2:10 P.M., interview with STNA #502 verified the resident had several days of facial hair growth and required staff assistance with shaving.

Based on record review and interview, the facility failed to ensure one resident (#65) who received antihypertensive medications with parameters for blood pressure (BP) was obtained prior to administration. This affected one (Resident #65) of five residents reviewed for unnecessary medications. The facility census was 64. Findings Include: Review of the medical record for Resident #65 revealed an initial admitted [DATE] with the admitting diagnoses including chronic obstructive pulmonary disease (COPD), dementia, low back pain, dysphagia, major depressive disorder, benign prostatic hyperplasia, neutropenia, psychosis, gastro-esophageal reflux disease, malignant neoplasm of pharynx, hypertension, convulsions and type I diabetes mellitus. Review of the resident's plan of care revealed no care plan addressing the resident's diagnosis of hypertension. Review of the resident's monthly physician's orders for August 2023 identified orders dated 04/12/23 for Lisinopril 2.5 milligrams (mg) via gastric tube with the special instructions to hold the medication if the systolic blood pressure is less than 90 or heart rate less than 60. All labs completed as ordered, however the resident refused labs frequently. Review of the Medication Administration Record (MAR) for June, July and August 2023 revealed the staff nurses had not obtained the resident's blood pressure and pulse prior to administration of the medication Lisinopril. On 08/15/23 at 4:40 P.M., interview with the Director of Clinical Services (DCS) verified the staff nurses had not obtained the resident's blood pressure and pulse prior to the administration of the Lisinopril.

Based on observation and staff interview the facility failed to provide a safe, comfortable environment for Resident #18 when his wall was cracked and the heater was rusted and for Resident #42 when his room walls needed painted and patched. This affected two Residents (Resident #18 and #42) of five residents reviewed for environment. The facility census was 64. Findings include: Observation on 08/17/23 at 12:46 P.M. of Resident #42's room revealed there was a large area by the bed that the drywall was damaged and needed repaired. This was verified with Registered Nurse #300 at the time of the observation. Observation on 08/17/23 at 12:55 P.M. of Resident #18's room revealed there was a crack in the wall that needed repaired and the heater was rusted and needed painted. This was verified with Registered Nurse #300 at the time of the observation.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual harm occurred on 06/16/21 when Resident #65 was admitted to the hospital and diagnosed with [CONDITION(S)] (inflammation of bone or bone marrow, usually due to infection) of the second left toe had to have the second left toe amputated. treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected two residents (#59 and #65) of three residents reviewed for hospitalization and/or skin conditions. Findings Include: 1. Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Non-Pressure Skin Condition Record, dated 04/28/21 revealed a skin tear to the left second toe of Resident #65 measured 3.0 centimeters (cm) long by 2.0 cm wide by 0.1 cm deep. On 05/03/21 the area was documented to measure 3.3 cm wide by 2.5 cm long, by 0.3 cm deep. Review of a physician order, dated 05/03/21 revealed an order was obtained at that time to cleanse the second toe to the left foot with soap and water, pat dry, apply calcium alginate and apply a clean, dry dressing. The order for the dressing was to be completed every other day and as needed until resolved. Review of the Treatment Administration Records (TARs) for 05/2021 and 06/2021 revealed physician ordered treatments were documented as being completed to the area on the left second toe until 05/13/21 when the treatment was discontinued on the TAR and documentation on the TAR identified the area had resolved. Continued review of the assessment records revealed on 05/31/21 the area to the left second toe measured 4.8 cm long, by 2.2 cm wide, by 0.2 cm deep. On 06/07/21 the area measured 4.8 cm long, by 2.2 cm wide, by 0.2 cm deep. Weekly Skin Integrity reviews for Resident #65, dated 04/28/21, 05/05/21, 05/12/21, 05/19/21, 05/26/21, 06/02/21 and 06/09/21 revealed the resident was documented to have a skin tear to the second left toe during each assessment. There was no evidence after 05/13/21 staff had identified the lack of treatment order or need for treatment to the area. Review of a podiatry visit note, dated 06/16/21 revealed Resident #65 was seen due to a large, infected wound to his left second toe which contained necrotic tissue and had bone visible. An order was obtained on 06/16/21 to send Resident #65 to the emergency room (ER) for further evaluation. Review of hospital documentation, dated 06/16/21 through 06/18/21 revealed Resident #65 was admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/12/21 revealed Resident #65 was assessed to require extensive assistance from one staff member for bed mobility. Review of the care plan, revised on 08/25/21 revealed Resident #65 had the potential for altered skin integrity related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included weekly skin checks, follow physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/01/21 at 1:55 P.M. interview with the Director of Nursing (DON) verified the physician ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON verified weekly skin assessments and weekly wound measurements showed the wound remained to the second toe from 04/28/21 through 06/16/21 when the resident was sent to the hospital and his second left toe was amputated. On 09/01/21 at 2:30 P.M. Resident #65 was observed with a small scabbed area to the second left toe which had been amputated. 2. Review of the medical record for Resident #59 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 3.0 assessment, dated 08/06/21 revealed the resident had moderate cognitive impairment with a Brief Interview for Mental Status score of 10. On 08/30/21 at 12:01 P.M. and 08/31/21 at 3:06 P.M. Resident #59 was observed to have a band-aid on his left thumb. Interview with Resident #59 on 08/31/21 at 3:06 P.M. revealed he burned his thumb while smoking. Interview with Licensed Practical Nurse (LPN) #999 on 09/01/21 at 2:20 P.M. revealed Resident #59 had a burn on his thumb from a cigarette. She stated he smokes his cigarettes down to the end and refuses to use any adaptive smoking equipment. She stated the burn was noticed a couple days ago. She stated a treatment was being completed to the burn daily. Observations, at that time, revealed LPN #999 removed the band-aid from Resident #59's thumb. The resident was observed with a dime sized red area with the top layer of skin gone from the back of his thumb. LPN #999 cleaned his thumb, applied [MEDICATION(S)] with [MEDICATION(S)] ointment, and applied a new band-aid. Review of the medical record revealed no documentation regarding the burn on the thumb. There was no evidence the physician was notified, no evidence of a physician's order for a treatment to the thumb, no documentation of any treatment being done to the thumb, and no evidence of a non-pressure skin condition form being initiated to monitor the condition of the burn. Review of the facility policy titled Care of Skin Tears, Abrasions and Minor Breaks revealed the purpose of the procedure was to guide the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy revealed to obtain a physician's order as needed and document physician notification in the medical record. Generate a non pressure form and complete. The policy revealed an abrasion was an area on the skin that had been damaged by friction, scraping, rubbing or trauma. The policy indicated to complete an in-house investigation of causation, how the resident tolerated the procedure, any complications and interventions implemented to prevent additional abrasions. Interview with the Director of Nursing on 09/02/21 at 8:00 A.M. confirmed non pressure skin conditions were to be monitored on a non pressure skin condition record when identified and weekly. Interview with LPN #999 on 09/01/21 at 2:20 P.M. confirmed there was no documentation related to the burn on Resident #59's thumb. She confirmed there was no evidence the physician was notified, a treatment was ordered, or a skin condition form was initiated to assess and monitor the burn.

Based on observation, record review and interview the facility failed to provide nutritional interventions, including timely and adequate assistance with meals to Resident #65 to prevent weight loss. Actual harm occurred when Resident #65, who was dependent on staff for eating and assessed to sustain a 20.9% severe weight loss in 180 days (on 02/12/21 the resident weighed 240.6 pounds and on 08/10/21 the resident weighed 190.2 pounds loss of 50.4 pounds in 180 days) did not receive adequate or timely assistance with meals on 08/30/21 and 09/01/21. This affected one resident (#65) of four residents reviewed for weight loss. Findings include: Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #65's weight on admission (01/15/21) was documented to be 254 pounds. Review of Resident #65's meal intake records revealed in January 2021 staff documented the resident was consuming 75% to 100% of meals. Continued meal intake records from February 2021 through April 2021 revealed the resident's intakes had decreased. On 03/26/21 the resident was assessed to weigh 230 pounds. The next recorded weight, on 04/07/21 was 210 pounds. This reflected a 20 pound weight loss in 12 days. There was no evidence a re-weight was obtained at that time. In April 2021 the dietitian recommended nutritional shakes twice a day which were documented as being provided as ordered. Review of the care plan, dated 05/14/21, revealed Resident #65 was at risk for imbalanced nutrition related to diuretic use, diabetes mellitus, hypertension and [CONDITION(S)]. Interventions included to monitor for signs or symptoms of dysphagia such as pocketing or holding food in mouth, dental consult as needed and assist with feeding as needed. Review of the meal intake records from June through August 2021 continued to reflect the resident had decreased intake for meals. There was no evidence the facility re-assessed to cause of the decreased intakes at this time or implemented new interventions to increase meal intake or prevent additional weight loss. Review of the facility Vital Sign and Weight Record from 02/12/21 through 08/10/21 revealed Resident #65 experienced a 20.9% severe weight loss in 180 days. On 02/12/21 Resident #65's weight was 240.6 pounds (lbs). On 08/10/21, Resident #65's weight was 190.2 lbs, a loss of 50.4 lbs in the past 180 days. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/12/21 revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require extensive assistance from one staff member for bed mobility and set-up assistance and supervision for meals. The MDS revealed the resident had a significant weight loss of over 10% in six months and was not on a prescribed weight loss regimen. Review of the dietary progress notes, dated 08/12/21 revealed the weight history for Resident #65 showed a significant weight loss over 180 days and a moderate weight loss over 90 days. The weight loss over 180 days had been contributed to a large fluid loss and decline in the residents status. There was no evidence of any new nutritional interventions being considered or implemented at this time. In addition, record review revealed no evidence the resident was prescribed diuretic medication. Review of the corresponding nursing progress notes from 01/13/21 to 08/30/21 revealed no evidence Resident #65 had any type of [CONDITION(S)] noted. Observations of the resident throughout the annual survey, from 08/30/21 through 09/01/21 revealed no signs of [CONDITION(S)] noted. In addition, there were no notes related to diuretic use. On 08/30/21 at 12:30 P.M. observation of the lunch meal revealed meal trays arrived to the unit on the dining cart at this time. Observation on 08/30/21 at 12:38 P.M. revealed State tested Nursing Assistant (STNA) #777 placed the lunch tray for Resident #65 on his bedside table and placed the table over the resident. STNA #444 opened the containers and cut up the chicken Parmesan on the resident's plate and walked out of the room. Observation on 08/30/21 at 12:56 P.M. revealed Resident #65 was leaning to his left side in the bed attempting to use his fork to pick up pieces of chicken but was unable to and was pushing the food off his plate onto his tray. No staff members were observed in the room while the resident was attempting to consume his lunch meal. Observation on 08/30/21 at 1:06 P.M. revealed Resident #65 was slumped to his left side in the bed with his lunch meal in front of him on the bedside table and had consumed less than 10% of his lunch meal. Multiple gnats were observed to have landed on the resident's lunch meal. Resident #65 was rolling a substance around in his mouth and spit out a piece of unchewed chicken Parmesan which was covered in saliva onto his tray. Interview with Registered Nurse (RN) #99 and Licensed Practical Nurse (LPN) #58 on 08/30/21 at 1:06 P.M. verified gnats had landed on Resident #65's lunch meal, the resident was slumped over to his left side, and the did not appear to be able to chew the chicken Parmesan on his lunch tray or feed himself his lunch meal. RN #99 revealed she would get an order to downgrade Resident #65's diet from regular texture to a dysphagia advanced diet. Observation on 08/30/21 at 1:10 P.M. revealed LPN #58 began cutting the food on Resident #65's tray into smaller pieces and was observed to feed the resident his lunch meal. Interview with STNA #777 on 08/30/21 at 1:20 P.M. revealed staff did not provide assistance with meals to Resident #65 as he was able to feed himself after his meal was set-up. Observation on 09/01/21 at 12:12 P.M. revealed STNA #959 removed the lunch meal tray for Resident #65 from the dining cart, took it into his room, removed the lid from his plate, and set it on his tray table which was located next to his bed out of his reach as he was lying in bed with the head of his bed not raised. STNA #959 exited the room without opening the container of milk or removing the lids from the container of ice cream of cup of coffee. Observation on 09/01/21 at 12:30 P.M. revealed Resident #65 continued to lie in bed with the head of his bed not raised. The lunch meal for Resident #65 continued to remain on the tray table next to his bed which was not within his reach. Gnats were observed to be landing on the residents meat loaf, mashed potatoes, and peas. Interview with Resident #65 on 09/01/21 at 12:30 P.M. revealed the resident stated he was hungry, wanted to eat and thought he could sit up by himself to be able to eat his lunch meal but was unable to do so. Attempts to obtain additional information from the resident regarding assistance with meals/feeding could not be obtained as the resident was noted to have some cognitive impairment and could only answer simple questions and would not engage in conversation with the surveyor. Observation on 09/01/21 at 12:42 P.M. revealed STNA #959 walked back into the room of Resident #65 and attempted to sit him up on the side of the bed but was unable to. STNA #959 raised the head of the resident's bed instead and positioned the tray table containing his lunch meal across him, did not open his container of milk or remove the lids from his coffee and ice cream, and then exited the room. Resident #65 was observed to ask where his milk was after STNA #959 exited the room, but no staff members were around to hear his question. Interview with Resident #65 on 09/01/21 at 12:47 P.M. revealed he was unsure where his container of milk was at and stated staff normally opened it and handed it to him. Observation on 09/01/21 at 12:52 P.M. revealed Resident #65 was picking peas up one at a time with his fingers and was putting them into his mouth. Observation on 09/01/21 at 12:54 P.M. revealed STNA #959 entered Resident #65's room, asked the resident if his food was good, moved the container of milk to the edge of the resident's tray but did not open it, then exited the residents room. Observation on 09/01/21 at 12:56 P.M. revealed Resident #65 picked up his straw from his tray, removed the wrapper, and was attempting to place the straw into the unopened container of milk. Interview with RN #5000 on 09/01/21 at 1:05 P.M. verified only a few peas and one bite of mashed potatoes had been eaten by Resident #65, gnats were flying around the residents food, and the cup of coffee and container of ice cream remained unopened on the residents tray. Interview on 09/01/21 at 2:55 P.M. with Registered Dietician (RD) #1000 revealed she was aware of the weight loss experienced by Resident #65. Dietician #1000 verified the Resident #65 continued to have gradual weight loss every week since being admitted to the facility and was unsure as to why the resident's weight continued to decline. As a result of the interview, there was no evidence the dietician had considered the weight loss a result of the resident requiring and not receiving adequate assistance from staff with meal intake. Resident #65 had a current plan of care intervention to assist with feeding as needed.

Based on observation, record review and interview the facility failed to ensure timely dental services were provided for Resident #9 and Resident #65. Actual harm occurred on 09/02/21 when Resident #65, who had been referred for tooth extraction (on 04/27/21) was assessed to have an infected tooth which required antibiotic treatment. The facility failed to ensure a follow up appointment for the extraction was completed timely after the need for the extraction was identified on 04/27/21 resulting in the resident developing an infection. This affected two residents (#9 and #65) of the three residents reviewed for dental services. Findings Include: 1. Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order, dated 04/20/21 revealed Resident #65 was ordered the antibiotic [MEDICATION(S)] 150 milligrams (mg) four times a day for 10 days due to an oral abscess. A dental visit progress note, dated 04/27/21 revealed Resident #65 was seen at the facility by the dentist and was recommended to have his one remaining tooth extracted. A referral was left with the facility to send the resident out to have the tooth extracted. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/12/21 revealed Resident #65 was assessed to require extensive assistance from one staff member for bed mobility and set-up assistance and supervision for meals. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing (DON) on 09/01/21 at 4:00 P.M. verified Resident #65 had been seen by the dentist on 04/27/21 and the dentist had recommended Resident #65 be sent to another dental facility to have his one remaining tooth extracted. The DON was unable to provide evidence the referral had been made or evidence of any follow-up regarding the needed appointment. The DON verified Resident #65 had not been seen by a dentist since 04/27/21 and no follow-up appointment had been scheduled. Interview with Licensed Practical Nurse (LPN) #999 on 09/02/21 at 1:30 P.M. revealed Resident #65 was seen at the facility by the Nurse Practitioner (NP) on this date and the NP had been prescribed antibiotics due the resident's tooth being infected. This was the tooth the dentist had recommended being extracted on 04/27/21. 2. Review of Resident #9's medical record revealed an admitted [DATE] with the admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's admission assessment, dated 05/07/21 revealed the resident had his own teeth with no carried or broken teeth. Review of the resident's comprehensive MDS 3.0 assessment, dated 05/14/21 revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. The resident was dependent on one staff for personal hygiene. The assessment indicated the resident had obvious or likely cavity or broken natural teeth. Review of the resident's plan of care revealed the resident had no plan of care related to the likely cavity or broken natural teeth. Review of the resident's medical record failed to provide any documented evidence the resident had seen or had been offered to be seen by a dentist since admission to the facility. On 08/30/21 at 10:35 A.M. observation of Resident #9 revealed the resident had obvious carries to his teeth. On 09/01/21 at 1:22 P.M. interview with Medical Records #400 verified the resident had not seen a dentist since being admitted to the facility.

Based on observation, record review and interview the facility failed to ensure the correct diet that met resident needs was provided when whole broccoli florets were given to residents on a dysphagia advanced diet instead of chopped broccoli. This had the potential to affect 18 residents (#5, #8, #14, #16, #17, #28, #33, #37, #38, #39, #44, #45, #48, #54, #58, #60, #63 and #268) of 18 residents identified to have orders for a dysphagia advanced diet. The facility census was 69. Findings Include: On 08/31/21 from 11:25 A.M. to 12:10 P.M. observation of the lunch meal service revealed two available vegetable options puree broccoli and regular broccoli florets. Further observation revealed 14 residents, Resident #5, #8, #14, #16, #17, #33, #39, #45, #48, #54, #58, #60, #63 and #268 on a dysphagia advanced diet were served regular broccoli florets. Review of the Diet Guide Sheet for lunch on Tuesday 08/31/21, day 10 of Week two of the menu cycle, revealed residents on the dysphagia advanced diet were to receive chopped broccoli florets. On 08/31/21 at 12:27 P.M. interview with Healthcare Services Group District Manager (HSDM) #236 confirmed residents on the dysphagia advanced diet were given regular broccoli florets when the diet guide called for chopped broccoli florets. HSDM #236 revealed the kitchen staff usually served chopped broccoli. On 08/31/21 at 3:42 P.M. interview with Dietary Manager (DM) #69 also confirmed residents on the dysphagia advanced diet were given the same full broccoli florets as those on the regular diet. DM #69 revealed the broccoli usually came in smaller pieces and not whole florets, so normally both diets would get the same broccoli. DM #69 revealed the cook had not considered the change in the broccoli Review of the resident list with diets revealed 18 residents, Resident #5, #8, #14, #16, #17, #28, #33, #37, #38, #39, #44, #45, #48, #54, #58, #60, #63 and #268 were ordered a dysphagia advanced diet. Review of the undated diet terminology conversion sheet revealed a dysphagia advanced diet was to be soft or ground, a dysphagia level 3 diet called for chopped, fine chopped and mechanical soft food items.