Every finding on record at Embassy of Willard

Based on review of the facility assessment, staff interview, and policy review, the facility failed to ensure the facility assessment evaluated residents to determine the number of staff needed in the facility. This had the potential to affect all residents. The facility census was 55. Findings include:Review of the Facility Assessment last dated 04/02/26 stated the facility determined the facility needed one full time Director of Nursing (DON), one full time Assistant Director of Nursing (ADON), nine full time licensed nurse supervisors, five as needed licensed nurse supervisors, 17 full time nursing assistants, two part time nursing assistants, and four as needed nursing assistants for nursing staff. Further review of the facility assessment revealed no evaluation was completed to determine the number of staff needed for the acuity of the residents.Interview on 07/16/26 at 9:41 A.M. with the Administrator verified the facility assessment did not evaluate resident needs to determine the number of staff needed in the facility. Furthermore, the Administrator verified the number of staff written on the facility assessment was the number of staff they currently had when they completed the assessment, and the number did not take into account the needs of the resident population.Review of the facility policy titled Facility Assessment, with a last revised date of October 2018 revealed the facility assessment included a detailed review of the resident population. This part of the assessment includes residents census data from the previous 12 months, resident capacity of the facility and its occupancy rate for the past 12 months, and factors that affect the overall acuity of the residents, such as the number and percentage of residents who need assistance with activities of daily living (ADLs), mobility impairments, incontinence, cognitive or behavioral impairments, conditions or diseases that require specialized care such as dialysis, ventilators, and wound care, religious, ethnic, or cultural factors that affect the delivery of care and services such as food and nutrition requirements, decision making and end of life care, activities, and language translation requirements.

Based on record review, staff interviews, review of resident fund accounts, and review of facility policy, the facility failed to appropriately manage resident funds. This affected one (#02) of one resident reviewed for personal funds. The facility census was 55.Findings include:Review of the medical record for Resident #02 revealed an admission date of 10/22/25 with diagnoses that included acute respiratory failure with hypoxia, hypertension, and type II diabetes mellitus.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated the resident was alert and oriented to person, place, and time. Further review of the MDS assessment revealed Resident #02 was dependent on staff for activities of daily living (ADLs) and had a lower extremity impairment on one side. Review of the care plan dated 10/29/25 revealed Resident #02 was independent with meeting emotional, intellectual, physical and social needs, and had an ADL self-care performance deficit with interventions that included assistance with ADLs and maintain involvement as desired.Review of the Resident Fund Management Services Authorization and Agreement to handle resident funds revealed Resident #02 opened a resident funded account on 10/23/25. Review of the document revealed Resident #02 opted to have or direct deposit (recurring income source) but had no designated selection for the type of checking account (automatic transfer of funds). Review of the Social Security Administration (SSA) benefit verification letter revealed Resident #02 had a total monthly awarded benefit payment of $1,335.00.Review of the facility's trial balance regarding resident funded accounts revealed Resident #02 had a current balance of $0.08 with a designated established allowance of $75.00.Review of the quarterly statements dated 10/28/25 through 12/31/25 revealed Resident #02 had one cash credit in the amount of $600.00 on 11/28/25 and one care cost payment debit of $600.00 on 06/25/26. Review of the quarterly statement revealed no other activity besides the interest paid credits.Review of the quarterly statement dated 01/01/26 through 03/31/26 revealed Resident #02 had no other activity besides interest paid credits.Review of the quarterly statement dated 04/01/26 through 06/30/26 revealed Resident #02 had one cash credit in the amount of $600.00 on 06/11/26 and one care cost payment debit of $600.00 on 12/02/25.Review of the Member Eligibility Verification Form from the Ohio Department of Medicaid (ODM) revealed Resident #02 had a patient liability of $402.00 for the month of October 2025. Resident #02 had a patient liability of $1,249.00 for the months of November and December of 2025, and a patient liability of $1,260.00 January 2026 through June 2026.Interview on 07/16/26 at 8:30 A.M. with Business Office Manager (BOM) #159 revealed Resident #02 had Representative Payee (RP) who was appointed by the SSA to manage Social Security or Supplemental Security Income (SSI) benefits for him. BOM #159 revealed the facility was having trouble getting Resident #02's RP to make payments to cover the resident's patient liability, causing Resident #02 to fall behind on payments. BOM #159 revealed she obtained Resident #02's bank card and every month starting April of 2026, the BOM withdrew two cash withdrawals equaling approximately $1,260.00 from the shared bank account for Resident #02 and the RP from the local automated teller machine (ATM). BOM #159 revealed she would then take the cash and transfer it into cashier check at the facility utilized bank. BOM #159 revealed Resident #02 had an opened account at the facility utilized bank for his funds, however, BOM #159 did not utilize that account and instead deposited the cashier checks into the facility designated account and apply the total to Resident #02's patient liability and/or care costs. BOM #159 revealed there was no documentation or written agreements that authorized her to utilize Resident #02's and/or the RP's bank card, to withdraw cash from the ATM, obtain cashier checks and then deposit it into the facility's account instead of Resident #02's personal account. BOM #159 revealed she obtained receipts for every transaction but could not provide authorization of bank transaction statements due to not being able to speak with bank staff at the inside counter because she was not listed on Resident #02's bank account. BOM #159 revealed all transactions were completed at ATMs and although all transactions were [NAME], she could not verify that the amounts withdrawn were the only funds taken from Resident #02's account and she could not verify if Resident #02 received his allotted monthly allowance of $75.00. BOM #159 confirmed at the time of the interview that she is not following the facility policy related to managing Resident #02's accounts and further verified no one would be able to track what the resident had paid toward his patient liability. Review of the undated facility policy titled Resident Trust Fund, Accounting and Records, stated the facility had the policy in place to ensure the facility establishes and maintains a system of full, complete and separate accounting of each resident's personal account funds. The policy states each resident shall receive a receipt for every transaction, provide a signature for every transaction, all revenues and expenses shall be documented for each resident on resident ledger, and the account ledger must be available at any time for the resident to review. The policy specifically stated for all funds received and deposited by the facility should be credited to the resident's individual account. The facility must have record, including the date and reason for all deposits and expenditures. Further review of the policy under the internal procedures stated that deposits cannot be comingled with operating funds and any checks containing operating and trust funds will be deposited into the trust account; a check will be written from the trust account and deposited into the operating account for the accounts receivable portion.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure advance directives were consistent throughout the medical record. This affected two (#14, #40) of two residents reviewed for advance directives. The facility census was 55.Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of [DATE]. Diagnoses included hypertension, atrial fibrillation, dementia, chronic kidney disease, and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of a signed Do Not Resuscitate (DNR) Comfort Care (CC) form dated [DATE] and located in the resident's physical paper chart revealed the resident had a chosen a DNRCC-Arrest (DNRCC-A) protocol (the DNR Comfort Care protocol would be implemented in the event of a cardiac or respiratory arrest). Review of a physician order in the electronic medical record, dated [DATE] and discontinued on [DATE], revealed the resident had chosen a DNRCC-A code status. Review of a nurse's note dated [DATE] revealed the resident's family wanted the resident's code status changed to a DNR-CC (immediate activation of the DNR Comfort Care protocol) and also requested a hospice consult. Review of a physician order dated [DATE] revealed an order for the resident to have a DNRCC code status. Interview on [DATE] at 12:51 P.M., Licensed Practical Nurse (LPN) #124 revealed she would first check the electronic medical record for a resident's code status. LPN #124 revealed if the electronic medical record could not be accessed, she would check for a resident's code status in the physical chart. LPN #124 verified the electronic medical record for Resident #14 stated the resident had a DNRCC code status however the paper medical record indicated Resident #14 had a DNRCC-A code status. Interview on [DATE] at 12:58 P.M., Social Worker (SW) #153 revealed Resident #14 had a DNRCC-A code status until she signed onto hospice services and then had elected a DNR-CC code status. SW #153 revealed the resident's family discontinued hospice services after one day, but the DNRCC code status remained in effect. SW #153 revealed the resident's electronic medical record had been updated but the paper medical record had not. SW #153 revealed she had forgotten to update the DNR form in the physical paper chart with the code status change. 2. Review of Resident #40's medical record revealed an admission date of [DATE]. Diagnoses included cystitis, hemiplegia and hemiparesis follow cerebral infarction affecting the left non-dominant side, hyperlipidemia, chronic obstructive pulmonary disease (COPD), and type two diabetes mellitus without complications. Review of Resident #40's Medicare five-day MDS assessment dated [DATE] revealed Resident #40 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11. Review of Resident #40's care plan dated [DATE] revealed Resident #40 had chosen Do Not Resuscitate (DNR) status with interventions that included to not perform cardiopulmonary resuscitation (CPR) if Resident #40 was in cardiac arrest and to have a physician signed DNR identification form to be placed in Resident #40's chart and the physician order written in the medical record. Review of Resident #40's Electronic Medical Record (EMR) physician orders revealed an order dated [DATE] for Resident #40's advanced directives to be a Do Not Resuscitate Comfort Care (DNRCC). Observation on [DATE] at 12:06 P.M. of Resident #40's paper chart revealed the signed DNR order was for a Do Not Resuscitate Comfort Care Arrest (DNR-CCA). Interview on [DATE] at 3:08 P.M. with LPN #125 verified Resident #40's EMR advanced directive was a DNR-CC and Resident #40's paper chart advanced directive was a DNR-CCA. Review of the facility policy titled Residents' Rights Regarding Treatment and Advanced Directives, with a last revision date of [DATE] revealed upon admission, should the resident have an advanced directive, copies will be made and placed on the chart as well as communicated to the staff.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure adequate monitoring for psychotropic medication effectiveness and adverse effects/side effects. This affected three (#03, #09, and #25) of five residents reviewed for unnecessary medications. The facility identified 47 residents receiving psychotropic medications. The facility census was 55.Findings include: 1. Review of the medical record for Resident #03 revealed an admission date of 05/06/26 and a readmission date of 07/10/26. Diagnoses included depression, anxiety, chronic kidney disease, chronic obstructive pulmonary disease, and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the plan of care initiated 05/07/26 revealed the resident was at risk for episodes of anxiety. Interventions revealed to administer medications as ordered and monitor for side effects and effectiveness. Review of the plan of care initiated 07/10/26 revealed the resident exhibited depressive behaviors related to a depression diagnosis. Interventions included administering medications as ordered and for staff to observe for medication effectiveness and adverse reactions. Also, for staff to monitor for increased side effects if the psychotropic medications had been increased or decreased and to notify the physician. Review of the physician orders dated 05/07/26 revealed an order for paroxetine 40 milligrams (mg) daily for major depressive disorder and an order for buspirone five mg, two times a day for anxiety. Review of the nurse's notes revealed the resident discharged to the hospital on [DATE] with chest pain. The resident returned to the facility on [DATE]. Review of the physician orders dated 07/10/26 revealed an order for buspirone five mg, two times a for anxiety and an order for paroxetine 40 mg daily for depression. There were no orders for monitoring for the effectiveness, adverse effects, and side effects of the medication. Review of the Treatment Administration Records (TAR) dated 06/01/26 through 07/12/26 revealed no documentation the staff were monitoring for effectiveness, side effects, and adverse effects of the psychotropic medications. 2. Review of the medical record for Resident #25 revealed he was admitted to the facility on [DATE] with diagnoses that included acute congestive heart failure, dissection of ascending aorta, anxiety disorder and hemorrhagic condition. Review of the MDS assessment dated [DATE] revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 14 that indicated the resident was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #25 required some assistance from staff for activities of daily living (ADLs). Review of the care plan dated 04/21/26 revealed Resident #25 had an ADL self-care performance deficit and used anti-anxiety medications with interventions that included assistance with care, administer anti-anxiety medications as ordered by physician, and monitor for side effects, effectiveness, and adverse reactions related to anti-anxiety medication. Review of the physician orders dated 04/17/26 revealed an order for Hydroxyzine Pamoate oral capsule 25 mg, one capsule to be given by mouth three times a day for anxiety. Review of the physician orders revealed no orders for monitoring for medication effectiveness, adverse effects and side effects. Review of the progress notes dated 04/17/26 through 07/16/26 revealed no documentation Resident #25 was monitored for medication effectiveness, adverse effects and side effects of anti-anxiety medication. Review of the medication administration records and treatment administration records dated 04/17/26 through 07/16/26 revealed no documentation Resident #25 was monitored for medication effectiveness, adverse effects and side effects of anti-anxiety medication. 3. Review of Resident #09's medical record revealed an admission date of 10/27/25. Diagnoses included dementia, Parkinson's disease, dysphagia, depression, anxiety, and adjustment disorder with anxiety. Review of Resident #09's modification of quarterly MDS assessment dated [DATE] revealed Resident #09 had moderately impaired cognition with a BIMS score of 10. Furthermore, Resident #09 required the use of antipsychotic and anticonvulsant medications. Review of Resident #09's care plan dated 05/01/26 revealed Resident #09 used anti-anxiety and antipsychotic medications with interventions that included to administer medications as ordered by the physician, and to monitor for side effects and effectiveness every shift. Review of Resident #09's physician orders revealed an order for Zyprexa five mg with instructions to give one tablet by mouth every morning and at bedtime related to the diagnoses of dementia with agitation. Review of Resident #09's TAR dated 06/01/26 through 07/12/26 revealed no documentation the staff were monitoring for effectiveness, side effects, and adverse effects of the psychotropic medication. Interview on 07/15/26 at 9:49 A.M., the Director of Nursing (DON) verified there was no documentation for Residents #03, #09 and #25 that the nursing staff had been monitoring the psychotropic medications for effectiveness, side effects and adverse effects. Review of the facility policy Use of Psychotropic Medication, dated 10/01/25 revealed the effect of psychotropic medications would be evaluated on an ongoing basis in accordance with nurse assessments and medication monitoring parameter, consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive care plan. The resident's response to the medications, including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record.

Based on resident record review, resident interview, staff interview, and facility policy review, the facility failed to implement a dental care plan for a resident. This affected one (#35) of one resident reviewed for dental services. The facility census was 55.Findings include:Review of the medical record for Resident #35 revealed she was admitted to the facility on [DATE] with diagnoses that included volvulus, intestinal obstruction, and epilepsy.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 12 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #35 required some assistance from staff for activities of daily living (ADLs).Review of the care plan dated 05/02/26 revealed Resident #35 required assistance with ADLs, was at risk for weight loss, chewing problems, and had oral and/or dental health problems with interventions that included refer to dental services, be free from pain, infection and/or bleeding, and coordinate arrangements for dental care.Review of the physician orders 10/06/25 revealed Resident #35 had an order to see ancillary providers including the dentist.Review of the physician orders 10/07/25 revealed Resident #35 had an order for dental consultations as needed.Review of the facility's previous dental visit revealed Resident #35 was last seen by the dentist on 04/02/26.Review of the upcoming dental visit of verified residents to be seen on 07/17/26 revealed Resident #35 was not a designated resident to be seen.Review of the progress note dated 06/22/26 at 7:20 P.M. revealed Resident #35 requested pain medication, hydrocodone-acetaminophen oral tablet 325 milligrams (mg) to be given every six hours as needed for pain, for tooth pain.Review of the progress note dated 06/23/26 at 9:55 P.M. revealed Resident #35 complained of toothache with a pain level of four out of 10 (zero equals no pain and 10 equals the worst pain) and stated, whole mouth hurts.Review of the progress note dated 07/10/26 at 9:05 P.M. revealed Resident #35 requested hydrocodone-acetaminophen with a pain level of 10 out of 10 for tooth pain due to a broken tooth.Review of the progress note dated 07/11/26 at 6:34 A.M. revealed Resident #35 requested hydrocodone-acetaminophen for toothache.Review of the progress note dated 07/11/26 at 6:40 P.M. revealed Resident #35 requested hydrocodone-acetaminophen for tooth pain.Review of the progress note dated 07/12/26 at 6:19 A.M. revealed Resident #35 requested hydrocodone-acetaminophen for tooth.Review of the email correspondence dated 07/13/26 at 12:54 P.M. with the Director of Social Services (DSS) #153 and the dental office, revealed Resident #35 was not listed to be seen for the upcoming visit scheduled on 07/17/26.Review of the email correspondence dated 07/13/26 at 2:01 P.M. with the DSS #153 and the dental office revealed DSS #153 requested to have Resident #35 added to the list to be seen on 07/17/26.Review of the email correspondence dated 07/13/26 at 4:06 P.M. with the DSS #153 and the dental office revealed Resident #35 was not enrolled to be seen by the dental provider and a request for her face sheet and enrollment forms were requested.Interview on 07/13/26 at 10:51 A.M. with Resident #35 revealed she had mouth and back pain and that she had already informed her assigned nurse. Resident #35 revealed the nurse assigned to her had not returned yet with the requested pain medication.Interview on 07/13/26 at 11:30 A.M. with Licensed Practical Nurse (LPN) #124 revealed she was aware of Resident #35's request for pain medication due to tooth pain. LPN #124 revealed she was unaware if Resident #35 was on the upcoming list to be seen by the dentist. Follow-up interview on 07/14/26 at 8:39 A.M. with LPN #124 revealed Resident #35 recently verbalized tooth pain due to a chipped tooth the previous day and that it had been addressed and she was on the list to be seen by dental services on 07/15/26. LPN #124 revealed Resident #35 was excited to be seen by dental due to ongoing issues with her teeth. LPN #124 revealed the facility was responsible for arranging visits with ancillary services such as the dentist.Interview on 07/15/26 at 8:38 A.M, with DSS #153 revealed she was responsible for arranging and scheduling all ancillary visits for residents. DSS #153 revealed if residents experienced pain and required immediate services, she would contact alternative resources, local dentists, for emergencies. DSS #153 revealed sometimes dental could see residents right away but if he could not, appointments would be scheduled with providers who accepted resident's insurance. DSS #153 revealed dental was scheduled to see residents on 07/17/26 and Resident #35 was not on the list to be seen.Follow-up interview on 07/15/26 at 9:31 A.M. with DSS #153 revealed Resident #35 was added to the list, after surveyor intervention, and was informed Resident #35's tooth had been bothering her. DSS #153 revealed she was unaware Resident #35 needed to be seen by the dentist. Review of the facility policy titled Comprehensive Care Plan, revised 10/24/25, revealed the facility had a policy in place that the facility would develop and implement a person-centered care plan with measurable objectives and timeframes.

Based on observation, review of the medical record, interview, and policy review, the facility failed to ensure wound treatments were administered per physician orders. This affected two (#14, #10) of two residents reviewed for pressure ulcers. The facility identified seven residents with pressure ulcers. The facility census was 55. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 05/29/26. Diagnoses included hypertension, atrial fibrillation, dementia, chronic kidney disease, and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident had a stage three pressure ulcer present on admission. The resident was dependent on staff for toileting and transfers. The resident required substantial/maximal assistance for bed mobility. Review of the care plan initiated 05/29/26 revealed the resident was admitted to the facility with a stage three pressure ulcer to the sacrum. Interventions included for staff to complete wound treatment per physician orders. Review of a physician order dated 05/29/26 revealed to cleanse the coccyx with wound cleanser, pat dry, apply calcium alginate with silver, and cover with border foam. Change daily on day shift for wound care. The order was not discontinued until 07/13/26. Review of a wound care progress note dated 06/10/26 revealed the resident had a stage three pressure ulcer to the sacrum measuring 3.5 centimeters (cm) in length, four cm in width, with a depth of 0.1 cm. The wound had 60 percent granulation tissue and 40 percent epithelial tissue with moderate serosanguinous drainage. The surrounding skin was moist and fragile. Review of a physician order dated 06/10/26 revealed a new physician order to cleanse the wound with wound cleanser, apply saline moistened collagen to the wound bed, and cover with silicone super absorbent dressing. Change daily and as needed. Review of the weekly wound care progress notes dated 06/17/26, 06/24/26, and 07/01/26 revealed the stage three pressure ulcer was improving as evidenced by decreases in the size of the wound. Review of the Treatment Administration Record (TAR) dated 06/11/26 through 07/12/26 revealed the nurses had documented completing both the wound treatment using calcium alginate and the wound treatment using collagen. Interview on 07/14/26 at 1:56 P.M., Licensed Practical Nurse (LPN) #125 revealed she thought the two orders were the same and thought it was weird there were two orders. LPN #125 revealed she treated the wound with calcium alginate and had not applied the collagen to the wound bed. LPN #125 revealed one of the orders should have been discontinued. Interview on 07/14/26 at 2:37 P.M., LPN #128 revealed she had been using calcium alginate for the wound treatment. LPN #128 revealed she had incorrectly documented completing both wound treatments and should have gotten the wound treatment orders clarified. Observation on 07/14/26 at 2:48 P.M. of wound care for Resident #14 with LPN #128 revealed the resident had a small pressure ulcer to the sacrum approximately one cm in length, 0.5 cm in width, with a depth of less than 0.1 cm. The wound bed had 100% granulation tissue. There were no signs of infection. The surrounding skin was reddened. LPN #128 cleansed the wound and applied the wound treatment per physician orders. Interview on 07/14/26 at 3:10 P.M., Registered Nurse (RN) #150 revealed the wound should have been treated with collagen and not the calcium alginate. RN #150 revealed the physician order should have been clarified. RN #150 verified she had documented completing both treatments but had only completed the order for the calcium alginate wound treatment. Interview on 07/15/26 at 9:56 A.M., RN #107 verified she had documented completing both wound treatments but had not completed the wound treatment using the collagen. RN #107 revealed the physician should have been contacted to clarify the two different wound care orders. Interview on 07/15/26 at 10:34 A.M., the Director of Nursing (DON) revealed the nurse who entered the new wound care orders should have discontinued the previous wound care orders. Interview on 07/16/26 at 12:47 P.M., LPN #122 revealed she had not noticed there were two different physician orders for wound care and probably assumed they were the same order. LPN #122 revealed she was not sure what treatment she had administered. LPN #122 revealed the orders should have been clarified with the physician. 2. Review of Resident #10's medical record revealed an admission date of 12/30/25. Diagnoses included bipolar disorder with psychotic features. chronic obstructive pulmonary disease (COPD), hypertension, anxiety, muscle weakness, pressure ulcer of the sacral region, hypertensive chronic kidney disease, mild persistent asthma, age-related osteoporosis, and urinary incontinence. Review of Resident #10's quarterly MDS assessment dated [DATE] revealed Resident #10 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11. Furthermore, Resident #10 had one unstageable pressure ulcer. Review of Resident #10's care plan dated 06/24/26 revealed Resident #10 had an actual area of impaired skin integrity as evidenced by an unstageable pressure ulcer at the sacrum that extended to the bilateral buttocks, an abrasion from 06/04/26, and pressure areas to the bilateral heels with interventions that included to keep shoes off, provide non-skid socks to Resident #10, to measure and complete skin grids weekly, and to complete treatments as ordered. Review of Resident #10's physician orders revealed an order with a start date of 07/07/26 with instructions to cleanse the right hell with wound wash, pat dry, apply skin prep and leave open to air twice a day every shift for skin impairment. Observation on 07/13/26 at 9:07 A.M. of Resident #10's feet revealed bilateral dressings in place. The kerlix dressings on Resident #10's bilateral feet appeared soiled as evidenced by yellow discoloration to both dressings. Furthermore, the bilateral dressings were dated 07/12/26. Interview on 07/13/26 at 9:12 A.M. with Licensed Practical Nurse (LPN) #125 verified there were wound dressings on Resident #10's bilateral feet and the dressings appeared to have yellow discoloration. Observation on 07/13/26 at 12:17 P.M. of wound care for Resident #10 completed by LPN #125 and assisted by Certified Nurse Aide (CNA) #200 revealed LPN #125 removed the wound dressing dated 07/12/26. LPN #125 used a saline flush to wash the wound, applied a saline moistened calcium alginate AG dressing to the right foot wound, applied a bordered dressing, and wrapped the foot with kerlix. Interview on 07/13/26 at 12:36 P.M. with LPN #125 verified she applied the saline moistened calcium alginate AG dressing to Resident #10's right foot, applied a bordered dressing, and wrapped the foot with kerlix. Interview on 07/13/26 at 4:33 P.M. with LPN #125 verified Resident #10's physician orders did not match the dressing she applied to Resident #10. LPN #125 stated the wound Nurse Practitioner (NP) gave her a verbal order to begin the same wound dressing as the left heel for the right heel if the right heel wound opened. LPN #125 verified there was no documentation in Resident #10's medical record regarding this order. Interview on 07/15/26 at 3:48 P.M. with RN #107 verified she had completed Resident #10's heel wound dressing change on 07/12/26. RN #107 verified the order read to cleanse the right hell with wound wash, pat dry, apply skin prep and leave open to air twice a day every shift for skin impairment. RN #107 verified she applied the same dressing as the left foot to the right foot because the right foot heel wound opened. RN #107 stated she should have updated the physician to obtain an order for a new wound dressing. Review of the facility policy titled Wound Treatment Management with a revision date of 12/01/25 revealed wound treatments would be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes. In the absence of treatment orders, the licensed nurse would notify the physician to obtain treatment orders. Further review of the policy revealed treatments would be documented on the treatment administration record.

Based on observation, medical record review, staff interview, review of the manufacturer's instructions for the mechanical lift slings, and policy review, the facility failed to ensure monitoring was in place for mechanical lift slings utilized in the facility. This affected two (#01 and #34) of two residents reviewed for mechanical lift slings. The facility identified 12 residents requiring the use of slings for mechanical lift transfers. The facility census was 55.Findings include:1. Review of Resident #01's medical record revealed an admission date of 01/09/25. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, type two diabetes mellitus, aphasia, muscle weakness, and hypertension.Review of Resident #01's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 had severely impaired cognitive skills for daily decision making. Furthermore, Resident #01 was dependent for chair to bed and bed to chair transfers.Review of Resident #01's care plan dated 07/13/26 revealed Resident #01 required assistance for activities of daily living (ADL's) related to hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side with interventions that included to use two staff for mechanical lift transfers, and resident was dependent for all ADLs.Review of Resident #01's physician orders revealed an order with a revision date of 01/10/25 that instructed staff to use a mechanical lift for all transfers.2. Review of Resident #34's medical record revealed an admission date of 02/02/23. Diagnoses included flaccid hemiplegia affecting the left dominant side, muscle weakness, chronic kidney disease stage two, and developmental disorder of speech and language.Review of Resident #34's quarterly MDS assessment dated [DATE] revealed Resident #34 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13. Furthermore, Resident #34 was dependent for chair to bed and bed to chair transfers.Review of Resident #34's care plan dated 05/02/26 revealed Resident #34 required assistance for ADLs related to left hemiplegia and lumbar disc disorder with an intervention that included to utilize the mechanical lift for transfers.Review of Resident #34's physician orders revealed an order with a date of 05/31/24 that instructed staff to use a mechanical lift for all transfers.Observation on 07/15/26 at 10:46 A.M. of a mechanical lift transfer for Resident #34 completed by Certified Nursing Assistant (CNA) #110 and CNA #101 revealed Resident #34's mechanical lift sling was worn and discolored on the fabric of the sling that supported the weight of the resident and where the sling attached to the mechanical lift.Interview on 07/15/26 at 10:48 A.M. with CNA #110 and CNA #101 verified the mechanical lift sling was worn and discolored on the fabric of the sling that supported the weight of the resident and where the sling attached to the mechanical lift.Observation and concurrent interview on 07/15/26 at 11:09 A.M. with Laundry Attendant (LA) #148 verified four mechanical lift slings that were cleaned and hanging in the laundry room had worn straps and were discolored. One of the slings had a hole in the fabric. LA #148 verified the CNAs in the facility should be monitoring the slings prior to each use. LA #148 stated she was unaware of any documentation regarding the monitoring of the mechanical lift slings in the facility and stated slings would be disposed of if they noticed any damage to them.Observation and concurrent interview on 07/15/26 at 11:31 A.M. with CNA #139 verified the mechanical lift sling under Resident #38 was frayed and discolored from use.Interview on 07/15/26 at 1:37 P.M. with the Director of Nursing (DON) verified laundry was responsible for monitoring the mechanical lift slings. Furthermore, the DON verified there was no documentation in the facility regarding the monitoring of slings and the facility did not have any documentation regarding what size slings should be used for each resident.Observation and concurrent interview on 07/15/26 at 2:53 P.M. with Licensed Practical Nurse (LPN) #124 verified the mechanical lift sling under Resident #01 had a hole in it and it was worn and discolored on the fabric of the sling that supported the weight of the resident and attached the sling to the mechanical lift.Review of the manufacturers owner's operator and maintenance manual revealed after each laundering (in accordance with instructions on the sling) slings are to be inspected for wear, tears, and loose stitching. Furthermore, bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury and are to be discarded immediately.Review of the facility policy titled Safe Resident Handling/Transfers, revised on 10/01/25 revealed the staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly. Damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility policy. The facility will ensure that there are appropriate amounts of varying sizes of slings to accommodate residents, and that residents will be measured correctly as per the manufacturer's instructions on proper sling sizes. Slings will be laundered according to the manufacturer's instructions, and any damaged, broken, or unsafe slings will be removed from service or replaced.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure oxygen orders specified liters per minute (lpm). This affected one (#10) of three residents reviewed for respiratory care. The facility census was 55.Findings include:Review of Resident #10's medical record revealed an admission date of 12/30/25. Diagnoses included bipolar disorder with psychotic features. chronic obstructive pulmonary disease (COPD), hypertension, anxiety, muscle weakness, pressure ulcer of the sacral region, hypertensive chronic kidney disease, mild persistent asthma, age-related osteoporosis, and urinary incontinence. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11. Furthermore, Resident #10 required the use of oxygen therapy. Review of Resident #10's care plan dated 06/24/26 revealed Resident #10 had altered respiratory status or difficulty breathing related to asthma and COPD with interventions that included to provide oxygen as ordered and to observe, document, and report abnormal breathing patterns to the Medical Director.Review of Resident #10's physician orders revealed an order dated 01/02/26 that read oxygen via nasal cannula at bedtime and as needed for shortness of breath every shift.Observation on 07/13/26 at 9:07 A.M. revealed Resident #10 to be receiving oxygen via nasal cannula at 2.5 lpm.Interview on 07/13/26 at 9:12 A.M. with Licensed Practical Nurse (LPN) #125 verified Resident #10 was receiving oxygen via nasal cannula at 2.5 lpm.Interview on 07/13/26 at 9:14 A.M. with LPN #125 verified Resident #10's physician order did not specify the liter flow of oxygen to be delivered.Review of the facility policy titled Oxygen Administration, with a revision date of 01/04/26 revealed oxygen is administered to residents who need it, consistent with professional standards of practice, comprehensive person-centered care plans, and the resident's goals and preferences.

Based on resident record review, resident interview, staff interview, and facility policy review, the facility failed to ensure timely dental services. This affected one (#35) of one resident reviewed for dental services. The facility census was 55. Findings include:Review of the medical record for Resident #35 revealed she was admitted to the facility on [DATE] with diagnoses that included volvulus, intestinal obstruction, and epilepsy.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 12 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #35 required some assistance from staff for activities of daily living (ADLs).Review of the care plan dated 05/02/26 revealed Resident #35 required assistance with ADLs, was at risk for weight loss, chewing problems, and had oral and/or dental health problems with interventions that included refer to dental services, be free from pain, infection and/or bleeding, and coordinate arrangements for dental care.Review of the physician orders 10/06/25 revealed Resident #35 had an order to see ancillary providers including the dentist.Review of the physician orders 10/07/25 revealed Resident #35 had an order for dental consultations as needed.Review of the facility's previous dental visit revealed Resident #35 was last seen by the dentist on 04/02/26.Review of the upcoming dental visit of verified residents to be seen on 07/17/26 revealed Resident #35 was not a designated resident to be seen.Review of the progress note dated 06/22/26 at 7:20 P.M. revealed Resident #35 requested pain medication, hydrocodone-acetaminophen oral tablet 325 milligrams (mg) to be given every six hours as needed for pain, for tooth pain.Review of the progress note dated 06/23/26 at 9:55 P.M. revealed Resident #35 complained of toothache with a pain level of four out of 10 (zero equals no pain and 10 equals the worst pain) and stated, whole mouth hurts.Review of the progress note dated 07/10/26 at 9:05 P.M. revealed Resident #35 requested hydrocodone-acetaminophen with a pain level of 10 out of 10 for tooth pain due to a broken tooth.Review of the progress note dated 07/11/26 at 6:34 A.M. revealed Resident #35 requested hydrocodone-acetaminophen for toothache.Review of the progress note dated 07/11/26 at 6:40 P.M. revealed Resident #35 requested hydrocodone-acetaminophen for tooth pain.Review of the progress note dated 07/12/26 at 6:19 A.M. revealed Resident #35 requested hydrocodone-acetaminophen for tooth.Review of the email correspondence dated 07/13/26 at 12:54 P.M. with the Director of Social Services (DSS) #153 and the dental office, revealed Resident #35 was not listed to be seen for the upcoming visit scheduled on 07/17/26.Review of the email correspondence dated 07/13/26 at 2:01 P.M. with the DSS #153 and the dental office revealed DSS #153 requested to have Resident #35 added to the list to be seen on 07/17/26.Review of the email correspondence dated 07/13/26 at 4:06 P.M. with the DSS #153 and the dental office revealed Resident #35 was not enrolled to be seen by the dental provider and a request for her face sheet and enrollment forms were requested.Interview on 07/13/26 at 10:51 A.M. with Resident #35 revealed she had mouth and back pain and that she had already informed her assigned nurse. Resident #35 revealed the nurse assigned to her had not returned yet with the requested pain medication.Interview on 07/13/26 at 11:30 A.M. with Licensed Practical Nurse (LPN) #124 revealed she was aware of Resident #35's request for pain medication due to tooth pain. LPN #124 revealed she was unaware if Resident #35 was on the upcoming list to be seen by the dentist. Follow-up interview on 07/14/26 at 8:39 A.M. with LPN #124 revealed Resident #35 recently verbalized tooth pain due to a chipped tooth the previous day and that it had been addressed and she was on the list to be seen by dental services on 07/15/26. LPN #124 revealed Resident #35 was excited to be seen by dental due to ongoing issues with her teeth. LPN #124 revealed the facility was responsible for arranging visits with ancillary services such as the dentist.Interview on 07/15/26 at 8:38 A.M, with DSS #153 revealed she was responsible for arranging and scheduling all ancillary visits for residents. DSS #153 revealed if residents experienced pain and required immediate services, she would contact alternative resources, local dentists, for emergencies. DSS #153 revealed sometimes dental could see residents right away but if he could not, appointments would be scheduled with providers who accepted resident's insurance. DSS #153 revealed dental was scheduled to see residents on 07/17/26 and Resident #35 was not on the list to be seen.Follow-up interview on 07/15/26 at 9:31 A.M. with DSS #153 revealed Resident #35 was added to the list, after surveyor intervention, and was informed Resident #35's tooth had been bothering her. DSS #153 revealed she was unaware Resident #35 needed to be seen by the dentist. Review of the facility document titled Ancillary Services undated, revealed the facility had a policy in place that the facility would assist residents in obtaining routine and emergency ancillary services as needed. Review of the policy revealed routine dental services and emergency dental services such as an episode of acute pain in teeth, gums or palate, broken or otherwise damaged teeth or any other problem of the oral cavity. Review of the document revealed the facility did not implement the policy.

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure infection control standards were maintained during wound care. Furthermore, the facility failed to implement Enhanced Barrier Precautions (EBP) when the staff failed to wear the appropriate personal protective equipment (PPE) for resident care when the resident was identified as requiring EBP. This affected three (#10, #33 and #14) of three residents reviewed for infection control practices. The facility identified 13 residents in the facility requiring EBP. The facility census was 55.Findings include: 1. Review of Resident #10's medical record revealed an admission date of 12/30/25. Diagnoses included bipolar disorder with psychotic features. chronic obstructive pulmonary disease (COPD), hypertension, anxiety, muscle weakness, pressure ulcer of the sacral region, hypertensive chronic kidney disease, mild persistent asthma, age-related osteoporosis, and urinary incontinence. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11. Furthermore, Resident #10 had one unstageable pressure ulcer. Review of Resident #10's care plan dated 06/24/26 revealed Resident #10 required Enhanced Barrier Precautions (EBP) related to wounds with interventions that included for staff to wear gloves and gown when providing high-contact resident care activities such as when providing incontinence care or wound care and for staff to clean their hands prior to entering and when leaving Resident #10's room. Review of Resident #10's physician orders revealed an order with a start date of 07/07/26 with instructions to cleanse the right hell with wound wash, pat dry, apply skin prep and leave open to air twice a day every shift for skin impairment. Further review of Resident #10's physician orders for the month of July 2026 revealed no order for EBP. Observation on 07/13/26 at 9:24 A.M. of Resident #10's room and door revealed no signage posted regarding EBP. Interview on 07/13/26 at 9:26 A.M. with Licensed Practical Nurse (LPN) #125 verified Resident #10 did not have a physician order for EBP and should have due to the wounds on Resident #10's body. Furthermore, LPN #125 verified no signage was posted regarding EBP for Resident #10 on or near Resident #10's room. Observation on 07/13/26 at 9:07 A.M. of Resident #10's feet revealed bilateral dressings in place. The kerlix dressings on Resident #10's bilateral feet appeared soiled as evidenced by yellow discoloration to both dressings. Furthermore, the bilateral dressings were dated 07/12/26. Interview on 07/13/26 at 9:12 A.M. with Licensed Practical Nurse (LPN) #125 verified there were wound dressings on Resident #10's bilateral feet and the dressings appeared to have yellow discoloration. Observation on 07/13/26 at 12:17 P.M. of wound care for Resident #10 completed by LPN #125 and assisted by Certified Nurse Aide (CNA) #200 revealed LPN #125 and CNA #200 did not wear a gown as required during wound care. Further observation revealed LPN #125 applied gloves, removed the soiled dressing from Resident #10's right foot and with the same gloves opened an abdominal pad (ABD) and saline flush to cleanse the wound. While flushing the wound, LPN #125 touched the flush to the wound and patted the wound dry with the ABD. Without changing gloves, LPN #125 opened a calcium alginate AG dressing. LPN #125 took off the gloves and without performing hand hygiene, applied a new pair of gloves. LPN #125 used the same flush that touched Resident #10's wound to moisten the calcium alginate AG dressing and applied the dressing to the wound. LPN #125 then applied a silicone super absorbent bordered dressing and wrapped the dressing with kerlix. LPN #125 took off her gloves and without performing hand hygiene, put on another pair of gloves. LPN #125 took off Resident #10's left heel wound dressing. LPN #125 changed gloves without performing hand hygiene in between and with a new pair of gloves, opened the calcium alginate AG. LPN #125 moistened the calcium alginate AG with a saline flush and applied the dressing over an old dressing that remained on Resident #10's foot. With surveyor intervention, LPN #125 and CNA #200 removed the old dressing and applied a new clean dressing to Resident #10's heel. Interview on 07/13/26 at 12:36 P.M. with LPN #125 verified the above findings. 2. Review of Resident #33's medical record revealed an admission date of 02/25/26. Diagnoses included brief psychotic disorder, anemia, depression, hypertension, edema, and vitamin D deficiency, and muscle weakness. Review of Resident #33's quarterly MDS assessment dated [DATE] revealed Resident #33 had severely impaired cognition with a BIMS score of four. Review of Resident #33's care plan dated 07/13/26 revealed Resident #33 required isolation/quarantine related to shingles or chicken pox with interventions that included to maintain isolation/quarantine by staff during the acute infection period and to discontinue isolation/quarantine as soon as the infection no longer exists. Review of Resident #33's physician orders revealed no order for contact precautions. Further review of the physician orders revealed an order for valacyclovir HCL with instructions to administer one one-gram tablet by mouth every morning and at bedtime for shingles for two days. Interview on 07/16/26 at 10:51 A.M. with the Director of Nursing (DON) verified Resident #33 was on contact precautions related to shingles and did not have a physician order for contact precautions. 3. Review of the medical record for Resident #14 revealed an admission date of 05/29/26. Diagnoses included hypertension, atrial fibrillation, dementia, chronic kidney disease, and congestive heart failure. Review of the admission MDS assessment dated [DATE] revealed the resident had impaired cognition. The resident had a stage three pressure ulcer present on admission. Review of the care plan initiated 05/29/26 revealed the resident was admitted to the facility with a stage three pressure ulcer. One intervention revealed for staff to maintain enhanced barrier precautions per facility protocol. Review of a physician orders dated 05/29/26 through 07/12/26 revealed no physician orders for enhanced barrier precautions. Observation on 07/13/26 at 10:18 A.M., revealed there was no sign posted on the resident's door indicating the resident was on enhanced barrier precautions. Interview on 07/13/26 at 10:18 A.M., LPN #128 verified there was no sign posted on the resident's door alerting staff of the required enhanced barrier precautions. LPN #128 revealed Resident #14 had a pressure ulcer and should have been placed on enhanced barrier precautions. Review of the facility policy Enhanced Barrier Precautions, dated 07/13/22, revealed staff would use gowns and gloves for high-contact resident care activities to prevent the transmission of novel or targeted multidrug-resistant organisms. High-contact resident care activities included dressing, bathing, transferring, providing hygiene, changing linens, changing incontinence briefs, providing toileting assistance, wound care, and device care. Further review of the policy revealed staff would obtain a physician order for residents placed on enhanced barrier precautions. Additionally, clear signage would be posted on the door or wall outside of the resident room indicating the type of precautions, the required personal protective equipment (PPE), and the high-contact resident care activities requiring the use of gowns and gloves.

Based on closed medical record review, interview, and review of the facility policy, the facility failed to ensure medications were administered as physician ordered. This affected one (#54) of three residents reviewed for medication administration. The facility census was 53.Findings include:Review of the closed medical record for Resident #54 revealed an admission date of 02/27/26 and a discharge date of 05/24/26. Diagnoses included malignant neoplasm of pancreas, paranoid schizophrenia, and Type II diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition as evidence by a Brief Interview for Mental Status (BIMS) score of 06. This resident was assessed to require substantial assistance with activities of daily living (ADLs).Review of the hospice admission orders dated 02/27/26 revealed Resident #54 had orders for Cardizem (treats cardiovascular conditions) 120 milligrams (mg) daily, insulin glargine 100 units (u) per milliliter (ml) inject 40 units into the skin two times daily, insulin lispro 100 u/ml follow sliding scale, levothyroxine (used to treat hypothyroidism) 25 micrograms (mcg) take one tablet by mouth daily, lisinopril (treats high blood pressure) 10 mg take one tablet by mouth daily, Latuda (antipsychotic) 40 mg take one tablet by mouth daily, Prilosec 20 mg take one capsule by mouth daily, pantoprazole 40 mg take one tablet by mouth two times daily, risperidone (antipsychotic) three mg take one tablet daily, and rivaroxaban (used to treat and prevent blood clots) 20 mg take one tablet by mouth daily.Review of the physician orders for February 2026 revealed Resident #54 had no orders in place for Cardizem, insulin glargine, insulin lispro, levothyroxine, lisinopril, Latuda, Prilosec, pantoprazole, risperidone, or rivaroxaban.Review of the Medication Administration Record (MAR) revealed no evidence Resident #54 was administered Cardizem, insulin glargine, insulin lispro, levothyroxine, lisinopril, Latuda, Prilosec, pantoprazole, risperidone, or rivaroxaban on 02/27/26, 02/28/26, 03/01/26, or 03/02/26.Interview on 05/28/26 at 10:20 A.M. with the Director of Nursing (DON) revealed Resident #54 admitted to the facility from home. The DON stated Hospice was involved due to his terminal pancreatic cancer diagnosis. Further interview with the DON revealed on 02/27/26, the resident's date of admission, Licensed Practical Nurse (LPN) #218 did not transcribe the medications because there was confusion over discontinued orders by Hospice. The DON verified Resident #54 did not receive any physician ordered medications on 02/27/26, 02/28/26, 03/01/26, or 03/02/26.Interview on 05/28/26 at 11:00 A.M. with Resident #54's Power of Attorney (POA) revealed the resident was removed from his home due to not being able to take care of himself. Resident #54 admitted to the facility to have a Hospice consult due to his terminal diagnosis of pancreatic cancer. Resident #54's POA further stated the resident was on medications; however, she was unsure of what medications he was on before admission to the facility. Resident #54's POA was not aware the resident was not given any medication from 02/27/26 through 03/02/26.Interview on 05/28/26 at 1:01 P.M. with Social Services (SS) #507 revealed Resident #54 was admitted to the facility from home. She was notified of Resident #54 needing placement on 02/25/26. SS #507 further stated when Resident #54 came to the facility, he did not bring any outside medications; however, he had a medication list from his oncologist. SS #507 stated the facility nurse and Hospice went through the medications together and the facility filled out a checklist, which included medication orders needing verified by the physician and transcribed into the Electronic Medical Record (EMR). SS #507 confirmed Resident #54 came to the facility with physician orders for Cardizem, insulin glargine, insulin lispro, levothyroxine, lisinopril, Latuda, Prilosec, pantoprazole, risperidone, and rivaroxaban.Interview on 05/28/26 at 1:39 P.M. with Hospice Registered Nurse (HRN) #219 revealed she was the nurse who admitted Resident #54 onto Hospice services. HRN #219 stated the medications that were ordered were based off Resident #54's oncologist's medication list. HRN #219 stated she verified the medication orders with LPN #218 and confirmed Resident #54 should have received the ordered medications the day he admitted to the facility.Review of the facility policy titled, admission Order Procedure, undated, revealed residents who were admitted to the facility may come with discharge orders from the community physician. Any nurse may transcribe the orders, however, the nurse completing the admission was responsible for verifying the orders were transcribed correctly. admission orders should be written on the preprinted physician order sheet as soon as possible after the resident arrived on the unit and faxed to the pharmacy. admission orders were to be verified with the attending physician and a notation made by the nurse. The pharmacy may be notified by phone that new admission orders were being faxed. The pharmacy should be notified of the next scheduled dose of diabetic medications.This deficiency represents noncompliance investigated under Complaint Number 2993954.

Based on closed medical record review, staff interview and review of facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (#54) of three residents reviewed for medication administration. The facility census was 53.Findings include:Review of the closed medical record for Resident #54 revealed an admission date of 02/27/26 and a discharge date of 05/24/26. Diagnoses included malignant neoplasm of pancreas, paranoid schizophrenia, and Type II diabetes mellitus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition as evidence by a Brief Interview for Mental Status (BIMS) score of 06. This resident was assessed to require substantial assistance with activities of daily living (ADLs).Review of the Hospice admission notes revealed Resident #54 was admitted to Hospice on 02/27/26. Resident #54 had orders to receive insulin glargine 100 units (u) per milliliter (ml); inject 40 units into the skin two times daily. Further review revealed an order for insulin lispro 100 u/ml; following a sliding scale of zero to twenty units.Review of the physician orders for February 2026 revealed Resident #54 had no orders for insulin glargine or insulin lispro 100 u/ml.Review of the Medication Administration Record (MAR) revealed no evidence Resident #54 was administered insulin glargine on 02/27/26, 02/28/26, 03/01/26, or 03/02/26. Further review revealed no evidence Resident #54 was administered insulin lispro or the facility completed Finger Stick Blood Sugars (FSBS) to determine whether the resident required the administration of insulin lispro or the dosage needed based on the sliding scale parameters on 02/27/26, 02/28/26, 03/01/26 or 03/02/26. Interview on 05/28/26 at 10:20 A.M. with the Director of Nursing (DON) revealed Resident #54 admitted to the facility from home. The DON stated Hospice was involved due to his terminal pancreatic cancer diagnosis. Further interview with the DON revealed on 02/27/26, the resident's date of admission, Licensed Practical Nurse (LPN) #218 did not transcribe the medications because there was confusion over discontinued orders by Hospice. The DON verified Resident #54 did not receive any insulin or have his FSBS obtained to monitor for the need of sliding scale insulin from 02/27/26 through 03/03/26.Interview on 05/28/26 at 11:00 A.M. with Resident #54's Power of Attorney (POA) revealed the resident was removed from his home due to not being able to take care of himself. Resident #54 admitted to the facility to have a Hospice consult due to his terminal diagnosis of pancreatic cancer. Resident #54's POA further stated the resident was on medications; however, she was unsure of what medications he was on before admission to the facility. Resident #54's POA was not aware the resident was not given any insulin or had his blood sugar monitored from 02/27/26 through 03/02/26.Interview on 05/28/26 at 1:01 P.M. with Social Services (SS) #507 revealed Resident #54 was admitted to the facility from home. She was notified of Resident #54 needing placement on 02/25/26. SS #507 further stated when Resident #54 came to the facility, he did not bring any outside medications; however, he had a medication list from his oncologist. SS #507 stated the facility nurse and Hospice went through the medications together and the facility filled out a checklist, which included medication orders needing verified by the physician and transcribed into the Electronic Medical Record (EMR). SS #507 confirmed Resident #54 came to the facility with physician orders for insulin.Interview on 05/28/26 at 1:39 P.M. with Hospice Registered Nurse (HRN) #219 revealed she was the nurse who admitted Resident #54 onto Hospice services. HRN #219 stated the medications that were ordered were based off Resident #54's oncologist's medication list. HRN #219 stated she verified the medication orders with LPN #218 and confirmed Resident #54 should have received insulin as ordered.Review of the facility policy titled, admission Order Procedure, undated, revealed residents who were admitted to the facility may come with discharge orders from the community physician. Any nurse may transcribe the orders, however, the nurse completing the admission was responsible for verifying the orders were transcribed correctly. admission orders should be written on the preprinted physician order sheet as soon as possible after the resident arrived on the unit and faxed to the pharmacy. admission orders were to be verified with the attending physician and a notation made by the nurse. The pharmacy may be notified by phone that new admission orders were being faxed. The pharmacy should be notified of the next scheduled dose of diabetic medications.This deficiency represents noncompliance investigated under Complaint Number 2993954.

Based on facility bus observation, staff interviews, medical record review, review of the incident log, review of the facility internal investigation, review of facility provided photographs, review of hospital records, review of facility bus safety manual, review of facility bus wheelchair restraint user manual, review of wheelchair manual, and review of facility policy, the facility failed to ensure Resident #11, who was identified to be dependent on staff for all aspects of care, was safely secured with a seat belt and positioned properly in a wheelchair during a transport on the facility bus. This resulted in Immediate Jeopardy and the potential for serious life-threatening injuries when Resident #11 fell out of her wheelchair mid-transport and landed on the floor, sustaining a subdural hematoma and subarachnoid hemorrhage to the left side of her head, requiring admission to the intensive care unit (ICU) for monitoring. This affected one (#11) of three residents reviewed for use of assisted device during transportation. The facility identified a total of 47 residents who utilized a wheelchair. The facility census was 56. On 04/17/25 at 11:55 A.M., the Administrator, Director of Nursing (DON), Regional Director of Clinical Services (RDCS) #884 were informed that Immediate Jeopardy began on 03/26/25 when Transportation Driver #830 failed to safely secure and position Resident #11's wheelchair appropriately. During the trip, Resident #11's left wheelchair arm broke and Resident #11 fell out of her wheelchair and onto the floor of the bus. Resident #11 hit her head and Transportation Driver #830 drove her to a local emergency room (ER) for evaluation. A computed tomography (CT) scan of Resident #11's head revealed a left subdural hematoma and subarachnoid hemorrhage, and Resident #11 was subsequently admitted to the ICU. The Immediate Jeopardy was removed on 03/28/25 when the facility implemented the following corrective actions: o On 3/26/25 at 5:10 P.M., the DON was notified of Resident #11's fall in the facility's bus and subsequent injury by Transportation Driver #830. o On 03/26/25 at 5:10 P.M., Resident #11's son was present at the appointment and was notified of the incident by Transportation Driver #830. o On 03/26/25 at 5:15 P.M., the facility initiated an incident report following the DON's notification of the incident. The incident report was completed on 03/28/25 after the resident's return to the facility. o On 03/26/25 at 5:43 P.M., Resident #11's provider, Certified Nurse Practitioner (CNP) #885, was notified of Resident #11's injury on the facility transport bus. This notification was completed by the DON. o On 03/26/25 at approximately 6:00 P.M., a written statement was obtained by Transportation Driver #830 following the incident upon his return to the facility. o On 03/27/25, all in-house wheelchairs were assessed by Maintenance Supervisor #880, Therapy Director #824, ADON #848, and Minimum Data Set (MDS) Nurse #835 for proper functioning. Any issues or concerns were corrected at the time of the assessments. All assessments were completed on 03/27/25. o Transportation Driver #830's personnel file was reviewed by the Administrator on 03/27/25. Transportation Driver #830 had no previous disciplinary action. Disciplinary action was given by the Administrator on 03/27/25. o On 03/27/25, Maintenance Supervisor #880 completed an inspection of the facility bus, including the lift, seatbelts and restraint mechanisms to assess for any malfunctioning or fraying of belts. There were no abnormalities identified; the bus was in good working order. o The facility identified three additional staff members, Certified Nurse Aide (CNA) #854, CNA #853, and Housekeeping Aide #866, approved to drive the facility bus. The additional bus drivers' personnel files were reviewed by the Administrator on 3/27/25 for bus safety and training. The personnel files were complete with no negative findings. o All facility bus drivers were re-educated by Maintenance Supervisor #880 on 3/27/25 with emphasis on proper securement of residents, proper positioning of residents in wheelchairs, and proper use of the bus's lifting mechanism. This included a step-by-step instruction on proper technique, and a return demonstration by each driver. o On 03/27/25, the bus driver re-education records were reviewed by the Administrator. All driver re-education was complete with no negative findings. o All staff education was provided on the facility's abuse and neglect policy by the DON on 03/27/25. o On 03/27/25, Resident #11's family requested a new wheelchair for Resident #11. Resident #11 was provided a new Broda (specialty wheelchair) upon her return from the hospital on [DATE]. This was completed by the Administrator. Beginning on 03/27/25, Maintenance Supervisor #880 began weekly observational audits of bus drivers for proper lift use, proper securement of residents using four-point base restraints and proper use of seat belt restraints. These audits will be completed three times weekly for four weeks. The results of the audits will be reviewed in the facility's Quality Assurance Performance Improvement (QAPI) meeting. Beginning on 03/27/25, Maintenance Supervisor #880 began weekly re-education with the facility bus drivers regarding return demonstration. This re-education will be completed for four weeks. The results of the audits will be reviewed in the facility's QAPI meeting. Beginning on 03/27/25, Maintenance Supervisor #880 and Therapy Director #824 began monthly wheelchair audits. Concerns with proper functioning of equipment were corrected at the time of the audit. The audits will be completed monthly for three months duration. The results of the audits will be reviewed in the facility's QAPI meeting. o On 03/28/25, an Ad Hoc QAPI meeting was held. In attendance were the Administrator, Medical Director (MD) #886, DON, RDCS #884, Dietary Manager #836, MDS Nurse #835, ADON #848, Human Resources Manager #863, Therapy Manager #824, Maintenance Supervisor #880, Social Service Director/Activity Director (SSD/AD) #812, Activity Aide #801, and CNP #885. o On 3/28/25 at 10:58 P.M., upon her return to the facility, Resident #11 was comprehensively assessed. This included a head-to-toe assessment and pain assessment. This was completed by Registered Nurse (RN) #857. o On 3/28/25, upon return to the facility, neurological checks for Resident #11 were initiated by RN #857 for a duration of 72 hours. The series of neurological checks were completed on 04/01/25 by a staff nurse. This was completed on 03/31/25. There were no identified physical or psychosocial changes. Resident #11 remained at her baseline. o On 03/28/25, the facility began 72-hour monitoring. Resident #11 was comprehensively assessed every shift by the direct care nursing staff. This was completed on 03/31/25, with the documentation overseen by the DON. There were no identified physical or psychosocial changes. Resident #11 remained at her baseline. o On 03/31/25, the facility began a daily comprehensive assessment of Resident #11, with the documentation overseen by the DON. There have been no negative findings or declines in condition. Although the Immediate Jeopardy was removed on 03/28/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #11 revealed an admission date of 01/09/25 and diagnoses including left non-dominant side hemiplegia (paralysis) and hemiparesis (muscle weakness), dysphagia following cerebral infarction (stroke), dysarthria (difficulty speaking) following cerebral infarction, diabetes mellitus with diabetic polyneuropathy, generalized muscle weakness, and lack of coordination. Review of the MDS quarterly assessment dated [DATE] revealed Resident #11 had unclear speech and rarely/never understands others or was understood by others. Resident #11 had short- and long-term memory deficits. Resident #11 had impairment of upper and lower extremity on one side and was dependent on staff for activities of daily living (ADLs). Resident #11 was unable to ambulate or stand on her own. Resident #11 utilized a wheelchair for mobility. Review of the care plan revised 04/15/25 revealed Resident #11 required assistance for ADLs due to hemiparesis and history of a cerebrovascular accident (stroke). Listed interventions included utilizing a wheelchair for mobility and transferring Resident #11 by using two staff and a Hoyer lift (a mechanical lift used by caregivers to safely transfer those with limited mobility). An additional care plan focus, revised 04/16/25, revealed Resident #11 had the potential for bleeding or hemorrhage related to previous use of blood thinning medications. Interventions included to protect Resident #11 from falls or injury as much as possible. Review of physician's order dated 02/14/25 revealed Resident #11 had an order for one tablet of Aspirin 81 milligram (mg) tablets every morning for anticoagulation therapy and an order for one tablet of Plavix (antiplatelet medication) 75 mg once daily for a history of a cerebrovascular accident. Review of a nursing note dated 03/19/25 revealed Resident #11 had an appointment scheduled with a pulmonologist on 03/26/25 at 2:00 P.M. The facility was to transport Resident #11 to her appointment with her son to accompany. Review of incident logs from February 2025 to April 2025 revealed on 03/26/25 Resident #11 had an unwitnessed fall on the facility transport van and sustained a bruise. Review of an incident report dated 03/26/25 timed at 5:15 P.M. revealed Resident #11 had an unwitnessed fall during transportation outside of the facility. Transportation Driver #830 reported Resident #11 fell out of the wheelchair during a transport to an outside appointment and Transportation Driver #830 drove her to a nearby hospital to assist with getting Resident #11 off the floor of bus. Resident #11 was taken into the emergency room (ER) for evaluation and admitted . Resident #11 was noted to have a bruise to the top of her scalp. Resident #11 was alert to person and unable to give a description of what had happened. The DON, Resident #11's son, and Resident #11's provider (CNP #885), were notified of the incident. Review of a witness statement dated 03/26/25 for Transportation Driver #830 revealed he had gotten Resident #11 onto the bus at approximately 12:50 P.M. Transportation Driver #830 stated when he loaded Resident #11 in her wheelchair into the bus, she was tilted back so she was hooked up long ways, facing the passenger side of the bus, so she could be comfortably tilted back. Transportation Driver #830 stated he felt the seat belt was in the way and Resident #11's upper body was not going to move anywhere. Transportation Driver #830 applied the four-point wheelchair securing hooks onto the base of her wheelchair. Transportation Driver #830 stated when they arrived at the first appointment, the doctor wanted an x-ray examination completed so they were sent to a local hospital. Transportation Driver #830 stated Resident #11 was re-loaded onto the transportation bus and during transport he heard a noise. Transportation Driver #830 stated he checked his mirrors and observed Resident #11 on the floor of the bus. Transportation Driver #830 stated the hospital was about three minutes away, so he kept driving to the hospital to get help. Upon arrival, Resident #11 was taken into the ER for assessment. Transportation Driver #830 stated he waited at the hospital for approximately one hour until a nurse dismissed him. Review of the hospital trauma and surgical history and physical assessment dated [DATE] timed at 8:54 P.M. revealed Resident #11 presented to the hospital post-fall out of a wheelchair. Resident #11 was traveling on a bus to the doctor's office when she fell out of her wheelchair, striking her face on the floor of the bus. There was no loss of consciousness. A CT scan was completed with findings of 0.4 centimeter (cm) subdural hematoma with trace subarachnoid hemorrhage within the left temporal sulci (groove located on the outer surface of temporal [NAME]). There were noted abrasions to Resident #11's left forehead and nose. Resident #11 had noted history of cerebrovascular incident with noted flaccidity of left upper extremity and left lower extremity. Resident #11 was noted to be on aspirin and Plavix. Resident #11 was admitted to the intensive care unit (ICU) and would have a neurosurgery consultation. Review of hospital imaging results of a CT scan of Resident #11's head dated 03/27/25 at 12:41 A.M. revealed a stable appearance of the left-sided subdural hematoma measuring 2.48 millimeters (mm) in thickness. No new hemorrhage was seen, and an area of chronic infarction was noted. Review of a general note dated 03/27/25 timed at 2:36 A.M. revealed Resident #11 had fallen out of wheelchair during transport to or from an appointment and had hit her head. Resident #11 was noted to be on blood thinners and was sent to the emergency room for evaluation. There had not been an update since shift change. Review of the hospital neurosurgery consult dated 03/27/25 timed at 9:49 A.M. revealed Resident #11 presented with a left middle cranial fossa acute subdural hematoma after fall with face strike. It was noted upon repeat CT scan; Resident #11 was stable with no new neurological deficits. It was noted that Resident #11's wheelchair arm broke and Resident #11 fell onto her face in a transport bus. Review of the undated facility investigative documentation revealed Resident #11 was being transported to an appointment on the facility transportation bus. Resident #11 left the faciity on [DATE] and was placed in a tilt-and-space wheelchair she had obtained prior to admission. The wheelchair was inspected by the therapy department on 03/25/25 and found to be in good working order. It was noted Resident #11 was not secured with a lap belt due to being tilted back in the wheelchair. While Transportation Driver #830 was driving the bus, he looked back and observed Resident #11 on the floor of the bus. Transportation Driver #830 was approximately three minutes' drive from a local hospital and drove directly to the hospital ER with Resident #11 remaining on the floor of the bus. Resident #11 was taken into the ER for evaluation. Resident #11 had a CT scan of her head, and a brain bleed was noted. Resident #11 was admitted to a local hospital and returned to the facility on [DATE]. Review of Disciplinary Action Form dated 03/27/25 revealed Transport Driver #830 was given a final written warning for a bus competency violation. The form listed Transportation Driver #830 failed to follow proper procedure when securing residents in wheelchairs in the facility transport bus. It was noted that Transportation Driver #830 had previously been trained on proper techniques for securing residents on the transport bus. Review of a social services note dated 03/28/25 timed at 11:02 A.M. revealed Resident #11 was expected to return to facility on 03/28/25. Review of the hospital Discharge summary dated [DATE] at 11:06 A.M. revealed Resident #11 had fallen out of her wheelchair while traveling on a transport bus to her doctor's office and had stuck her face on the floor of the bus. Resident #11 sustained a subdural hematoma and subarachnoid hemorrhage and was treated in the ICU. Resident #11 demonstrated stability of intracranial hemorrhage and was discharged back to the facility on [DATE]. Outpatient neurosurgery follow-up was recommended. Review of a general note dated 03/28/25 timed at 8:41 P.M. revealed Resident #11 returned to facility with all blood thinners discontinued. Resident #11 was not responsive to stimulation upon return. Review of Ad Hoc QAPI Notes dated 03/28/25 revealed Resident #11 was on the facility transportation bus on 03/26/25 and was being transported to hospital for a scan after a doctor's appointment. Resident #11 was in a tilt-in-space wheelchair. During secondary transport for scan, a bolt on Resident #11's wheelchair broke causing the side of the wheelchair to bend off. This resulted in Resident #11 coming out of the wheelchair onto the floor of the transportation bus. It was noted Resident #11's wheelchair was secured using four-point floor latches; however, Resident #11 was not secured using a lap belt due to being in a tilted back position in the wheelchair. Interview on 04/16/25 at 11:15 A.M. with Transportation Driver #830 revealed he had worked at the facility for the last five years. Transportation Driver #830 indicated he had never driven a transport bus prior. Transportation Driver #830 stated he had limited training which included driving a former administrator around the block and verbal instruction on how to load a wheelchair. Transportation Driver #830 indicated he did approximately two resident transports per day. Transportation Driver #830 stated on 03/26/25 he had loaded Resident #11 into the transport bus wrong. Transportation Driver #830 stated he had loaded Resident #11 in her wheelchair facing the passenger side windows of the bus. Transportation Driver #830 stated he felt Resident #11 was in pain while sitting upright in the wheelchair, so he had kept her tilted backwards. Transportation Driver #830 stated he was unable to use the seat belt due to Resident #11's wheelchair being in the tilted back position and positioned facing the passenger side of the bus (instead of forward facing). Transportation Driver #830 stated Resident #11 does not really move anyways so he felt she was secure in the chair despite not using the seat belt. Transportation Driver #830 stated he had applied Resident #11's wheelchair brake and applied four-point hooks to the wheelchair. Transportation Driver #830 indicated while driving to the hospital he heard a noise. He stated Resident #11 was not in her wheelchair when he checked the mirrors, and he saw her lying on the ground of the transport bus. Transportation Driver #830 stated they were approximately two minutes from the hospital, so he kept driving to the ER. Transportation Driver #830 stated the bolt on Resident #11's wheelchair had broken, and Resident #11 was leaning to the left side. Transportation Driver #830 stated the arm of the wheelchair completely bent off and caused Resident #11 to roll out onto the floor of the bus. Transportation Driver #830 stated he had gotten help from EMTs at the hospital and they were able to help her off the floor. Transportation Driver #830 stated Resident #11 did not have any bleeding, and she was not making any noises. Transportation Driver #830 stated Resident #11 just laid on the floor looking uncomfortable and embarrassed until she could be assisted up. Transportation Driver #830 denied any hard braking, speeding, or hard turns when Resident #11 had fallen from her wheelchair. Transportation Driver #830 stated the speed limit was 35 miles per hour and there was traffic near the hospital. Observation on 04/16/25 at 11:20 A.M. with Transportation Driver #830 of the facility transportation bus revealed the bus had three rows of seats with two seats on each side of the bus. There was a space at the back of the bus to secure two residents with wheelchairs. There were four straps with hooks to secure wheelchairs and a shoulder/lap seat belt for each wheelchair space. The equipment was in working order with no frays or tears in the straps. Transportation Driver #830 demonstrated the use of the wheelchair lift located at the back passenger side of the bus. The bus appeared in good working order. Interview on 04/16/25 at 2:16 P.M. with Therapy Director #824 revealed he had done a visual inspection of Resident #11's tilt-in-space wheelchair prior to the transport with no abnormal findings. Therapy Director #824 indicated he had also shown Transportation Driver #830 how to use the tilt-in-space wheelchair. Therapy Director #824 stated Resident #11 had not used the tilt-in-space wheelchair while admitted to the facility as they had been working on her trunk control and strengthening with a standard wheelchair. Therapy Director #824 indicated Resident #11 had not been progressing with a standard wheelchair and the tilt-in-space wheelchair was appropriate for use during transport to her appointment. Interview on 04/16/25 at 2:34 P.M. with the Administrator and RDCS #884 revealed Resident #11's tilt-in-space wheelchair did not return to the facility with her from the hospital. The Administrator indicated there were pictures of the wheelchair. Review of a series of three facility provided photographs, undated, revealed a wheelchair identified by the facility as Resident #11's tilt-in-space wheelchair. In the photographs it was seen the left side arm of the wheelchair was bent towards the back of the wheelchair and the front securing bracket had broken from the frame of the wheelchair. There were two noted brackets to secure the arm to the wheelchair frame. Review of Q'Straint Installation Instructions for Four-Point Wheelchair Securement System undated revealed tiedowns should only be installed so wheelchair passengers were facing forward. Lap belts must always lie against the bony structure of the passenger's body and never infringe on any component of the wheelchair such as armrests, wheels, or frames. Shoulder belts should always be positioned so the belt lies across the center of the passenger's shoulder and extends upward and rearward of the passenger's shoulder. Review of the safety manual for transport van wheelchair secure restraint system titled Doing It Right: A guide to the Proper Use of Sure-Lok Wheelchair Securement and Occupant Restraint Systems undated revealed the correct securement of a wheelchair was extremely important for safety and comfort of the passenger and injury or death could occur due to improper securement. The passenger should be facing the front of the vehicle with the wheelchair centered between the floor tracks or plates. Four straps should secure the wheelchair. A lap belt with a shoulder belt should be used to secure the passenger. The lap belt should be secured across the passenger's pelvic area near hips. The shoulder belt should be secured diagonally across the passenger's upper chest. Review of Invacare Solara 3G Wheelchair User Manual dated 2018 revealed always make sure the wheelchair was stable and engage wheel locks before using reclining option. The wheelchair must be operated by a healthcare professional or assistant when in any tilt position. It was not recommended to transport a wheelchair user in any kind of vehicle while in a wheelchair. It was recommended to complete regular cleaning and inspection of the wheelchair. Review of the facility policy Regularly Scheduled Transportation dated July 2018 revealed the facility would provide transportation using a facility vehicle for medically necessary appointments, activities, and outings. A third-party transportation service could be utilized when indicated. This deficiency represents noncompliance investigated under Complaint Number OH00164661.

Based on observation, record review, and staff interview, the facility failed to ensure the menu was followed for residents receiving pureed diets. This affected six residents (#3, #27, #30, #37, #45, and #50) who were prescribed a pureed diet. The facility census was 50. Findings include: Review of the lunch meal spreadsheet for 04/23/24 revealed residents on a pureed diet should include pureed dinner rolls using one #20 scoop (equivalent to 3.5 tablespoons). Observation of tray line on 04/23/24 from approximately 12:15 P.M. to 12:45 P.M. revealed the facility did not include the pureed dinner rolls and/or an appropriate substitution to residents receiving pureed food items. Interview on 04/23/24 at 12:45 P.M. with Cook #405 verified pureed dinner rolls were available on the tray service line but were not served to residents receiving pureed meals at the time of observation. Review of the facility's list of residents on a pureed diet revealed Residents #3, #27, #30, #37, #45, and #50 were on a pureed diet. Review of the facility policy titled Accuracy and Quality of Tray Line Service, dated 2019, revealed tray line positions and set up procedures will be planned for efficient and orderly delivery. All meals will be checked for accuracy by the food and nutrition services staff, and by the service staff prior to serving the meal to the individual. Individuals will receive the appropriate portions of food as outlined on the menu. Control at the point of service is necessary to assure that accurate portion sizes are served.

Based on medical record review, observations, resident and staff interviews, and review of the facility policy, the facility failed to ensure the resident's sheets were maintained in a clean condition. This affected one (Resident #39) of 50 residents reviewed for clean linens. The facility census was 50. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE] with a diagnosis of psoriasis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition and was independent for bed mobility, lying to sitting, sitting to standing, and transferring from the bed to the chair. Review of the current physician orders for April 2024 revealed Resident #39 was scheduled for showers on Fridays and Tuesdays. Interview and observation on 04/22/24 at 12:08 P.M. with Resident #39 revealed his sheets were stained along the edge of the mattress near the head of his bed, and his pillow case had several spots that appeared to be dried blood. Resident #39 stated he had asked for his sheets to be changed since his previous shower (04/19/24). Interview and observation on 04/23/24 at 3:57 P.M. with Resident #39 revealed he was in bed relaxing. His sheets and pillow remained stained. Resident #39 stated he was scheduled for a shower that night and he would insist staff change his bedding. Interview and observation on 04/24/24 at 10:23 A.M. with State tested Nurse Aide (STNA) #370 confirmed Resident #39's sheet was stained near the head of the bed and his pillowcase was stained with dark drops. STNA #370 stated Resident #39 refused his shower the previous evening. STNA #370 confirmed bedding was normally changed on shower days, and also confirmed bedding should be changed when obviously soiled. Interview on 04/24/24 at approximately 10:26 A.M. with Resident #39 confirmed he refused his shower the previous evening and expected to have a shower on night shift 04/24/24. Review of the facility policy titled Safe and Homelike Environment, revised 10/01/22, revealed the facility would provide and maintain bed and bath linens that are clean and in good condition.

Based on observation, medical record review, staff interview, and review of the facility incontinence policy, the facility failed to ensure timely incontinence care was provided to a resident who was incontinent and dependent on staff for toileting This affected one (Resident #30) of two residents reviewed for incontinence care. The facility census was 50. Findings include: Review of the medical record revealed Resident #30 admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, mood disorder, seizure disorder, chronic obstructive pulmonary disease, dementia, anxiety disorder, and major depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #30 had severely impaired cognition, dependent on staff for the completion of activities of daily living, always incontinent of bowel and bladder, and at risk for pressure ulcer development. Review of the nursing plans of care dated 01/09/24 revealed Resident #30's plan addressed an actual area of skin impairment related to moisture associated skin damage (MASD) to bilateral buttocks with interventions including: lay resident down and offload after every meal. Reposition every two hours when in bed. Pressure relieving cushion to wheelchair. On 05/24/23, a nursing plan of care was revised to address the resident has bowel incontinence related to rule out decreased mobility and memory impairment. Interventions included to assist the resident to the bathroom as needed. Provide peri care after each incontinence episode. Check the resident for incontinence as needed. Review of the bowel and bladder evaluation dated 02/08/24 revealed Resident #30 was noted to have the diagnosis of Alzheimer's disease of dementia, completely immobile, unable to ambulate, and incontinent of bowel and bladder. Review of the skin risk assessment dated [DATE] revealed Resident #30 was at moderate risk of developing skin breakdown. Continuous observations and interview on 04/23/24 starting at 9:37 A.M. revealed Resident #30 was placed in a reclining geriatric chair (Geri-chair) in the dining room. Resident #30 was positioned on his back with feet elevated. At 10:37 A.M., State tested Nurse Aide (STNA) #341 approached Resident #30 and wheeled the resident in the chair to his room. Interview with STNA #341 at 10:37 A.M. revealed she last checked the resident for incontinence and repositioning at 7:15 A.M. Continued observation noted STNA #341 and STNA #531 transferred Resident #30 to his bed utilizing a mechanical lift. Resident #30 was soiled with urine soaking through an adult incontinence brief, shorts, lift sling and onto the seat cushion. Urine was also observed on the back of the resident's shirt. STNA #341 removed the soiled clothing and brief and discovered Resident #30 was incontinent of a medium amount of stool, which was contained in the brief. STNA #341 and #531 cleansed the resident, placed a clean adult brief with clean clothing on the resident. On 04/23/24 at 11:12 A.M., an interview with STNA #341 verified Resident #30 was incontinent of bowel and bladder, was dependent on staff for all care, and required frequent checks with repositioning. On 04/23/24 at 11:13 A.M., an interview with Registered Nurse (RN) #502 verified Resident #30 required incontinence checks and repositioning every two hours due to the resident being unable to inform staff of need to utilize restroom or reposition self. On 04/23/24 at 1:20 P.M., an interview with the Director of Nursing (DON) verified Resident #30 was assessed as incontinent. The DON confirmed no interventions were implemented to determine Resident #30's bowel of bladder habits including frequency of incontinence checks to prevent heavy soiling. Review of the facility's incontinence policy dated 10/01/22 revealed residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.

Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure medications were administered and were not left at the resident bedside. This affected one (#40) of one resident reviewed for pharmaceutical services. The facility census was 50. Findings include: Review of Resident #40's medical record revealed an admitted [DATE]. Diagnoses included chronic gout, type II diabetes mellitus, malignant melanoma of skin, hypokalemia, hydronephrosis, hypertension, hyperlipidemia, lymphedema, muscle weakness, and supraventricular tachycardia. Observation on 04/22/24 at 10:21 A.M. revealed Resident #40 had a medication cup containing eight unidentified pills located on a table in the resident's room. During an interview on 04/22/24 at 10:25 A.M., Resident #40 reported the medications were their morning medications. Resident #40 reported staff were not supposed to leave medications in the room but they always did because they trusted Resident #40 and because Resident #40 took approximately 15 minutes to consume all of their morning medications. During an interview on 04/22/24 at 10:45 A.M., Licensed Practical Nurse (LPN) #807 verified they had taken Resident #40's morning medications into Resident #40's room and left them there without observing the resident consume them. LPN #807 reported Resident #40 always administered their own medications. During an interview on 04/24/24 at 7:09 A.M., LPN #801 reported there were no residents in the building who administered their own medications and the nurses were required to observe all residents swallow their medications. During an interview on 04/24/24 at 9:06 A.M., the Director of Nursing (DON) verified Resident #40 should have been observed while taking their medications. Review of the facility policy titled Medication Administration, dated 08/22/22, revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. The policy explanation and compliance guidelines contained in the policy stated to observe resident consumption of medication.

Based on observations, staff interview, and review of the facility policy, the facility failed to ensure staff used appropriate hand hygiene during meal services. This affected three (#17, #21, and #22) of four residents observed during meal service on the 400-hall. The facility census was 50. Findings include: Observation on 04/22/24 at 7:57 A.M. revealed State tested Nurse Aide (STNA) #301 passing breakfast trays to residents eating in their rooms. STNA #301 entered Resident #13's room and provided her breakfast tray and removed the lids from the food items. Resident #13 requested some assistance and STNA #310 adjusted the socks on Resident #13's feet. STNA #301 exited Resident #13's room, did not perform hand hygiene, and picked up the tray for Resident #22. STNA entered Resident #22's room, picked up her computer tablet and placed the breakfast tray on the overbed table. STNA #301 then removed the lids from Resident #22's meal items and exited her room without performing hand hygiene. Interview on 04/22/24 at 8:00 A.M. with STNA #301 confirmed she touched Resident #13's socks and did not perform hand hygiene before providing Resident #22 her breakfast tray. STNA #301 stated she performed hand hygiene before passing the first tray on the hall, then performed hand hygiene after she finished passing all trays for the hall. Observation on 04/22/24 at approximately 8:01 A.M. revealed STNA #301 did not perform hand hygiene and picked up the breakfast tray for Resident #21 and placed it on her overbed table, then returned to the tray cart, without performing hand hygiene, and picked up the tray for Resident #17 and delivered it to her room. Continued observation revealed STNA #301 was called by staff to assist with care in another resident's room and STNA #301 stopped passing meal trays to assist with care. Review of the policy titled Hand Hygiene, copyright 2023, revealed hand hygiene is indicated and will be performed under the conditions listed in the attached hand hygiene table. Review of the undated Hand Hygiene Table revealed hand hygiene should occur between resident contacts.

Based on record review, observations, staff interviews, review of the facility policy and review of staff in-service, the facility failed to ensure staff wore personal protective equipment (PPE) when providing care to residents in enhanced barrier precautions (EBP). This affected one resident (#26) of two residents observed in EBP. The facility census was 50. Findings include: Review of the medical record for Resident #26 revealed an admitted [DATE] with a diagnosis of acquired absence of right toe. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition and required limited assistance of one person for transfers. Review of the current physician order dated 04/05/24 revealed Resident #26 was in EBP precautions for a chronic wound. The order stated gloves and gown should be worn when transferring the resident. Review of the current care plan for Resident #26 revealed he had an area of skin impairment related to a right foot stump wound. Interventions included EBP as ordered. Observations on 04/22/24 at 7:47 A.M. revealed a sign posted on Resident #26's door indicating he was in EBP and PPE was required while providing care. There was a plastic cart outside Resident #26's room with gowns and gloves. State tested Nurse Aide (STNA) #408 opened Resident #26's door from inside the room and asked STNA #404 to come into the room to assist with a transfer for Resident #26. STNA #408 was not wearing PPE inside the room. STNA #404 donned PPE before entering Resident #26's room. During this observation, interview with STNA #404 confirmed STNA #408 was not wearing PPE inside Resident #26's room. Interview on 04/22/24 at 7:52 A.M. with STNA #301, who came out of Resident #26's room after providing care with a transfer alongside STNA #404 and STNA #408 confirmed she also did not wear PPE while providing care to Resident #26. Interview on 04/22/24 at 7:53 A.M. with STNA #404 confirmed staff were required to wear PPE (gown and gloves) while transferring residents who were in EBP. Interview on 04/25/24 at 10:21 A.M. with Regional Director of Clinical Services #802 revealed all staff were educated in March 2024 regarding EBP and donning and doffing PPE when providing care for residents in EBP. Review of the undated staff in-service sign-in sheet revealed the topics of EBP and donning and doffing PPE were provided. STNA #301 and STNA #408 signed the sign-in sheet for the education. Review of the policy Enhanced Barrier Precautions, revised 03/20/24, revealed EBP referred to the use of gown and gloves during high-contact resident care activities. It defined high-contact resident care activities included transfers.

Based on observation, record review, and facility staff interview the facility failed to provide wound care as ordered for one (#30) of three residents reviewed for wound care. The facility census was 52. Findings Include: Review of Resident #30's medical record revealed the resident was admitted on [DATE], diagnoses included basal cell carcinoma of face, heart disease, type two diabetes, history of falls and myocardial infarction. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #30, revealed the resident was cognitively intact, had no behaviors and required extensive assistance with dressing and toileting. Review of the active physician orders for Resident #30, revealed the resident had a daily wound care order for her basal cell carcinoma wound to her chin that stated to wash hands prior to changing the dressing, cleanse the wound once daily gently with soap and water or normal saline, pat dry, do not rub the wound, apply Aquaphor (healing ointment), Cerave (healing ointment) or pure Vaseline (skin protectant) to the wound, and cover with new bandage until healed. Observation of wound care for Resident #30 on 11/06/23 at 12:23 P.M. performed by Licensed Practical Nurse (LPN) #300 revealed the nurse washed her hands with soap and water, donned her gloves while Resident #30 was observed to remove the bandage off her chin. LPN #300 was observed to put a washcloth under the flow of water from the room sink and provided the wet washcloth to the resident to cleanse the wound. The resident gently dabbed the wound with the wet washcloth and then gave the cloth back to the nurse. LPN #300 placed Vaseline on two Q-tips and placed the Vaseline in the wound bed on Resident #30's chin. LPN #300 then placed a bandage over the wound, removed her gloves and washed her hands. Interview with LPN #300 on 11/06/23 at 4:31 P.M., verified Resident #30's wound care to her chin was only cleaned with tap water and not soap and water or normal saline per the physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00147738.

Based on interview and record review, the facility failed to ensure a resident with a known history of small bowel obstruction, received appropriate bowel care. This resulted in actual harm when Resident #38 experienced severe abdominal pain, loose stools, nausea and vomiting with abdominal distention on 09/26/18, 02/03/19 and 03/17/19, resulting in hospitalization s with nasogastric suctioning and resolution of the small bowel obstruction. This affected one of three residents sampled for bowel continence. The facility census was 45. Findings include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #38's significant change of condition Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident required an extensive assist of one person for bed mobility, transfers and toilet use. The MDS assessments dated 01/04/19, 02/03/19 and 03/17/19 documented the resident was not on a bowel program and was frequently incontinent of stool. Review of Resident #38's medical record revealed the resident did not have a plan of care for bowel incontinence or a care plan to monitor the resident for signs and symptoms of a bowel obstruction. Review of Resident #38's nursing notes dated 09/25/18 at 10:00 P.M. revealed a call was placed to the physician informing the physician the resident had a large liquid emesis and continued to feel bad. The physician said to send resident to hospital for evaluation and treatment, due to abdominal distention, guarding left side, and vomiting. A call was placed to the local police department for 911 to transport the resident to the emergency department, an order was faxed to the primary care associate, spouse was made aware of transport as she was at the facility with resident. A call was placed to the hospital and spoke with the nurse, gave report on resident's condition, and that he was being sent to them. Resident #38 was admitted to the hospital on [DATE] for a small bowel obstruction. Review of Resident #38's hospital discharge record dated 09/26/18 revealed the resident was admitted with severe abdominal pain, abdominal distention and diagnosed with [REDACTED].>Review of Resident #38 nursing notes dated 02/03/19 at 1:15 P.M. revealed the resident was having loose stools and complained of severe abdominal pain. His abdomen was very distended with hypoactive bowel sounds. Vital signs were obtained. The physician was notified, and an order was received to send Resident #38 to the emergency room via 911 for evaluation. The spouse was notified. Report was given to the nurse at the hospital. The hospital discharge for the second small bowel obstruction dated 02/03/19 was not provided by the facility Review of Resident #38's hospital discharge records dated 03/17/19 revealed the resident was admitted to the hospital for complaints of abdominal pain with nausea and vomiting. A CT scan had been done which showed a small bowel obstruction with transition in the medium ileum. A nasogastric tube was placed. Surgery was consulted, and the resident was seen. The rsident was managed conservatively, nausea and abdominal pain resolved and the nasogastric tube was discontinued. Nursing notes dated 03/29/19 at 5:20 P.M. revealed a late entry documenting the resident was readmitted from the hospital at 5:20 P.M. via squad on a cart, accompanied only by the two squad personnel. Review of Resident #38's bowel tracking record from 01/01/19 to 05/23/19 revealed some dates had been changed on some of the tracking forms, other dates had been scribbled and state tested nursing assistant's (STNA) documentation at the time of review was difficult to decipher. Interview with STNA #29 on 05/23/19 at 4:00 P.M. revealed STNAs are to document daily on the incontinence tracking form if the resident were incontinent of urine and stool. STNA #29 stated staff were to report any changes in the resident's condition, especially urine, if confusion, color change or odor. STNA # 29 stated as for documenting bowel movements, they mark if it is small, medium, large or loose. STNA #29 stated the bowel movements and urinary incontinency tracking are marked two times a day, once on day shift and once on night shift. STNA #29 stated aides worked 12-hour shifts. STNA #29 was not sure of the accuracy of the tracking because of the difference of opinions for the size and shape of the bowel movement. STNA #29 stated Resident #38 required help to transfer from the wheelchair to the toilet. Other times he was independent and would go to the toilet on his own and not tell staff if he had a bowel movement. STNA #29 stated she had not been educated on what to report to the nurse regarding how to monitor the resident for signs and symptoms of constipation or a bowel obstruction. Interview with the Director of Nursing (DON) on 05/23/19 at 4:45 P.M. revealed there was no documentation from the (MONTH) 2019 hospital visit that documented when or why Resident #38 was transferred from the facility to the hospital. The DON verified the resident was sent to the hospital for a small bowel obstruction. The DON revealed the facility had a policy and procedure for Bowel and Bladder Assessment to identify individuals with reversible causes of incontinence and to institute the appropriate interventions to meet the resident's needs. The DON stated the facility had no written bowel protocol in place. Nurses were to monitor resident's bowel movements. If no bowel movement after three days, the resident was administered milk of magnesia. It not effective, the resident would be administered a suppository, if no results the resident was administered an enema. If no results from the enema, the physician was notified for further instructions. The DON verified the facility did not have standing orders to ensure this unwritten protocol was initiated. The DON verified as of 05/23/19 at 5:20 P.M. Resident #38 did not have a plan of care in place for monitoring bowel movements to prevent bowel obstruction.

Based on medical record review, resident interview, staff interview, review of fall investigtion, and review of facility policy, the facility failed to ensure fall interventions were in place to prevent falls for two (#1, #3) residents. This resulted in actual harm when Resident #1 was left alone seated on the edge of the bed by staff, fell off of the bed and suffered a [MEDICAL CONDITION] requiring a transfer to the hospital and ten staples to repair. The deficient practice affected two (#1, #3) of three residents reviewed for falls. The facility census was 45. Findings include: 1. Review of Resident #1's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 01/10/19, revealed the resident had moderately impaired cognitive function. The resident had required extensive assistance of two staff with bed mobility and transfers. Balance during transitions, walking, and surface to surface transfers was assessed as not steady and only able to stabilize with staff assistance. Resident #1's functional range of motion revealed an impairment on one side. Review of Resident #1's most recent care plan revealed the resident had left [MEDICAL CONDITION]. Resident #1 was at risk for falls and injury related to incontinence, psychoactive drug use and vision problems. Interventions included the resident required extensive assistance of two staff for transfers. Review of Resident #1's most fall assessment, dated 06/22/18, revealed Resident #1 was at high fall risk due to the inability to independently come to a standing position, exhibited loss of balance while standing, required hands on assistance to move from place to place and had decreased muscle coordination. Review of the nurses' notes dated 03/21/2019 at 8:30 A.M. revealed Resident #1 was assisted to a sitting position on the side of the bed by Licensed Practical Nurse (LPN) #220. The resident was set up to eat breakfast and take her morning medications. LPN #220 heard a loud noise and heard the resident yell. Upon re-entering the room, Resident #1 was observed lying on the floor, on her left side, with a laceration to left the side of her head. A large amount of bleeding was noted. Emergency medical service were called and resident was transported to the local hospital. Review of the nurses' note dated 03/21/19 at 12:45 P.M. revealed Resident #1 returned from the emergency room with 10 staples to the left side of her head. An abrasion was also noted to the right knee. Review of the nurses' note dated 03/27/19 revealed new interventions were in place which included a mechanical Hoyer with two assist for transfers. The resident was noted to have poor bed mobility due to paralysis to the left side. Interview on 04/03/19 at 8:33 A.M., Resident #1 revealed on 03/21/19, prior to the fall, LPN #220 had sat her up on the side of her bed with her feet dangling off the bed. The resident was waiting for breakfast to be served. The resident stated her left leg (paralyzed side) began to have spasms after approximately one and a half minutes and the she fell on the floor and hit her head on the linoleum covered floor. Resident #1 stated when her head hit the floor she saw stars and then a lot of blood. LPN #220 came back into the room immediately and emergency services were called and the resident was transported to the hospital. Interview on 04/03/19 at 11:10 A.M., State tested Nursing Aide (STNA) #400 revealed prior to Resident #1's fall, interventions included a mat to the bedside floor, never leave resident alone on the bed, and never let the resident sit on the side of the bed. New interventions after the fall included transfers with a Hoyer lift with two staff assist. Telephone interview on 04/03/19 1:32 P.M., LPN #220 revealed she sat Resident #1 on the side of bed to eat breakfast in a sitting position. The LPN revealed Resident #1 had sat on the side of the bed eating many times before with no problems and the left side deficit was no issue prior to this event. LPN #220 state she went out into the hall for less than a minute when she heard Resident #1 fall. Resident #1 informed the nurse she started to have a leg spasm, bent down to rub the leg and fell off of the bed. LPN #220 immediately called emergency medical services. LPN #220 stated prior to that fall no known fall interventions were in place. Review of the facility policy titled Fall Response Policy and Procedure, dated 12/01/18, revealed it is the policy of this facility to ensure to the best of its ability the safety and well-being of residents who are at risk for falls. 2. Review of Resident #3's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED].>[MEDICAL CONDITION] and [MEDICAL CONDITION] due to a [MEDICAL CONDITION], abnormal posture, anxiety, and dementia. Review of Resident #3's physician order dated 12/14/18 indicated to double check bed lock making sure bed was locked (low bed). Review of Resident #3's quarterly MDS assessment, dated 03/21/19, revealed the resident had low cognitive functioning. The resident required an extensive assist of two people for bed mobility and transfers. Review of Resident #3's most recent care plan revealed the resident was at a high risk for falls related to dementia and impaired balance. Interventions included to have the bed in a low position and have commonly used articles within easy reach. Review of Resident #3's nurses note dated 03/03/19 at 9:45 A.M. revealed the resident was found lying on his back on the floor positioned between the bed and the wall. The resident denied any pain or discomfort and there were no visible injuries. Intervention to be implemented was to educate staff members on properly positioning of resident while in bed as well as ensuring the bed was locked. Review of the fall investigation revealed the resident's bed was found not locked, as well as pillows had been placed under Resident #3's mattress versus at his side for positioning. Interview on 04/03/19 at 2:25 P.M., LPN #230 stated when he/she arrived in the room, Resident #3 was lying on the floor between the wall and the bed. LPN #230 revealed the bed was noted to be unlocked and had rolled away from the wall. In addition, staff had placed pillows underneath the mattress instead of at the resident's side to assist in repositioning. The resident received no injuries. This deficiency substantiates Complaint Number OH 556.