Every finding on record at Englewood Health and Rehab

Based on record review, staff and resident interviews, observation and policy review, the facility failed to ensure resident dental appointments were scheduled timely to relieve dental pain. This resulted in Actual Harm on 03/03/26 when Resident #75 had three root tips exposed and extraction was recommended. No dental appointment was scheduled for over four months and Resident #75's teeth continued to deteriorate to class three fractures (a serious dental emergency where the break goes through the outer enamel and middle dentin layers to expose the soft nerve center). Resident #75 complained of oral pain rating it a 10 on a one to ten scale. This affected one (Resident #75) out of two reviewed for dental. The facility census was 96.Findings include: Record review revealed Resident #75 was admitted on [DATE]. Diagnoses included chronic respiratory failure with hypoxia, type two diabetes mellitus, paroxysmal atrial fibrillation, chronic systolic (congestive) heart failure, major depressive disorder, and morbid (severe) obesity due to excess calories. Review of the physician order dated 12/17/25 revealed an order to evaluate pain every shift. Review of the Dentist Visit dated 03/03/26 revealed Resident #75 had multiple missing teeth, had three root tips exposed with recommendations for extraction of teeth #12, #18, #19, and #30 for decay. Review of the physician order dated 04/22/26 revealed a physician order to schedule an appointment with oral surgeon due to dental pain. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #75 was cognitively intact. No dental concerns were identified. Review of the Dentist Visit dated 07/13/26 revealed Resident #75 presented with pain in teeth #12, #18, #19, and #30. Resident #75 had class three fractures (a serious dental emergency where the break goes through the outer enamel and middle dentin layers to expose the soft nerve center) on teeth #12, #18, #19, and #30. Recommend extractions of those teeth listed above due to being broken deep. Tooth #30 was extracted. Order to refer to oral surgeon for extraction of teeth #12, #18, and #19 due to the level of difficulty. Review of the Medication Administration Record dated July 2026 revealed on 07/24/26 it was documented Resident #75 had a pain level of six out of 10 on day shift and a pain level of 10 out of 10 on night shift. Review of the physician progress note dated 07/24/26 revealed Resident #75 was seen for disorders of the teeth and supporting structures. Orders included Benzocaine topical gel apply every eight hours for 10 days for dental pain and Chlorhexidine 0.12 percent oral rinse 15 milliliter (ml) twice daily for 10 days for dental hygiene/tooth pain. Review of the physician order dated 07/24/26 revealed an order for Orajel 2X Toothache and Gum Mouth/Throat Gel 20-0.26 percent (Benzocaine-Menthol (Mouth-Throat)) give one dose by mouth every eight hours for broken teeth for 10 days. There was an order dated 07/25/26 for Chlorhexidine Gluconate Solution 0.12 percent give 15 ml by mouth two times a day for broken teeth for 10 days (swish and spit). During an interview on 07/20/26 at 11:53 A.M., Resident #75 stated he has had tooth pain and tooth decay for a while. He said he was supposed to go to the oral surgeon months ago but had not been scheduled nor had he heard anything of his appointment. Resident #75 said he pulled one of his broken teeth himself and had the tooth in a medicine cup on his windowsill. He said the dentist finally came in a couple weeks ago. During an interview on 07/25/26 at 12:07 P.M., Resident #75 complained of a pain level of 8.5 out of 10 in his left upper teeth and right bottom rear teeth. During an interview on 07/25/26 at 10:58 A.M., the Director of Nursing confirmed Resident #75's MDS assessments dated 03/20/26 and 06/18/26 did not assess the resident of having any dental concerns and no appointment has been scheduled for Resident #75 to see an oral surgeon. Review of the policy titled Dental Services, dated December 2016, revealed routine and emergency dental services are available to meet the residents' needs. Routine and 24-hour emergency dental services will be provided to residents through licensed dentists that come to the facility or a referral to community dentists of other health care organizations that provide dental services. This deficiency represents non-compliance investigated under Complaint Number 3040119 and 1382136.

Based on observations, staff interviews, and policy review, the facility failed to ensure food items were stored in a safe manner, failed to dispose of outdated/expired food, and failed to serve food in a safe manner. This had the potential to affect 91 of the 96 residents who reside in the facility who receive meals from the kitcehn, the facility identified five residents (#4, #8, #33, #63, and #100) whom are nothing by mouth (NPO). The facility census was 96. Findings include: Brief tour of kitchen on 07/20/26 at 8:21 A.M. revealed in the small refrigerator a bundle of saran wrapped cheese slices with an expiration date of 07/01/26, an opened package of butter with no open date in the large refrigerator, and an open and exposed bag of [NAME] cheese omelets in the walk-in freezer. Interview on 07/20/26 at 8:29 A.M. with Dietary Aide #254 confirmed the cheese was expired on 07/01/26. Interview on 07/20/26 at 8:29 A.M. with Dietary Aide #254 also confirmed the butter in the large refrigerator had no open date. Interview on 07/20/26 at 8:35 A.M. with Dietary Manager # 270 confirmed the box of [NAME] cheese omelets was open and exposed to air in the walk-in freezer. Observation of food serving line on 07/21/26 at 11:43 A.M. revealed Dietary Aide # 258 touched tortillas with her gloved hand, then touched the beef scoop with same gloved hand, handled the cheese tongs with same gloved hands then went back to the tortilla with same gloved hands and folded the tortilla into a burrito shape. Interview on 07/21/26 at 12:00 P.M. with Dietary Manager #270 confirmed Dietary Aide # 258 touched multiple items, including the tortillas without changing gloves. The facility confirmed 91 of the 96 residents receive meals from the facility kitchen, and there are five residents (#4, #8, #33, #63, and #100) whom are NPO. Policy titled Food Receiving and Storage and undated confirms aal foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen or discarded.

Based on medical record review, observations, staff interviews, and policy review, the facility failed to perform appropriate hand hygiene when serving food to residents. This affected 18 (#2, #8, #9, #11, #16, #17, #18, #35, #37, #44, #46, #48, #76, #77, #79, #106, #109 and #116) of 30 residents observed for meal service. Additionally, the facility failed to sanitize medical equipment between residents, affecting three (#20, #49, and #103) of four residents sampled for medication administration, and failed to handle soiled linen appropriately, affecting three (#41, #49, and #110) of three residents sampled for incontinence care. Lastly, the facility failed to wear appropriate personal protective equipment (PPE) when providing high-contact care to residents in Enhanced Barrier Precautions (EBP). This affected one (#10) of three residents sampled for catheter care. The facility census was 96. Findings include: 1. Observation on 07/21/26 from 7:45 A.M to 8:05 A.M. revealed Certified Nursing Assistant (CNA) #231 was passing breakfast trays to Resident #2, #8, #9, #11, #16, #17, #18, #35, #37, #44, #46, #48, #76, #77, #79, #106, #109 and #116. CNA #231 was observed wearing gloves throughout the time she was passing trays. She did not perform hand hygiene between handling each tray and serving the residents. Interview on 07/21/26 at 8:05 A.M. with CNA #231 verified that she wore gloves while delivering meal trays to all residents on the hall and that she did not perform hand hygiene in between serving each resident. Interview on 07/27/26 at 1:27 P.M. with Director of Nursing (DON) verified that hand hygiene should be performed after each meal tray is delivered and that gloves should not be worn while delivering the trays. Review of the facility policy titled, Handwashing/Hand Hygiene dated October 2023 revealed hand hygiene is indicated after touching the resident resident's environment. The use of gloves does not replace hand washing/hand hygiene. 2. Observations made on 07/22/26 from 8:50 A.M. to 9:15 P.M. revealed Licensed Practical Nurse (LPN) #276 assessed blood pressure for Residents #20, #49, and #103 using the same wrist-cuff monitor and did not sanitize the device appropriately between uses. During an interview on 07/22/26 at 9:13 AM with LPN #276 verified she did not sanitize the wrist -cuff device between uses and stated she did not know when the device had last been sanitized. LPN #276 stated she did not know how often devices needed to be sanitized and speculated that hand sanitizer or a bleach wipe might provide appropriate disinfection. 3. Observations made on 07/22/26 from 10:27 A.M. to 11:28 A.M. revealed CNA #236 threw soiled briefs, washcloths, towels, and sheets on the floor while providing incontinence care to Residents #41, #49, and #110. During an interview on 07/22/26 at 10:36 A.M. with CNA #236 stated she always threw soiled briefs and linen on the floor during care because she did not always have plastic liner bags available. 4. Review of the medical record for Resident #10 revealed an admission date of 06/17/26. Diagnoses included heart failure, chronic kidney disease stage three B, and atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of one. This resident was assessed to require substantial assistance with eating, toileting, dressing, and transfers. Review of the care plan dated 06/17/26 for Resident #10 revealed there was no care plan for catheter care. Review of the medical chart revealed Resident #10 had no catheter orders. Review of the medication administration record (MAR) and treatment administration record (TAR) dated June and July 2026 revealed Resident #10 did not have catheter care orders. Observation on 07/23/26 at 9:21 A.M. revealed Resident #10 had a urinary catheter. Observation on 07/23/26 at 9:23 A.M. revealed incontinence care and catheter care to Resident #10 was performed by CNA #224. CNA #224 did not wear a gown for EBP when providing care. CNA #224 did not properly clean the catheter tubing. CNA #224 provided Peri care to Resident #10 and used contaminated wash cloth from Peri care to clean catheter tubing. CNA #10 did not remove gloves during care and then proceeded to touch Resident #10, sheets, bed controls, and wheelchair. Interview on 07/23/26 at 9:30 A.M. with CNA #224 verified she did not wear appropriate PPE, used a soiled washcloth to clean the catheter tubing, and did not change gloves during care. Interview on 07/23/26 at 9:36 A.M. with DON verified Resident #10 did not have catheter orders. Review of the facility policy titled, Enhanced Barrier Precautions, revised March 2024 revealed enhanced barrier precautions were utilized to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. EBP was indicated for indwelling medical devices which included central lines, urinary catheters, feeding tubes, and tracheostomies. Gown and gloves should be worn during high-contact resident care activities including bathing, dressing, transferring, personal hygiene, changing linens, changing briefs or assisting with toileting, and device care.

Based on medical record review, observations, staff and resident interviews, and policy review, the facility failed to ensure residents received timely assistance with Activities of Daily Living (ADLs). This affected 11 (#6, #10, #18, #41, #49, #61, #62, #91, #110, #118, and #124) of twenty-nine residents sampled for ADL assistance. The facility census was 96. Findings include: 1. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included unspecified Parkinsonism, unspecified dementia, type II diabetes, unspecified bipolar disorder, Unspecified major depressive disorder, unspecified cerebrovascular disease, and bed confinement status. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #41 was occasionally incontinent of bowel and bladder, was dependent of staff for assistance with toileting, and was not on a toileting program. Review of care plan dated 04/28/22 revealed Resident #41 had an alteration in bowel and bladder. Interventions included administering bowel medications as ordered, checking and changing, and using incontinence briefs/pads for protection. Observation on 07/22/2026 at 9:28 A.M. revealed Certified Nurse Assistant (CNA) #236 checked Resident #41 for incontinence and Resident #41's brief was soiled with urine. CNA #236 told Resident #41 she would return to change him as soon as she had linen available. Observation on 07/22/2026 at 9:33 A.M. revealed the linen closet located across from the nurse's station for Magnolia and [NAME] units had no towels or washcloths available. Observation on 07/22/2026 at 10:22 A.M. revealed unspecified laundry assistant delivered a stack of linen to the linen closet located across from the nurse's station for Magnolia and [NAME] units including 20 towels ,28 washcloths, 11 drawsheets, 3 fitted sheets, 3 waterproof pads, and 3 bath blankets. Observation on 07/22/26 at 10:27 A.M. revealed CNA #236 provided incontinence care for Resident #41 and applied zinc cream to reddened skin on groin and bilateral buttocks. 2. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE]. Diagnoses included type II diabetes with diabetic chronic kidney disease and chronic ischemic heart disease. Review of MDS assessment dated [DATE] revealed Resident #49 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #49 was always incontinent of bowel, and was occasionally incontinent of bladder. Review of care plan date 11/14/25 revealed Resident #49 was occasionally incontinent of urine. Interventions included checking for incontinence before and after meals and providing incontinence care when necessary. Observation on 07/22/2026 at 9:30 A.M. revealed CNA #236 entered the room and asked permission to check Resident #49 for incontinence. Resident #49 stated she needed to be changed. CNA #236 checked and confirmed Resident #49's brief was wet with urine. CNA #236 explained she would get Resident #49 up when she had access to clean linen. Observation on 07/22/2026 at 11:28 A.M. revealed CNA #236 returned to Resident #49's room to assist with morning care. Resident #49's brief was filled with urine and had soaked through to the waterproof pad underneath her. CNA #236 provided incontinence care, applied Moisture Barrier Cream to reddened skin located on Resident #49's bilateral buttocks and coccyx, dressed and transferred Resident #49 to her wheelchair, removed soiled bed linens, and applied clean bed linens. 3. Review of the medical record revealed Resident #110 was admitted to the facility on [DATE]. Diagnoses included stage III chronic kidney disease, unspecified dementia, type II diabetes, and unspecified cerebral infarction. Review of MDS assessment dated [DATE] revealed Resident #110 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Review of care plan dated 02/26/20 revealed Resident #110 had a physical functioning deficit. Interventions included one staff assistance with toileting, oral care, personal hygiene, transfers, and bed mobility. Review of care plan dated 02/26/20 revealed Resident #110 was at risk for pressure ulcers. Interventions included conducting weekly skin inspections, providing pressure relieving devices, and assessing during weekly wound rounds. Review of care plan dated 01/27/23 revealed Resident #110 had an alteration in in bowel and bladder due to incontinence. Interventions included keeping call light in reach and providing briefs/pads for protection of incontinence. Observation on 07/22/2026 at 9:29 A.M. revealed CNA #236 checked Resident #110 and found he had been incontinent of bladder. CNA #236 explained to Resident #110 she would come back and change later when she had access to clean linen. Observation on 07/22/26 at 10:45 A.M. revealed CNA #236 returned to Resident #110's room with clean linen and asked permission to complete incontinence care. Resident #110's gown, brief, and bed were visible saturated with urine. CNA #236 completed incontinence care, dressed Resident #110 in a clean hospital gown, and replaced soiled bed linens. During interview conducted on 07/22/26 at 9:24 A.M. CNA #236 confirmed she had not completed her first rounds for patients on the Magnolia unit due to not having clean linen available. CNA #236 stated the facility did not provide wipes and used towels and washcloths with soap and water for bathing and incontinence care. CNA #236 stated she had gone to the laundry room to get linens and there was no clean linen to be found. CNA #236 stated management was aware this was a recurring problem because there were no laundry personnel staffed at night to ensure enough clean linens in the facility for the morning rounds. 4. Review of the medical record revealed Resident #124 was admitted to the facility on [DATE] and was discharged on 06/28/25. Diagnoses included end stage renal disease with hemodialysis, congestive heart failure, and type II diabetes. Review of MDS assessment dated [DATE] revealed Resident #124 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #124 was always incontinent of bowel and bladder and required total assistance with toileting, bathing, and dressing. Review of task sheet dated June 2025 revealed Resident #124 had no assistance with ADLs including eating, dressing, transferring, toileting, or oral hygiene on 06/26/25 and 06/27/25. During an interview on 07/27/2026 at 10:06 A.M. the DON confirmed Resident #124's medical record had no task documentation completed and no evidence that Resident #124 received ADL assistance from 06/26/25 to 06/28/25. 5. Review of the medical record for Resident #118 revealed an admission date of 10/15/23 with a discharge date of 01/15/26. Diagnoses included chronic obstructive pulmonary disease (COPD), type II diabetes mellitus (DM II), and congestive heart failure (CHF). Review of the Quarterly MDS assessment dated [DATE] revealed Resident #118 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of eight. This resident was assessed to require setup with eating, substantial assistance with toileting, dressing, and transfers, and dependent with showers. Review of the activity of daily living (ADL) log dated November 2025 revealed Resident #118 did not receive a shower on 11/13/25, 11/20/25, and 11/27/25. Review of the ADL log dated December 2025 revealed Resident #118 did not receive a shower on 12/04/25 and 12/15/25. Interview on 07/23/26 at 11:34 A.M. with interim Director of Nursing (DON) verified Resident #118 did not receive showers as scheduled. Interim DON also reported her expectation from staff was to document care throughout the shift. 6. Review of the medical record for Resident #10 revealed an admission date of 06/17/26. Diagnoses included heart failure, chronic kidney disease stage three B, and atrial fibrillation. Review of the admission MDS assessment dated [DATE] revealed Resident #10 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of one. This resident was assessed to require substantial assistance with eating, toileting, dressing, and transfers. Review of the ADL task log dated June 2026 revealed Resident #10 did not receive a shower on 06/19/26, 06/23/26, and 06/26/26. Review of the ADL task log dated July 2026 revealed Resident #10 did not receive a shower on 07/10/26, 07/14/26, and 07/17/26. Interview on 07/23/26 at 11:36 A.M. with interim Director of Nursing (DON) verified Resident #10 did not receive showers as scheduled. Interim DON also reported her expectation from staff was to document care throughout the shift. 7. Review of the medical record revealed Resident #18 had an admissions date of 04/08/25 with diagnoses including dysphagia and need for assistance with personal care. Review of the MDS assessment dated [DATE] revealed Resident #18 was unable to be assessed for cognition. Resident #18 is dependent for eating, toileting, bathing, mobility and transfers. Review of the Documentation Survey Report for June 2026 revealed Resident #18 had showers scheduled but were not signed off as completed on 06/04/26, 06/08/26, 06/11/26, 06/18/26, 06/22/26, 06/25/26, and 06/29/26. Further review revealed that oral care was scheduled to be completed twice a day and was not documented as given 31 times. Review of the Documentation Survey Report for July 2026 revealed Resident #18 had showers scheduled but were not signed off as completed on 07/02/26, 07/06/26, 07/09/26, 07/13/26, 07/20/26, 07/23/26, and 07/30/26. Further review revealed oral hygiene was scheduled to be completed twice a day and was not documented as given 32 times. Interview on 07/21/2026 at 12:32 P.M. with Registered Nurse (RN) #315 verified that shower and oral care were frequently not being signed off as completed for Resident #18. RN #315 verified the aides are supposed to chart after care is provided and document any refusals. Interview on 07/27/2026 at 11:30 A.M. with Director of Nursing #261 verified staff were not documenting if showers and oral hygiene were being completed. She stated that without documentation she could not verify that the care was being completed. 8. Resident #6 was admitted on [DATE] with the following diagnoses: aphasia, essential hypertension, osteoarthritis, hyperlipidemia, schizophrenia, systolic heart failure, unspecified dementia, dysphagia. Review of the MDS assessment dated [DATE] revealed Resident #6's cognitive abilities were unable to be assessed as evidenced by a Brief Interview for Mental Status (BIMS) score of 99. Resident was unable to answer due to aphasia. Functional abilities revealed Resident #6 was dependent for eating, oral hygiene, toileting hygiene, and bathing, and transfers. Resident #6 required maximal assistance for dressing, personal hygiene, and bed mobility. Review of the Functional Abilities and Goals assessment dated [DATE] reveals Resident #6 is dependent for showering/bathing. Review of the Documentation Survey Report revealed Resident # 6 received only 1 shower the month of March and only 2 showers for the month of April. Resident #6 is scheduled to receive baths every Tuesday and every Friday. Interview on 07/22/26 at 11:40 AM with Registered Nurse # 302 confirmed resident only received 1 shower for the month of March and 2 showers for the month of April. Policy titled Activities of Daily Living (ADLs) and dated March 2018 reveals Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 9. Resident #61 was admitted on [DATE] with the diagnoses of chronic resp failure with hypoxia, acute on chronic diastolic heart failure, Type II diabetes mellitus with neuropathy, COPD, anxiety, suicidal ideations, schizoaffective disorder, and bipolar disorder. Review of the MDS assessment dated [DATE] revealed Resident #61 is cognitively intact as evidenced by a BIMS score of 15. Resident #61 requires set up assistance with eating and oral hygiene, moderate assistance with dressing, maximal assistance with toilet hygiene and bathing, moderate assistance with bed mobility and maximal assistance with transfers. Review of MDS assessment dated [DATE] revealed Resident #61 requires maximal assistance with bathing/showering. Review of care plan dated 07/20/26 reveals Resident #61 requires assistance with one or more activities of daily living. Goal listed is: I will receive assistance as necessary for my activities of daily living through next care plan review. Interventions include, assist resident as needed and as requested by resident. Referral to therapy as appropriate and ordered by physician Review of the Documentation Survey Tool reveals Resident #61 is to have showers on Tues/Fri schedule. Resident #61 admitted Friday, June 12. Baths documented as Not Applicable for 4 days and not documented at all on 2 days for June. For July the resident refused 1 bath and was marked not applicable 1 day and documented independent for 2 days. Interview on 07/22/26 at 2:10 PM with Regional Clinical Director #337 confirmed that staff are documenting Not Applicable for baths. She is unsure of what that means. Policy titled Activities of Daily Living (ADLs) and dated March 2018 reveals Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 10. Review of Resident #62 medical record revealed an admission date of 02/13/23 with diagnoses of type 2 diabetes mellitus, major depressive disorder, heart failure, anxiety disorder, and contracture of muscle of left hand. Review of the Quarterly MDS dated [DATE] revealed Resident #62 was cognitively intact. Further review revealed Resident #62 required set-up assistance with eating, required partial assistance with bed mobility, required substantial assistance with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and was dependent on staff assistance with transfers. Further review revealed Resident #62 was frequently incontinent of bowel and bladder. Review of the care plan with a revision date of 06/29/26 revealed Resident #62 had a physical functioning deficit related to mobility impairment and self-care impairment with interventions of extensive assistance with personal hygiene and toileting. Interview on 07/22/26 at 9:50 A.M. with Certified Nursing Assistant (CNA) #208 confirmed the facility was out of linen on [NAME] hall every morning until about 10:30 A.M. through 11:00 A.M. when laundry brings the linen down after washing it. Interview confirmed Resident #62 has not had incontinent cares this morning due to no linens being available. Interview on 07/22/26 at 10:02 A.M. with CNA #238 confirmed there was no linen available on Oak hall. Interview confirmed this occurs every day and night shift, there is never any linen available in the facility. Staff is unable to provide incontinence cares or baths due to no linen being available. Interview confirmed incontinence care has not being provided to to Resident #62 due to no linen being available. Interview confirmed Resident #62 is currently lying in urine due to no linen being available. 11. Review of Resident #91 medical record revealed an admission dated of 07/11/26 with diagnoses of essential (primary) hypertension, type 2 diabetes mellitus without complications, chronic kidney disease, stage 3, and acute on chronic diastolic (congestive) heart failure. Review of the admission Data Collection assessment dated [DATE] revealed Resident #91 was frequently incontinent of urine and bowel. Review of the admission Data Collection assessment dated [DATE] revealed Resident #91 was dependent on staff assistance with toileting and bathing and was frequently incontinent of urine and bowel. Review of the admission MDS dated [DATE] revealed Resident #91 had moderate cognitive impairment. There was no assessment completed on assistance needs due to new resident. Interview on 07/22/26 at 9:50 A.M. with CNA #208 confirmed the facility is out of linen on [NAME] hall every morning until about 10:30 A.M. through 11:00 A.M. when laundry brings the linen down after washing it. Interview confirmed Resident #91 has not had incontinent cares this morning due to no linens being available. Interview on 07/22/26 at 10:02 A.M. with CNA #238 confirmed there is no linen available on Oak hall. Interview confirmed this occurs every day and night shift, there is never any linen available in the facility. We are unable to provide incontinence cares or baths due to no linen being available. Interview confirmed incontinence care has not being provided to to Resident #91 due to no linen being available. Review of the policy titled Activities of Daily Living (ADLs), dated March 2018 reveals residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. This deficiency represents non-compliance investigated under Complaint Number 1382129, 1382132, 1382134, 1382136, 2609429, 2692083, 2702995, 2804246, 3040119, 3047241, 3051378, 3071851, and 3120219.

Based on medical record review, staff interviews and policy review, the facility failed to revise care plans and conduct care conferences in a timely manner. This affected five (Residents #2, #7, #9, #10, and #18) of 22 residents sampled for care plans. The facility census was 96. Findings include: Findings include: 1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] and had diagnoses including unspecified cerebrovascular disease, chronic respiratory failure with hypoxia, type II diabetes, generalized anxiety disorder, major depressive disorder, non-ruptured cerebral aneurysm, and displacement of indwelling ureteral stent. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had severely impaired cognition, had no behaviors, did not wander, and did not reject care. Review of a care plan dated 04/27/22 revealed Resident #7 had an Advance Directive as evidenced by Full Code. Interventions included performing Cardiopulmonary Resuscitation (CPR) as ordered, following facility protocol for identification of code status, informing family of change in condition, obtaining advanced directive with physician and resident/representative signatures, and revising code status quarterly. Review of paper titled DNR Comfort Care dated 05/05/26 revealed the physician and Resident #7's Representative signed authorization for DNR Comfort Care (DNRCC). During an interview on 07/23/26 at 7:52 A.M., the Director of Nursing (DON) verified Resident #7 was care planned as a Full Code status, and Resident #7 was DNRCC. The DON verified Resident #7's care plan was inaccurate and should have been revised when his code status was changed. Review of policy titled Advance Directives, dated 09/2022 revealed the interdisciplinary team was informed of changes and or revocations regarding advance directive so that appropriate changes were made in the resident medical record and care plan. 2. Review of the medical record for Resident #10 revealed an admission date of 06/17/26. Diagnoses included heart failure, chronic kidney disease stage three B, and atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of one. The resident was assessed to require substantial assistance with eating, toileting, dressing, and transfers. Review of the weekly skin check dated 06/23/26 revealed Resident #10 had a calloused area/deep tissue injury (DTI) noted to the right inner heel, which measured 3.0 centimeters (cm) in length (L) by 4.0 cm in width (W). Resident #10 was also noted to have moisture associated skin damage (MASD) to the coccyx. No orders were implemented at this time. No documentation of family or physician notification. Review of the initial wound evaluation note dated 06/25/26 revealed Resident #10 had an unstageable deep tissue injury, purple/maroon dry blister, which measured 3.0 cm in L by 3.0 cm in W by unable to be determined (UTD) for depth (D). New orders to apply skin prep once daily and as needed. Resident #10 had an unstageable deep tissue injury to the coccyx, intact normal color 90 percent (%), which measured 6.0 cm in L by 6.0 cm in W by 0.1 cm in D. New orders to apply house barrier cream every shift and as needed. Review of the care plan dated 07/08/26 revealed Resident #10 had a pressure injury and was at risk for further impaired skin integrity and delay wound healing related to impaired mobility, incontinence, and chooses to sit in wheelchair for long periods of time. Resident #10 had an unstageable due to necrosis for coccyx and right medial heel. Interventions included air mattress with lateral supports, assist to encourage turning and repositioning to off-load wounds and promote wound healing, complete weekly skin evaluation per policy, elevate heels off bed, and wound care as ordered by physician. Interview on 07/22/26 at 2:25 P.M. with MDS #297 verified a care plan was not created for pressure sores that were discovered on 06/23/26 until 07/08/26. 3. Review of the medical record revealed Resident #2 had an admissions date of 08/16/24 with diagnoses including acute chronic diastolic heart failure, type 2 diabetes, dementia, and delusional disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 is cognitively impaired. Review of the medical record revealed Resident #2 last had a care conference on 12/20/25. Interview on 07/27/2026 at 11:25 A.M., with Social Services #309 verified that he did not have documentation of Resident #2 being offered a care conference in 2026 and that they should be done quarterly. 4. Review of the medical record revealed Resident #9 had an admission date of 11/23/25 with diagnoses including chronic obstructive pulmonary disease, flaccid neuropathic bladder, and resistance to multiple antibiotics. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 is cognitively impaired. Resident #9 was dependent on staff for eating. Review of the care plan revealed Resident #9 has a physical functioning deficit related to mobility impairment and self care impairment. Interventions include moderate assistance with eating. Interview on 07/23/26 at 11:30 A.M., with the DON verified the care plan had not been updated to reflect Resident #9's care needs with eating. 5. Review of the medical record revealed Resident #18 had an admissions date of 04/08/25 with diagnoses including dysphagia and need for assistance with personal care. Review of the MDS assessment dated [DATE] revealed Resident #18 was unable to be assessed for cognition. Resident #18 is dependent for eating, toileting, bathing, mobility and transfers. Review of the care conferences for Resident #18 for 04/23/25, 06/17/25, 01/30/26, 04/09/26, and 07/01/26 revealed the only staff in attendance were Social Services and a nurse. Review of the progress note dated 10/21/25 revealed Resident #18's family declined the quarterly care conference. Further review of the medical record revealed no documentation of the facility having a care plan meeting. Interview on 07/22/26 at 9:24 A.M. with Social Services (SS) #309 verified the only staff in attendance was him and a nurse. SS #309 verified that he did not have documentation of the interdisciplinary team meeting to discuss Resident #18's care after family declined to have a meeting in October 2025. Review of the facility policy titled Care Planning – Interdisciplinary Team, dated March 2022 revealed the interdisciplinary team (IDT) is responsible for development of resident care plans. The IDT includes but is not limited to: residents attending physician, registered nurse, nursing assistant, member of the food and nutrition services staff, extent practicable the resident or resident representative, and other staff as appropriate. This deficiency represents non-compliance investigated under Complaint Number 2702995.

Based on medical record review, observation, staff and resident interviews, and policy reviews, the facility failed to provide appropriate services for residents on dialysis. This affected two (#91 and #124) of two residents sampled for dialysis. The facility census was 96. Findings include: 1. Review of Resident #91 medical record revealed an admission date of 07/11/26 with diagnoses of essential hypertension, type 2 diabetes mellitus without complications, chronic kidney disease, stage 3, and acute on chronic diastolic (congestive) heart failure. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #91 had moderate cognitive impairment. Further review resident assessment was not complete due to resident admitting to the facility recently. Review of the physician orders for Resident #91 revealed an order dated 07/18/26 for dialysis on Tuesday and Saturday with [NAME] Dialysis Center on [NAME] with chair time of 10:00 A.M. Review of Resident #91 medical record revealed no documentation of communication with the dialysis center. Interview and observation on 07/22/26 at 3:17 P.M. with Medical Records #299 confirmed she is responsible for filing all paperwork, including dialysis paperwork. Interview confirmed Resident #91 does not have dialysis communication paperwork present showing pre and post dialysis assessments. Interview also confirmed there is no proof of documentation between the dialysis center and the facility. Interview with Resident #91 on 07/22/26 at 3:18 P.M. with Medical Records #299 present confirmed resident does not have any type of documentation she is given to take to dialysis and there is no documentation available showing what the dialysis physician has communicated to the facility. Interview also confirmed Resident #91 has attended dialysis two to three times weekly since admission on [DATE]. 2. Review of the medical record revealed Resident #124 was admitted to the facility on [DATE] and was discharged on 06/28/25. Diagnoses included end stage renal disease with hemodialysis, congestive heart failure, and type II diabetes. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #124 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #124 received hemodialysis. Review of the medical record revealed Resident #124 had physician orders dated 06/25/25 for dialysis services through [NAME] Trotwood Dialysis every Tuesday, Thursday, and Saturday. Pick-up at 9:15 A.M. for a Chair time of 10:15 A.M. Review of progress note dated 06/27/25 revealed the Administrator met with Resident #124's daughter regarding concerns that Resident #124 had been late returning to the facility from dialysis on 06/26/25 related to the transport being cancelled. Review of progress note dated 06/28/26 revealed Resident #124 was not picked up for dialysis on Saturday, 06/28/26. The nurse called the transport company and discovered transportation had not been scheduled. During an interview on 07/27/2026 at 10:05 A.M. the DON verified Resident #124 missed her dialysis appointment on 06/28/25 due to transportation not set up. Review of policy titled End Stage Renal Disease (ESRD), Care of a Resident with dated 09/2010 revealed residents receiving dialysis care outside the facility were care for by staff trained on the care and special needs of residents with ESRD according to currently recognized standards of care. This is deficiency represents noncompliance investigated under Complaint Number 1382136.

Based on medical record review, review of facility self-reported incidents (SRI's) and staff interviews, the facility failed to provide behavioral health services to adequately address a residents sexual behaviors. This affected one (#14) out of two reviewed for behavioral health services. The facility census was 96. Findings include: Review of Resident #14 medical record revealed an admission date of 01/03/26 with diagnoses of type 2 diabetes mellitus without complications, spinal stenosis, cervical region, chronic viral hepatitis c, paranoid schizophrenia, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #14 quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact. Resident required set-up assistance with eating, oral hygiene, and wheelchair mobility, and required supervision assistance with toileting hygiene, bathing, dressing, personal hygiene, bed mobility, transfers, and ambulation. Review of Resident #14 physician orders revealed an order dated 06/17/26 for one-on-one monitoring every shift. Review of the care plan dated 01/09/26 revealed Resident #14 required set-up assistance with transfers, dressing, and ambulating. Review of a SRI, dated 03/20/26 revealed Resident #14 was observed alone in his room with Resident #59. Resident #59 pants were down and Resident #14 had his hand on Resident #59 vagina. Resident #59 had a diagnoses of dementia and a brief interview for mental status of 10, moderate cognitive impairment. Residents were separated. Facility found the incident to be consensual. Further review revealed a care plan dated 05/28/26 Resident #14 has a behavior problem with interventions of administer medications as ordered. Monitor/document for side effects and effectiveness, caregivers to provided opportunity for positive interaction, attention, stop and talk with him/her as passing by, minimize potential for the resident's disruptive behaviors by offering tasks which divert attention, monitor triggers for behaviors and de-escalated. Review of the progress note dated 06/14/26 at 7:24 P.M. revealed Resident #14 was observed motioning another female resident with dementia to come to his room. Review of further progress notes revealed one-on-one monitoring was done on 06/17/26, 06/18/26, 06/27/26, 07/01/26, 07/13/26, 07/14/26, and 07/19/26. Review of the 30-Day notice, dated 07/08/26 revealed Resident #14 was issued a 30-day notice due to the safety of individuals in the home was endangered. Interview on 07/21/26 at 2:19 P.M. with the Administrator (LNHA) confirmed Resident #14 tried to entice another female into his room, with this not being the first incident. Interview confirmed another female resident was found with her pants down in Resident #14 room, with his hand on the other resident's vagina area. Interview also confirmed Resident #14 does not have a care plan for sexual behaviors and does not have a care plan for one - on - one monitoring. Interview confirmed Resident #14 has not been referred to psych services for sexual behaviors. Interview also confirmed there is no physician order for Resident #14 to see psych services. Interview also confirmed Resident #14 was given a 30-day notice due to his behaviors of entice female residents to his room and is awaiting the results of his appeal. Interview also confirmed there is no policy for referring to psych services. This deficiency represents non-compliance investigated under Complaint Number 2609543.

Based on record review, observations, staff interviews, and policy review, the facility failed to ensure speech therapy (ST) evaluations were completed as ordered for Resident #18. Additionally, the facility failed to follow up with ST when Resident #109 had coughing concerns following successfully being discharged from services. This affected two (#18 and #109) of two residents reviewed for therapy services. The facility census was 96. Findings include: 1. Review of the medical record revealed Resident #18 had an admissions date of 04/08/25 with diagnoses including dysphagia and need for assistance with personal care. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was unable to be assessed for cognition. Resident #18 is dependent for eating, toileting, bathing, mobility and transfers. Review of the progress note dated 11/09/25 revealed Resident #18 was having episodes of coughing. When an aide provided fluids the Resident #18 per family's request, she was noted to cough each time she eats or drinks. The physician was notified, stat chest x-ray was ordered, and it was noted that a swallow evaluation may be needed. Review of the speech therapy notes revealed Resident #18 was discharged on 12/05/25 with the recommendation of an NPO (nothing by mouth) diet. Review of the Modified Barium Swallow results dated 12/18/25 revealed that Resident #18 was recommended a puree diet with thin liquid. Resident #18 would likely benefit from skilled dysphagia feeding and/or management plan directed by a speech language pathologist. The treatment plan included for the tolerance of treatment recommendations to be assessed by facility speech language pathologist for appropriateness. Review of the medical records revealed that Resident #18 was not evaluated by the speech therapist for tolerance of the diet order. Interview on 07/22/26 at 11:16 A.M. with Rehab Director #312 verified that Resident #18 should have been seen by the speech therapist after the Modified Barium Swallow test on 12/18/25. Rehab Director #312 verified that Resident #18 was last seen by speech therapy on 12/05/25 and the recommendation was for an NPO diet. 2. Review of the medical record revealed Resident #109 had an admissions date of 05/20/21 with diagnoses including dysphagia. Review of the MDS assessment dated [DATE] revealed Resident #109 was cognitively impaired. Resident #109 required set up and clean up assistance with eating and dependent for toileting and showering. Resident #109 was dependent for transfers and bed mobility. Review of the speech therapy notes revealed that he started therapy on 05/19/26 due to difficulty swallowing and was discharged from therapy on 06/30/26 with a puree diet after 20 successful trials. Review of the Documentation Survey Report for July 2026 revealed Resident #109 was reported coughing at meals on 07/08/26, 07/15/26, and 07/16/26. Observation on 07/21/2026 at 8:18 A.M. revealed Resident #109 in the dinning room with a Certified Nursing Assistant helping him with his meal. Resident #109 was observed coughing throughout the meal. Interview on 07/21/2026 at 8:20 A.M. with Registered Nurse #315 verified that it was normal for Resident #315 to cough throughout his meal as he has had problems with swallowing. Interview on 07/22/26 at 11:22 A.M. with Rehab Director #312 verified that the last time Resident #109 was seen by speech therapy was at the end of June 2026 and that no new concerns have been reported to her. Rehab Director #312 stated that she would expect the facility to notify the therapy department if a resident was coughing during meals so the resident could be evaluated. Review of the facility policy titled Speech Therapy dated May 2013 revealed the purpose is to identify, assess and treat speech and language problems including swallowing disorders. Review of the facility policy titled Dysphagia - Clinical Protocol dated September 2017 revealed staff and practitioner, in conjunction with the speech language pathologist, will define the situation carefully and whether the situation needs additional evaluation and clarification. This deficiency represents non-compliance investigated under Complaint Number 3040119.

Based on record review, observation, resident and staff interviews, and policy review, the facility failed to administered medications as ordered. This affected two (#62 and #69) out of eight residents reviewed for medication administration. The facility census was 96. Findings include: 1. Review of Resident #62 medical record revealed an admission date of 02/13/23 with diagnoses of type 2 diabetes mellitus, major depressive disorder, heart failure, anxiety disorder, and contracture of muscle of left hand. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #62 was cognitively intact. Resident required set-up assistance with eating, required partial assistance with bed mobility, required substantial assistance with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and was dependent on staff assistance with transfers. Review of the care plan dated 06/29/26 revealed Resident #62 had a physical functioning deficit related to mobility impairment and self-care impairment with interventions of bilateral half side rails as enabler bars, bed mobility assistance of two staff, call bell within reach, encourage choices with care, and praise efforts at participation. Interview on 07/20/26 at 10:34 A.M. Resident #62 confirmed she has not received her 8:00 A.M. medication yet today. Further review of the Medication Administration Record for July 2026 revealed on 07/20/26 Resident #62 had not received fourteen (14) of her 8:00 A.M. medications including Apixaban oral tablet 5 MG that was scheduled twice daily at 8:00 A.M. and 8:00 P.M. for blood clot prevention, Buspirone HCl 15 MG Tablet that that was scheduled twice daily at 8:00 A.M. and 8:00 P.M. for anxiety, Carvedilol Oral Tablet 6.25 MG that that was scheduled twice daily at 8:00 A.M. and 8:00 P.M. for hypertension, Sacubitril-Valsartan oral tablet 24-26 MG that that was scheduled twice daily at 8:00 A.M. and 8:00 P.M. for heart failure, Vistaril Oral Capsule 25 MG tablet that that was scheduled twice daily at 8:00 A.M. and 8:00 P.M. for anxiety, Interview on 07/20/26 at 11:07 A.M. with Licensed Practical Nurse (LPN) #285 confirmed she has not administered Resident #62 8:00 A.M. medications due to not having time. Interview on 07/23/26 at 8:44 A.M. with Licensed Practical Nurse (LPN) #285 confirmed on 07/20 26 at 1:13 P.M. she administered the 7:30 A.M. and 8:00 A.M. medications to residents on the Oak unit, including Resident#62. Interview also confirmed the medication administration times should be one hour before and one hour after the scheduled administration times. 2. Review of Resident #69 medical record revealed an admission date of 01/14/26 with diagnoses of unspecified fracture of shaft of left tibia, subsequent encounter for closed fracture with routine healing, presence of right artificial hip joint, acute and chronic respiratory failure with hypoxia, major depressive disorder, unspecified fracture of shaft of left fibula, subsequent encounter for closed fracture with routine healing, and acute on chronic diastolic (congestive) heart failure. Review of the Discharge Return Anticipated MDS dated [DATE] revealed Resident #69 was cognitively intact. Resident was independent with bed mobility, required set-up assistance with eating, oral hygiene, and wheelchair mobility, required supervision assistance with personal hygiene, transfers, and ambulation, required partial assistance with dressing, and required substantial assistance with toileting hygiene, and bathing. Review of the care plan dated 05/29/26 revealed Resident #69 had activities of daily living (ADLs) self-care performance deficit r/t activity intolerance with interventions of set-up assistance with ADLs. Review of the Medication Administration Record for July 2026 revealed on 07/20/26 revealed Resident #69 had not received fourteen (11) of his 8:00 A.M. medications including Linzess Oral Capsule 290 MCG daily for acid reflux, Doxycycline Monohydrate Oral Tablet 100 MG that that was scheduled twice daily at 8:00 A.M. and 8:00 P.M. for sepsis, Tamsulosin HCl Oral Capsule 0.4 MG that that was scheduled twice daily at 8:00 A.M. and 8:00 P.M. for benign prostatic hyperplasia (BPH), Sucralfate Oral Suspension (Sucralfate) Give 10 ml by mouth before meals that that was scheduled at 7:30 A.M., 11:30 A.M., 4:00 P.M. and 9:00 P.M. for supplement. Interview on 07/20/26 at 11:07 A.M. with Licensed Practical Nurse (LPN) #285 confirmed she has not administered Resident #69 8:00 A.M. medications due to not having time. Interview on 07/23/26 at 8:44 A.M. with LPN #285 confirmed on 07/20 26 at 1:13 P.M. she administered the 7:30 A.M. and 8:00 A.M. medications to residents on the Oak unit, including Resident #69. Interview also confirmed the medication administration times should be one hour before and one hour after the scheduled administration times. Review of the Administering Medications policy, dated April 2019 revealed medications are administered in a safe and timely manner as prescribed. Further revealed medications will be administered within one hour of their prescribed time. This deficiency represents non-compliance investigated under Complaint Number 1382132, 1382133, 2702995, and 3047241.

Based on record review, staff interview and policy review, the facility failed to prevent resident to resident sexual abuse and staff to resident verbal abuse for residents. This affected two (Resident #14 and #75) out of seven residents reviewed for abuse. The facility census was 96.1. Review of Resident #14's medical record revealed an admission date of 01/03/26. Diagnoses included type II diabetes mellitus without complications, spinal stenosis, cervical region, chronic viral hepatitis c, paranoid schizophrenia, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Review of the care plan dated 01/09/26 revealed Resident #14 required set-up assistance with transfers, dressing, and ambulating. Review of Resident #14's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Resident #14 required set-up assistance with eating, oral hygiene, and wheelchair mobility, and required supervision assistance with toileting hygiene, bathing, dressing, personal hygiene, bed mobility, transfers, and ambulation.Review of Resident #14's physician orders revealed an order dated 06/17/26 for one-to-one monitoring every shift.Review of the Self Reported Incident Number 272304 dated 03/20/26 revealed Resident #14 was observed alone in his room with Resident #59. Resident #59 pants were down and Resident #14 had his hand on Resident #59's vagina. Resident #59 had a diagnoses of dementia and a brief interview for mental status of 10, moderate cognitive impairment. Residents were separated. Resident #59 thought Resident #14 was someone else and requested her husband not to be told of the incident even though her husband had passed away. The facility found the incident to be consensual and did no other preventative measures.Further review revealed a care plan dated 05/28/26 Resident #14 had a behavior problem with interventions of administer medications as ordered. Monitor/document for side effects and effectiveness, caregivers to provided opportunity for positive interaction, attention, stop and talk with him/her as passing by, minimize potential for the resident's disruptive behaviors by offering tasks which divert attention, monitor triggers for behaviors and de-escalate.Review of the progress note dated 06/14/26 at 7:24 P.M. revealed Resident #14 was observed motioning another female resident with dementia to come to his room.Review of further progress notes revealed one-to-one monitoring was done on 06/17/26, 06/18/26, 06/27/26, 07/01/26, 07/13/26, 07/14/26, and 07/19/26.Review of the 30-Day notice, dated 07/08/26 revealed Resident #14 was issued a 30-day notice due to the safety of individuals in the home was endangered.Interview on 07/21/26 at 2:19 P.M., with the Administrator confirmed Resident #14 tried to entice another female into his room, with this not being the first incident. Interview confirmed another female resident was found with her pants down with Resident #14 in his room, with his hand on other resident's vagina area. Interview also confirmed Resident #14 does not have a care plan for sexual behaviors and does not have a care plan for one-to-one monitoring. The Administrator confirmed Resident #14 had not been referred to psychiatric services for sexual behaviors and there was no physician order for Resident #14 to see psychiatric services. The Administrator said Resident #14 was given a 30-day notice due to his behaviors of enticing female residents to his room and was awaiting the results of his appeal. 2. Review of Resident #75's medical record revealed an admission date of 12/16/25 with diagnoses of chronic respiratory failure with hypoxia, type II diabetes mellitus, paroxysmal atrial fibrillation, chronic systolic congestive heart failure, major depressive disorder, and morbid obesity.Review of the care plan for Resident #75 dated 03/2026 revealed the resident sometimes has behaviors which include shouting at staff and refusing medication with interventions of helping resident to avoid situations or people that are upsetting to resident, make sure resident is not in pain or uncomfortable, and refer me to my psychologist/psychiatrist as needed.Further review of the care plan for Resident #75 revealed a care plan dated 05/29/26 where resident was at risk for being socially inappropriate and disrupt to the facility with interventions including resident to reduce the number of times of being socially inappropriate and disruptive, discuss with the physician the need for medication, mental health referral if appropriate, observe for triggers for socially inappropriate and disruptive episodes and intervene at first sign of trigger, and redirect resident and remove from area to provide calming.Review of the general note dated 07/13/26 at 4:30 P.M. revealed allegations were made and the Administrator was aware. Investigation initiated per facility policy. Review of the Self Reported Incident Number 276907 dated 07/13/26 revealed Resident #75 reported Licensed Practical Nurse (LPN) #283 called him an expletive. Resident #75 was observed asking for assistance from LPN #283 at the nurses station. Resident #75 requested a dressing change to a skin area being treated. LPN #283 informed Resident #75 that his treatment was not due. Resident #75 continued to request the dressing change and started to raise his voice. The facility unsubstantiated the allegation of abuse.Review of LPN #283's witness statement revealed Resident #75 requested a dressing change immediately. LPN #283 informed Resident #75 the wound nurse would be in to assess the wound. Resident #75 began yelling and screaming. LPN #283 then told Resident #75 you don't need to be an expletive about it.Interview on 07/27/26 at 1:04 P.M., with Regional Director #330 confirmed the facility did not substantiate the Self Reported Incident for abuse due to the nurse just said you don't have to be an expletive about it out of frustration. The Regional Director #330 confirmed Resident #75 had no ill effects.Review of the policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021 revealed residents have the right to be free from abuse. This includes but is not limited to verbal, mental, sexual or physical abuse. The facility will identify and investigate all incidents of abuse. The facility will establish and implement a review and analysis of reports, allegations or findings of abuse, neglect mistreatment or misappropriation of property.This deficiency represents non-compliance investigated under Complaint Number 1382131, 1382134 and 2596502.

Based on review of the medical record, self-reported incident (SRI) review, review of the facility investigation, interviews, and policy review, the facility failed to ensure resident narcotic medications were not misappropriated. This affected one (Resident #99) of one resident reviewed for misappropriation of medications. The facility census was 96.Findings include:1. Review of the medical record for Resident #99 revealed an admission date of 10/04/23. Diagnoses included congestive heart failure (CHF), anxiety disorder, and major depressive disorder.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #99 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup with eating, supervision with toileting, bathing, dressing, and transfers.Review of the physician order dated 11/24/25 revealed Resident #99 was ordered Oxycodone 10 milligrams (mg), give one tablet by mouth every six hours for pain (12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.).Review of the medication administration record (MAR) dated May 2026 revealed Resident #99 did not miss any doses of Oxycodone 10 mg.Review of the narcotic count sheets dated May 2026 for Resident #99 revealed the following administrations of Oxycodone 10 mg:05/09/26 - given at 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M., and 11:30 P.M. = 5 pills 05/10/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:50 P.M. = 4 pills 05/11/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M. = 3 pills 05/12/26 - given at 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M. = 4 pills 05/13/26 - given at 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M., and 11:30 P.M. = 5 pills 05/14/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 4 pills 05/15/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 4 pills 05/16/26 - given at 6:00 A.M. (CARD GONE) = 30 pills 05/16/26 - given at 12:00 P.M., 6:00 P.M., 11:30 P.M. = 3 pills 05/17/26 - given at 600: A.M., 12:00 P.M., 6:00 P.M., 11:20 P.M. = 4 pills 05/18/26 - given at 6:00 A.M., 2:00 P.M., 10:00 A.M., 2:00 P.M., 6:00 P.M., 2:00 P.M., and one wasted = 7 pills 05/19/26 - given at 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 5 pills 05/20/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M., and 12:00 A.M. = 5 pills 05/21/26 - given at 6:00 A.M., 11:30 A.M., no time written, no time written, no time written = 5 pills 05/22/26 - given at no time written (CARD GONE) = 30 pills 05/22/26 - given at 7:00 A.M., 12:00 P.M. = 2 pills (medication administration record showed signed off for 6:00 P.M. and 12:00 A.M.) 05/23/26 - given at 12:00 P.M. and 6:00 P.M. - 2 pills (medication administration record signed off 12:00 A.M. and 6:00 A.M.) 05/24/26 - given at 12:00 A.M., 6:00 A.M., 8:00 A.M. (crossed out but given), 12:00 P.M., 12:00 P.M., 6:00 P.M., 6:00 P.M., 11:30 P.M. = 8 pills 05/25/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M. = 3 pills 05/26/26 - given at 12:00 A.M., 6:00 A.M., 10:00 A.M., 6:00 P.M., 9:00 P.M. = 5 pills 05/27/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 4 pills 05/28/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 4 pills 05/29/26 - given at 6:00 A.M. and 12:00 P.M. = 2 pills = 30 pillsReview of the self-reported incident dated 05/29/26 revealed on 05/28/26, staff attempted to refill Resident #99's Oxycodone 10 mg. Pharmacy reported the prescription was not available for refill and 30 tablets should be at the facility. Assistant Director of Nursing (ADON) was notified of missing medications. Medication refilled at expense of facility with no doses missed by Resident #99. Medication cart and medication room were searched with no findings. Drug tests were initiated for nurses who had access to the medication cart since delivery of medication. It was identified that narcotic signature sheet for medication cart was missing. Nurses were interviewed. Education was completed by the ADON with all nurses on required narcotic and narcotic count process. Upon review of information, misappropriation was substantiated. Local police were notified as well as Board of Nursing.Interview on 07/27/26 at 9:09 A.M., with pharmacy representative #400 revealed on 05/08/26, the facility received a 15-day supply of 60 tablets of Oxycodone 10 milligrams (mg) for Resident #99, which would have gotten them to 05/23/26. On 05/19/26, the facility received a 15-day supply of 60 tablets of Oxycodone 10 mg for Resident #99, which would have gotten them to 06/07/26. On 05/28/26, the facility received a 15-day supply of 60 tablets of Oxycodone 10 mg for Resident #10. Pharmacy representative #400 verified the facility called and requested Resident #10's Oxycodone 10 mg early on 05/28/26. Pharmacy representative #400 also verified Resident #10's Oxycodone was never pulled from the Pyxis (an emergency supply) during the month of May.Interview on 07/27/26 at 12:02 P.M., with the Administrator, Regional Director (RD) #330, and Regional Clinical Director (RCD) #337 revealed staff tried to reorder the medication on 05/28/26 but pharmacy said it was too early. Staff notified the ADON, and then the facility started to search the medication rooms and medication carts. Once they couldn't locate the medication, interviews and drug screens were started on nurses who had access to that medication cart. Police were notified and filed a report. The board of nursing was notified for four different nurses - Registered Nurse (RN) #341, RN #303, RN #304, and Licensed Practical Nurse (LPN) #284. Medication was reordered, and Resident #99 did not miss any doses of Oxycodone 10 mg. All nurses were educated for narcotic use. It was reported that no discrepancies were found on the narcotic count sheet.Interview on 07/27/26 at 12:12 P.M. with RCD #337 verified discrepancies on Resident #99's narcotic sheet on 05/18/26, 05/22/26, 05/23/26, and 05/24/26.Review of the facility policy titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating revised September 2022 revealed if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source was suspected, the suspicion must be reported immediately to the administrator and to the other officials according to state law. All allegations were thoroughly.This deficiency represents non-compliance investigated under Complaint Number 1382131 and 1382134.

Based on review of the medical record, review of the self-reported incident (SRI), review of the facility investigation, interviews, and policy review, the facility failed to implement the abuse policy regarding misappropriation. This affected one (Resident #99) of one resident reviewed for misappropriation of medications. The facility census was 96.Findings include:1. Review of the medical record for Resident #99 revealed an admission date of 10/04/23. Diagnoses included congestive heart failure (CHF), anxiety disorder, and major depressive disorder.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #99 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup with eating, supervision with toileting, bathing, dressing, and transfers.Review of the physician order dated 11/24/25 revealed Resident #99 was ordered Oxycodone 10 milligrams (mg), give one tablet by mouth every six hours for pain (12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.).Review of the medication administration record (MAR) dated May 2026 revealed Resident #99 did not miss any doses of Oxycodone 10 mg.Review of the narcotic count sheets dated May 2026 for Resident #99 revealed the following administrations of Oxycodone 10 mg:05/09/26 - given at 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M., and 11:30 P.M. = 5 pills 05/10/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:50 P.M. = 4 pills 05/11/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M. = 3 pills 05/12/26 - given at 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M. = 4 pills 05/13/26 - given at 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M., and 11:30 P.M. = 5 pills 05/14/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 4 pills 05/15/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 4 pills 05/16/26 - given at 6:00 A.M. (CARD GONE) = 30 pills 05/16/26 - given at 12:00 P.M., 6:00 P.M., 11:30 P.M. = 3 pills 05/17/26 - given at 600: A.M., 12:00 P.M., 6:00 P.M., 11:20 P.M. = 4 pills 05/18/26 - given at 6:00 A.M., 2:00 P.M., 10:00 A.M., 2:00 P.M., 6:00 P.M., 2:00 P.M., and one wasted = 7 pills 05/19/26 - given at 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 5 pills 05/20/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M., and 12:00 A.M. = 5 pills 05/21/26 - given at 6:00 A.M., 11:30 A.M., no time written, no time written, no time written = 5 pills 05/22/26 - given at no time written (CARD GONE) = 30 pills 05/22/26 - given at 7:00 A.M., 12:00 P.M. = 2 pills (medication administration record showed signed off for 6:00 P.M. and 12:00 A.M.) 05/23/26 - given at 12:00 P.M. and 6:00 P.M. - 2 pills (medication administration record signed off 12:00 A.M. and 6:00 A.M.) 05/24/26 - given at 12:00 A.M., 6:00 A.M., 8:00 A.M. (crossed out but given), 12:00 P.M., 12:00 P.M., 6:00 P.M., 6:00 P.M., 11:30 P.M. = 8 pills 05/25/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M. = 3 pills 05/26/26 - given at 12:00 A.M., 6:00 A.M., 10:00 A.M., 6:00 P.M., 9:00 P.M. = 5 pills 05/27/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 4 pills 05/28/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 4 pills 05/29/26 - given at 6:00 A.M. and 12:00 P.M. = 2 pills = 30 pillsReview of the self-reported incident 05/29/26 revealed 05/28/26, staff attempted to refill Resident #99's Oxycodone 10 mg. Pharmacy reported the prescription was not available for refill and 30 tablets should be at the facility. Assistant Director of Nursing (ADON) was notified of missing medications. Medication refilled at expense of facility with no doses missed by Resident #99. Medication cart and medication room were searched with no findings. Drug tests were initiated for nurses who had access to the medication cart since delivery of medication. Review of the drug screens for nurses revealed Licensed Practical Nurse (LPN) #284 was never drug tested. It was also identified that narcotic signature sheet for medication cart was missing. Nurses were interviewed. Education was completed by ADON with all nurses on required narcotic and narcotic count process. Upon review of information, misappropriation was substantiated. Local police were notified as well as the Board of Nursing.Review of the nursing staff meeting and in-service dated 06/01/26 revealed all nurses were not educated.Interview on 07/27/26 at 9:09 A.M., with pharmacy representative #400 revealed on 05/08/26, the facility received a 15-day supply of 60 tablets of Oxycodone 10 milligrams (mg) for Resident #99, which would have gotten them to 05/23/26. On 05/19/26, the facility received a 15-day supply of 60 tablets of Oxycodone 10 mg for Resident #99, which would have gotten them to 06/07/26. On 05/28/26, the facility received a 15-day supply of 60 tablets of Oxycodone 10 mg for Resident #10. Pharmacy representative #400 verified the facility called and requested Resident #10's Oxycodone 10 mg early on 05/28/26. Pharmacy representative #400 also verified Resident #10's Oxycodone was never pulled from the Pyxis during the month of May.Interview on 07/27/26 at 12:02 P.M., with the Administrator, Regional Director (RD) #330, and Regional Clinical Director (RCD) #337 revealed staff tried to reorder the medication on 05/28/26 but pharmacy said it was too early. Staff notified the ADON, and then the facility started to search the medication rooms and medication carts. Once they couldn't locate the medication, interviews and drug screens were started on nurses who had access to that medication cart. Police were notified and filed a report. The board of nursing was notified for four different nurses - Registered Nurse (RN) #341, RN #303, RN #304, and Licensed Practical Nurse (LPN) #284. Medication was reordered, and Resident #99 did not miss any doses of Oxycodone 10 mg. All nurses were educated for narcotic use. It was reported that no discrepancies were found on the narcotic count sheet.Interview on 07/27/26 at 12:12 P.M., with RCD #337 verified discrepancies on Resident #99's narcotic sheet on 05/18/26, 05/22/26, 05/23/26, and 05/24/26.Interview on 07/27/26 at 1:29 P.M., with interim Director of Nursing (DON) verified all nurses were not educated during in-service on 06/01/26.Review of the facility policy titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating revised September 2022 revealed if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source was suspected, the suspicion must be reported immediately to the administrator and to the other officials according to state law. All allegations were thoroughly.

Based on review of the medical record, review of the self-reported incident (SRI), review of the facility investigation, interviews, and policy review, the facility failed to thoroughly investigate misappropriation of narcotics. This affected one (Resident #99) of one resident reviewed for misappropriation of medications. The facility census was 96.Findings include:1. Review of the medical record for Resident #99 revealed an admission date of 10/04/23. Diagnoses included congestive heart failure (CHF), anxiety disorder, and major depressive disorder.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #99 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup with eating, supervision with toileting, bathing, dressing, and transfers.Review of the physician order dated 11/24/25 revealed Resident #99 was ordered Oxycodone 10 milligrams (mg), give one tablet by mouth every six hours for pain (12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.).Review of the medication administration record (MAR) dated May 2026 revealed Resident #99 did not miss any doses of Oxycodone 10 mg.Review of the narcotic count sheets dated May 2026 for Resident #99 revealed the following administrations of Oxycodone 10 mg:05/09/26 - given at 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M., and 11:30 P.M. = 5 pills 05/10/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:50 P.M. = 4 pills 05/11/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M. = 3 pills 05/12/26 - given at 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M. = 4 pills 05/13/26 - given at 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M., and 11:30 P.M. = 5 pills 05/14/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 4 pills 05/15/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 4 pills 05/16/26 - given at 6:00 A.M. (CARD GONE) = 30 pills 05/16/26 - given at 12:00 P.M., 6:00 P.M., 11:30 P.M. = 3 pills 05/17/26 - given at 600: A.M., 12:00 P.M., 6:00 P.M., 11:20 P.M. = 4 pills 05/18/26 - given at 6:00 A.M., 2:00 P.M., 10:00 A.M., 2:00 P.M., 6:00 P.M., 2:00 P.M., and one wasted = 7 pills 05/19/26 - given at 12:00 A.M., 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 5 pills 05/20/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M., and 12:00 A.M. = 5 pills 05/21/26 - given at 6:00 A.M., 11:30 A.M., no time written, no time written, no time written = 5 pills 05/22/26 - given at no time written (CARD GONE) = 30 pills 05/22/26 - given at 7:00 A.M., 12:00 P.M. = 2 pills (medication administration record showed signed off for 6:00 P.M. and 12:00 A.M.) 05/23/26 - given at 12:00 P.M. and 6:00 P.M. - 2 pills (medication administration record signed off 12:00 A.M. and 6:00 A.M.) 05/24/26 - given at 12:00 A.M., 6:00 A.M., 8:00 A.M. (crossed out but given), 12:00 P.M., 12:00 P.M., 6:00 P.M., 6:00 P.M., 11:30 P.M. = 8 pills 05/25/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M. = 3 pills 05/26/26 - given at 12:00 A.M., 6:00 A.M., 10:00 A.M., 6:00 P.M., 9:00 P.M. = 5 pills 05/27/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 4 pills 05/28/26 - given at 6:00 A.M., 12:00 P.M., 6:00 P.M., 11:30 P.M. = 4 pills 05/29/26 - given at 6:00 A.M. and 12:00 P.M. = 2 pills = 30 pillsReview of the self-reported incident 05/29/26 revealed 05/28/26, staff attempted to refill Resident #99's Oxycodone 10 mg. Pharmacy reported the prescription was not available for refill and 30 tablets should be at the facility. Assistant Director of Nursing (ADON) was notified of missing medications. Medication refilled at expense of facility with no doses missed by Resident #99. Medication cart and medication room were searched with no findings. Drug tests were initiated for nurses who had access to the medication cart since delivery of medication. Review of the drug screens for nurses revealed Licensed Practical Nurse (LPN) #284 was never drug tested. It was also identified that narcotic signature sheet for medication cart was missing. Nurses were interviewed. Education was completed by ADON with all nurses on required narcotic and narcotic count process. Upon review of information, misappropriation was substantiated. Local police were notified as well as the Board of Nursing.Review of the nursing staff meeting and in-service dated 06/01/26 revealed all nurses were not educated.Interview on 07/27/26 at 9:09 A.M., with pharmacy representative #400 revealed on 05/08/26, the facility received a 15-day supply of 60 tablets of Oxycodone 10 milligrams (mg) for Resident #99, which would have gotten them to 05/23/26. On 05/19/26, the facility received a 15-day supply of 60 tablets of Oxycodone 10 mg for Resident #99, which would have gotten them to 06/07/26. On 05/28/26, the facility received a 15-day supply of 60 tablets of Oxycodone 10 mg for Resident #10. Pharmacy representative #400 verified the facility called and requested Resident #10's Oxycodone 10 mg early on 05/28/26. Pharmacy representative #400 also verified Resident #10's Oxycodone was never pulled from the Pyxis during the month of May.Interview on 07/27/26 at 12:02 P.M., with the Administrator, Regional Director (RD) #330, and Regional Clinical Director (RCD) #337 revealed staff tried to reorder the medication on 05/28/26 but pharmacy said it was too early. Staff notified the ADON, and then the facility started to search the medication rooms and medication carts. Once they couldn't locate the medication, interviews and drug screens were started on nurses who had access to that medication cart. Police were notified and filed a report. The board of nursing was notified for four different nurses - Registered Nurse (RN) #341, RN #303, RN #304, and Licensed Practical Nurse (LPN) #284. Medication was reordered, and Resident #99 did not miss any doses of Oxycodone 10 mg. All nurses were educated for narcotic use. It was reported that no discrepancies were found on the narcotic count sheet.Interview on 07/27/26 at 12:12 P.M., with RCD #337 verified discrepancies on Resident #99's narcotic sheet on 05/18/26, 05/22/26, 05/23/26, and 05/24/26.Interview on 07/27/26 at 1:29 P.M., with interim Director of Nursing (DON) verified all nurses were not educated during in-service on 06/01/26.Review of the facility policy titled, Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating revised September 2022 revealed if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source was suspected, the suspicion must be reported immediately to the administrator and to the other officials according to state law. All allegations were thoroughly.

Based on medical record review, observations, staff interviews, and policy review, the facility failed to timely implement interventions for newly identified pressure ulcer. This affected one (#10) of five residents reviewed for pressures. The facility census was 96. Findings include:Review of the medical record for Resident #10 revealed an admission date of 06/17/26. Diagnoses included heart failure, chronic kidney disease stage three B, and atrial fibrillation. Review of the Braden Scale dated 06/17/26 revealed Resident #10 was at moderate risk for pressure ulcers. Review of the care plan dated 06/20/26 revealed Resident #10 had potential impairment to skin integrity. Interventions included to avoid scratching and keep hands and body parts from excessive moisture, encourage good nutrition and hydration, obtain blood work as ordered, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of one. This resident was assessed to require substantial assistance with eating, toileting, dressing, and transfers. Review of the weekly skin check dated 06/23/26 revealed Resident #10 had a calloused area/deep tissue injury (DTI) noted to right inner heel, which measured three centimeters (cm) in length (L) by four cm in width (W). Resident #10 was also noted to have moisture associated skin damage (MASD) to the coccyx. No orders were implemented at this time. No documentation of family or physician notification. Review of the treatment administration record (TAR) dated June 2026 for Resident #10 revealed no orders were implemented for skin breakdown from 06/23/26 until 06/25/26 when seen by the wound care team. Review of the initial wound evaluation note dated 06/25/26 revealed Resident #10 had an unstageable deep tissue injury, purple/maroon dry blister, which measured three cm in L by three cm in W by unable to be determined (UTD) for depth (D). New orders to apply skin prep once daily and as needed. Resident #10 had an unstageable deep tissue injury to the coccyx, intact normal color 90 percent (%), which measured six cm in L by six cm in W by 0.1 cm in D. New orders to apply house barrier cream every shift and as needed. Observation on 07/23/26 at 1:15 P.M. revealed wound care was completed by Wound Physician (WP) #353. Areas had improved. Right heel blister was removed with new skin underneath. Coccyx measured six cm in L by 2 cm in W by 0.1 D. Wound bed was pink (granulation tissue). Wound was cleaned with no concerns. Interview on 07/23/26 at 3:21 P.M. with WP #353 verified staff should have received treatment orders and implemented them on 06/23/26 when the areas were discovered on Resident #10. Review of the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018 revealed the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. The physician will order pertinent wound treatments including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. The physician will guide the care plan as appropriate. This deficiency represents non-compliance investigated under Complaint Number 1382132, 2804246, 3047241, and 3071851.

Based on medical record review, observations, staff interviews, review of the admission packet, and policy review, the facility failed to ensure fall interventions were in place as ordered and/or failed to provide adequate supervision to ensure residents adhered to the smoking policy. This affected four (#19, #63, #92, and #98) of nine residents reviewed for accidents. The facility census was 96. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 01/02/26. Diagnoses included type II diabetes mellitus (DM II), anxiety disorder, and diverticulitis. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require independent with eating, supervision with toileting, bathing, and dressing, and independent with transfers. Review of the smoking evaluation dated 07/07/26 revealed Resident #19 was a current smoker. Observation on 07/20/26 at 1:05 P.M. of resident outside on facility property smoking. Interview on 07/21/26 at 11:05 A.M. with the Administrator verified the facility was a non-smoking facility. Interview on 07/22/26 at 10:52 A.M. with Regional Clinical Director (RCD) #337 verified residents were not supposed to keep smoking devices on their person, and the nurses were responsible for keeping the smoking devices. RCD #337 also verified residents were not to smoke on facility grounds. Observation on 07/22/26 at 11:04 A.M. revealed Resident #19 was in her room rolling her own cigarettes. Resident #19 had about 15 cigarettes lying on her dresser. Interview on 07/22/26 at 11:06 A.M. with Resident #19 revealed she was never asked to turn in her smoking devices. 2. Review of the medical record for Resident #63 revealed an admission date of 05/05/26. Diagnoses included malignant neoplasm of the mouth, transient cerebral ischemic attack, and pneumonia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. This resident was assessed to require partial assistance with toileting, transfers, and dressing, and supervision with bathing. Review of section J for health conditions of the admission MDS assessment dated [DATE] revealed Resident #63 was a current tobacco user. Review of the care plan dated 05/19/26 revealed Resident #63 was a smoker and lived in a non-smoking facility. Interventions included to discuss facility smoking protocol with resident and emphasize importance of compliance for safety, discuss smoking cessation programs and invite resident to try one, and place all smoking equipment in a safe area. Observation on 07/20/26 at 9:06 A.M. revealed Resident #63 was outside smoking on the facility property. Observation on 07/21/2026 at 10:58 A.M. revealed Resident #63 had two packs of cigarettes and lighter inside her purse in her room. Interview on 07/21/2026 at 11:00 A.M. with Resident #63 revealed she kept her smoking devices on her and reported the facility knew she smoked upon admission. Interview on 07/21/2026 at 11:05 A.M. with the Administrator revealed they are a non-smoking facility. Review of the admission packet revealed the facility was a smoke-free environment. Smoking was prohibited unless the building had designated smoke times and designated smoking areas. Residents were not to keep lighters, matches, and other tobacco products in their room. These items must remain at the nurse's station. Review of the facility policy titled, Resident Smoking – Smoke Free Facility, revised August 2022 revealed the policy of the facility was to provide a safe and healthy environment for residents, visitors, and employees. Therefore, it was the policy of the facility to promote smoking cessation efforts while ensuring resident safety as related to residents who smoke. Smoking was prohibited in all areas. 3. Review of the medical record for Resident #98 revealed an admission date of 05/01/26. Diagnoses included displaced fracture of left femur, atrial fibrillation, and congestive heart failure (CHF). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #98 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. This resident was assessed to require setup with eating, dependent with toileting, dependent with dressing, and transfers. Review of the progress note dated 06/15/26 at 6:10 P.M. revealed bilateral fall mats were implemented for a new fall intervention. Review of the progress note dated 06/16/26 at 9:30 A.M. revealed interdisciplinary team reviewed fall on 06/15/26 for Resident #98, who attempted to get out of bed unassisted. New intervention was floor mats to both sides of bed. Observation on 07/23/26 at 10:25 A.M. revealed Resident #98 had one fall mat between window and bed. Interview on 07/23/26 at 10:32 A.M. with Licensed Practical Nurse (LPN) #292 verified Resident #98 did not have bilateral fall mats in place. Review of the facility policy titled, Falls and Fall Risk Managing, revised March 2018 revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. 4. Review of Resident #92 medical record revealed an admission date of 06/12/26 with diagnoses of conversion disorder with seizures or convulsions, hemiplegia, unspecified affecting right dominant side, schizoaffective disorder, bipolar type, delusional disorders, and personal history of traumatic brain injury. Review of the Medicare 5-Day Minimum Data Set (MDS) dated [DATE] revealed Resident #92 had severe cognitive impairment. Resident required substantial assistance with oral hygiene and was dependent on staff assistance all other activities of daily living. Review of the care plan dated 06/15/26 revealed Resident #92 had impaired neurological status related to seizure disorder. Further review revealed there was not a care plan for risk for falls. Review of the progress note dated 07/27/26 at 3:58 P.M. revealed Resident #92 a family member had transferred resident to bed when resident slid off the bed and fell to the floor. Family member was educated that Resident was Hoyer lift for transfers. Observation on 07/29/26 at 11:18 A.M. with Resident #92's family member, along Certified Nursing Assistant (CNA) #356. Resident's family member positioned resident on the side of the bed. The family member told the CNA #356 come on and pulled resident closer to the edge of the bed. When asked if they were going to get the Hoyer lift for the transfer, ethe family member said no and CNA #356 didn't say anything. The family member applied the gait belt to Resident #92, loosely, then the family member and CNA #356 transferred Resident #92 via two person assist to the wheelchair using the gait belt. Then the family member and CNA #356 used the gait belt and under the resident's arms to pull her back in the chair. During the transfers, the back of the gait belt was pulled all the way up to the resident's neck due to being loose. Interview on 07/29/26 at 11:36 A.M. with the Director of Nursing (DON) confirmed Resident #92 had a fall with a family member recently and Resident #92 is to use a Hoyer lift with all transfers with staff and family. Interview confirmed CNA #356 should have used the Hoyer to transfer Resident #92. Interview also confirmed CNA #356 is an agency CNA and new to the facility. Interview on 07/29/26 at 12:01 P.M. with MDS Licensed Practical Nurse (LPN) confirmed Resident #92 does not have an activities of daily living (ADL) care plan, a fall care plan or a positioning care plan and should have one. This deficiency represents non-compliance investigated under Complaint Numbers 1382131, 1382133, 2804246, and 3051378.

Based on medical record review, observations, staff interviews, and policy review, the facility failed to offer feeding assistance to residents as ordered and/or care planned. This affected two (#7 and #10) of 11 residents sampled for ADL assistance. The facility census was 96. Findings include: 1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] and had diagnoses including unspecified cerebrovascular disease, chronic respiratory failure with hypoxia, type II diabetes, generalized anxiety disorder, major depressive disorder, non-ruptured cerebral aneurysm, and displacement of indwelling ureteral stent. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had severely impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #7 was dependent on staff for feeding assistance. Review of the medical record revealed Resident #7 had physician orders dated 04/20/26 for Patient to receive 1:1 assists from staff with meals due to inability to feed self, two times a day and 04/29/26 to Please feed patient at each meal every shift for diet. Review of care plan dated 03/30/2022 revealed Resident #7 was at risk for malnutrition and dehydration. Interventions included providing diet as ordered, monitoring percent of meals consumed, and feeding/assisting with meals as needed. Observation on 07/20/2026 at 3:15 P.M. revealed Resident #7 lay in bed with eyes closed and was mouth-breathing. Resident #7's lunch tray was uncovered on the bedside table positioned over Resident #7's abdomen and the food was untouched. Observation on 07/20/26 at 4:25 P.M. revealed Resident #7 lay in bed with eyes closed. Lunch tray remained uncovered and untouched on the tray table in front of the Resident. Certified Nurse Assistant (CNA) #217 entered Resident #7's room, woke the resident up, placed the fork in his hand, and encouraged Resident #7 to eat. Resident #7 closed his eyes while holding fork. CNA #217 left the room. During an interview on 07/20/26 at 4:25 P.M. CNA #217 stated there were no feeds on the hall and Resident #7 fed himself. During an interview on 07/20/26 at 4:26 P.M. Registered Nurse (RN) #307 stated Resident #7 fed himself sometimes. RN #307 verified he had active orders for feeding assistance in the medical record and stated I don't know why they put that in. During an interview on 07/22/2026 at 9:32 A.M. CNA #236 stated aides set up Resident #7's meal trays, handed him his silverware, and Resident #7 fed himself. CNA #236 stated Resident #7 had not been a 1:1 feed since she had started working at the facility, stated there were no residents who required feeding assistance on the Magnolia unit. 2. Review of the medical record for Resident #10 revealed an admission date of 06/17/26. Diagnoses included heart failure, chronic kidney disease stage three B, and atrial fibrillation. Review of the care plan dated 06/18/26 revealed Resident #10 had an activity of daily living (ADL) self-care performance deficit related to disease process and ischemic stroke resulted in expressive aphasia and right-sided deficits. Interventions included required assist with one-to-one assist with eating. Review of the admission MDS assessment dated [DATE] revealed Resident #10 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of one. This resident was assessed to require substantial assistance with eating, toileting, dressing, and transfers. Review of the physician order dated 06/23/26 revealed Resident #10 was ordered one-to-one assist with meals. Observation on 07/23/26 at 8:24 A.M. revealed Resident #10 was sleeping in bed with breakfast tray on bedside table that was approximately three feet away from the bed and out of reach. Observation revealed breakfast tray had not been touched. Observation on 07/23/26 at 8:37 A.M. revealed Certified Nursing Assistant (CNA) #224 came in to pick up breakfast tray. CNA #224 asked Resident #10 if she wanted to eat, and Resident #10 shook her head no. CNA #224 did not attempt to feed Resident #10. CNA #224 asked Resident #10 if she was thirsty, and Resident #10 shook her head yes. CNA #10 did not attempt to give her fluids but left the juice on the bedside table, which was out of reach for Resident #10. Interview on 07/23/26 at 8:39 A.M. with CNA #224 reported Resident #10 was not a feed. CNA #224 verified Resident #10's breakfast tray and bedside table were out of reach for Resident #10. Interview on 07/23/26 at 9:40 A.M. with MDS #298 verified Resident #10 was a one-to-one assist with meals. Review of the facility policy titled, Activities of Daily Living (ADLs), revised on March 2018 revealed residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming, personal, and oral hygiene. This deficiency represents non-compliance investigated under Complaint Numbers 3071851 and 2702995.

Based on medical record review, staff interviews, and policy reviews, the facility failed to ensure wound care was completed as ordered and failed to send a resident to the emergency department as ordered. This affected one (#97) out of three residents reviewed for wound care and services and changes in condition. The facility census was 95. Findings include: Review of the medical record for Resident #97 revealed an admitted [DATE] with medical diagnoses of influenza, chronic kidney disease stage III, atrial fibrillation, diabetes mellitus, congestive heart failure, peripheral vascular disease. The medical record indicated Resident #97 was discharged on [DATE] to the hospital. Review of the medical record for Resident #97 revealed an Admission Data Collection assessment, dated 03/11/25, which indicated Resident #97 was cognitively intact and required limited staff assistance with bed mobility and extensive staff assistance with transfers and toileting. Review of the medical record for Resident #97 revealed a weekly non-pressure documentation assessment, dated 03/13/25, which stated Resident #97 admitted with arterial ulcers to right heel, left medical foot, left heel and right great toe. Review of the medical record for Resident #97 revealed a physician order dated 03/14/25 for left heel to clean with wound cleaner, pat dry, apply medi-honey to wound bed, cover with dry dressing and to change daily and as needed. Review of the medical record for Resident #97 revealed the March 2025 Treatment Administration Record (TAR) which did not have documentation to support the treatment to Resident #97's left heel was completed on 03/18/25. Review of the medical record for Resident #97 revealed a nurse's note, dated 03/17/25 at 7:03 P.M., written by Registered Nurse (RN) #226, which stated nurse was notified that Resident #97 was having a seizure for approximately two minutes. The note stated vital signs were obtained and the physician on call was notified. The note stated orders were given for stat (immediate) labs and to send Resident #97 to the emergency department (ED) if he had another seizure. The note stated Resident #97's wife was at the bedside and verbalized understanding. Further review of Resident #97's nurse's note dated 03/18/25 at 6:28 P.M., stated the resident had a seizure for two minutes and his wife was present. The note did not have documentation to support Resident #97's physician was notified of second seizure or Resident #97 was sent to the ED as ordered on 03/17/25. Interview on 04/02/25 at 9:10 A.M. with Director of Nursing (DON) confirmed the medical record for Resident #97 did not have documentation to support wound care was done to left heel as ordered on 03/18/25. Interview on 04/02/25 at 9:16 A.M. with RN #226 confirmed Resident #97 had a seizure on 03/17/25 and she had been given orders for stat labs and to send Resident #97 to the ED if he had another seizure. RN #226 stated she entered the orders for the labs into the electronic health record and noted on the nurse report sheet that if Resident #97 had another seizure to send to the ED. RN #226 stated she was not aware Resident #97 had a seizure on 03/18/25 until she returned to work on 03/19/25. RN #226 stated on 03/19/25 Resident #97's daughter requested Resident #97 be sent to the hospital due to second seizure on 03/18/25 and as per physician order on 03/17/25. Review of the facility policy titled, Dressings, dry/clean, revised September 2013 stated staff are to verify physician order for the procedure, check treatment record, review resident's care plan, and current orders, assemble equipment and supplies and explain procedure to the resident. Review of the facility policy titled, Change in Resident's Condition or Status, revised February 2021 stated the facility would promptly notify resident, his or her attending physician, and resident representative of changes in the resident's medical/mental condition and/or status. This deficiency represents non-compliance investigated under Complaint Number OH00164034.

Based on medical record review, staff interview, and policy review, the facility failed to develop a comprehensive person-centered care plan to address a resident's Activities of Daily Living (ADL) and incontinence care needs. This affected one (#37) out of the three residents reviewed for care plans. The facility census was 95. Findings include: Review of the medical record for Resident #37 revealed an admitted [DATE] with medical diagnoses of sepsis, convulsions, hypertension, cerebral infarction, atrial fibrillation, diabetes mellitus, and hypothyroidism. Review of the medical record for Resident #37 revealed a quarterly Minimum Data Set (MDS) assessment, dated 01/28/25, which indicated Resident #37 was cognitively intact and required substantial/maximum assistance with toilet hygiene, bathing, transfers, and bed mobility. The MDS indicated Resident #37 had a indwelling catheter and was always incontinent of bowel. Review of the medical record for Resident #37 revealed there was no documentation to support the facility had developed a comprehensive person-centered care plan to address the residents ADL's and incontinence needs. Interview on 04/02/25 at 11:50 A.M. with Administrator confirmed the medical record for Resident #37 did not have documentation to support a comprehensive person-centered ADL or incontinence care plan had been developed for Resident #37 until 04/02/25. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022 stated the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, would develop and implement a comprehensive, person-centered care plan for each resident. The policy stated the comprehensive, person-centered care plan would include measurable objectives and timeframe's and describe the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being and includes resident's stated goals. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, observations, staff and resident interviews, and policy review, the facility failed to provide timely incontinence care for a dependent resident. This affected one (#37) out of the three residents reviewed for timely incontinence care. The facility census was 95. Findings include: Review of the medical record for Resident #37 revealed an admitted [DATE] with medical diagnoses of sepsis, convulsions, hypertension, cerebral infarction, atrial fibrillation, diabetes mellitus, and hypothyroidism. Review of the medical record for Resident #37 revealed a quarterly Minimum Data Set (MDS) assessment, dated 01/28/25, which indicated Resident #37 was cognitively intact and required substantial/maximum assistance with toilet hygiene, bathing, transfers, and bed mobility. The MDS indicated Resident #37 had a indwelling catheter and was always incontinent of bowel. Review of the medical record for Resident #37 revealed there was no documentation to support the facility had developed a comprehensive person-centered care plan to address the residents Activities of Daily Living (ADL's) and incontinence needs. Observation on 03/31/25 at 2:25 P.M. revealed Resident #37 turned on his call light. The observation revealed a strong odor outside of Resident #37's door. Observation also revealed Licensed Practical Nurse (LPN) #217 was sitting at the nurses station at the time Resident #37 turned his call light on no other staff was observed on the hall. Interview on 03/31/25 at 2:30 P.M. with Resident #37 confirmed he turned on his call light at 2:25 P.M. Resident #37 stated he needed staff assistance to be cleaned up after being incontinent of bowel. Observation on 03/31/25 at 3:12 P.M. revealed Certified Nursing Assistant (CNA) #219 knocked on Resident #37's door and asked if he needed assistance. CNA #219 turned off Resident #37's call light and as she exited Resident #37's room stated she would be back soon to help him get cleaned up. Interview on 03/31/25 at 3:21 P.M. with Resident #37 confirmed CNA #219 turned off his call light and informed Resident #37 she would be back soon to help get him cleaned up. Resident #37 stated he usually has to wait up to 45 minutes for his call light to be answered. Observation on 03/31/25 at 3:23 P.M. revealed CNA #219 entered Resident #37's room and closed the door. Interview on 03/31/25 at 3:35 P.M. with CNA #219 confirmed she completed incontinence cares for Resident #37 and he had been incontinence of his bowel. CNA #219 stated she was not aware of how long Resident #37's call light had been on. CNA #219 also confirmed she entered Resident #37's room and turned off his call light and then left and came back to provide the cares about 10 minutes later. Review of the facility policy titled, Activities of Daily Living (ADL's), revised March 2018 stated residents who are unable to carry out ADL's independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy stated staff would provide the appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care), mobility, elimination (toileting), dining, and communication. This deficiency represents non-compliance investigated under Complaint Number OH00162075.

Based on medical record review, staff interview, and policy review, the facility failed to ensure resident representatives were notified of changes in medications. This affected one (#100) out of the three residents reviewed for notification of medication changes. The facility census was 95. Findings include: Review of the medical record for Resident #100 revealed an admitted [DATE] with medical diagnoses of acute kidney failure, diabetes mellitus, schizophrenia, and anxiety. Review of the medical record for Resident #100 revealed a quarterly Minimum Data Set (MDS) assessment, dated 12/09/24, which indicated Resident #100 had moderate cognitive impairment and required supervision with toilet hygiene, bathing, bed mobility, and transfers. The MDS indicated Resident #100 received an antipsychotic medication, but no other psychotropic medications noted. Review of the medical record for Resident #100 revealed a physician order dated 02/14/25 for sertraline 25 milligram (mg) one tablet by mouth daily for anxiety. The medical record indicated the sertraline was discontinued on 02/21/25. Review of the medical record for Resident #100 revealed the February 2025 Medication Administration Record (MAR) which indicated Resident #100 received sertraline 25 mg tablet daily from 02/16/25 through 02/19/25. The MAR revealed Resident #100 refused the sertraline on 02/20/25 and 02/21/25. Review of the medical record for Resident #100 revealed no documentation to support the facility notified Resident #100 representative of sertraline 25 mg order on 02/14/25. Review of the medical record for Resident #100 revealed a nurse's note, dated 02/21/25 at 8:09 P.M., which stated sertraline was discontinued by psychology nurse practitioner per family request. Interview on 04/02/25 at 9:08 A.M. with Director of Nursing (DON) confirmed the medical record for Resident #100 did not have documentation to support the facility notified Resident #100's representative of the order for sertraline. DON stated the facility did not have a policy for notification of order for new medication. Review of the facility policy titled, Change in Resident's Condition or Status, revised February 2021 stated the facility would promptly notify resident, his or her attending physician, and resident representative of changes in the resident's medical/mental condition and/or status. This deficiency represents non-compliance investigated under Complaint Number OH00162952.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of written statements, review of hospital records, and review of facility policy, the facility failed ensure a resident was provided incontinence care with two-person assistance. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or injuries when Resident #01, who required the assistance of two staff for bed mobility, was provided incontinence care by only one staff, State tested Nursing Assistant (STNA) #05. Resident #01 rolled off the bed and onto the floor, suffering closed fractures to both femurs that required surgical repair. Resident #01 had surgery on 02/05/23 and the surgeon could only place external fixators to both femurs because Resident #01 went into atrial fibrillation with rapid ventricular response (RVR) and had to be mechanically ventilated. When she became stable on 02/08/23, it was discovered the pin on her left femur was causing tension on her skin and she was taken back to surgery to place a left femoral nail. This affected one (Resident #01) of three residents reviewed for falls. The census was 87. On 02/13/23 at 2:40 P.M., the Administrator, Director of Nursing (DON), Chief Operating Officer (COO) #03, and Regional Clinical Nurse (RCN) #04 were notified Immediate Jeopardy began on 02/04/23 at 4:55 P.M. when Resident #01, who required two staff assistance for bed mobility, was rolled out of the bed by one STNA (#05) during incontinence care and fell to the floor. STNA #05 asked Licensed Practical Nurse (LPN) #07 to come into the room and stated the resident fell out of bed while she was changing her. LPN #07 went into the room and found Resident #01 laying on her back with her left leg bent and underneath her bottom. The right femur was protruding from of her right leg. Resident #01 stated she was in a lot of pain and was screaming. The nurse called nine-one-one (911) and the resident was sent to the hospital for evaluation and treatment. Consequently, the resident sustained closed fractures to both femurs that required surgical repair. Resident #01 had surgery on 02/05/23 and the surgeon could only place external fixators to both femurs because Resident #01 went into atrial fibrillation with RVR and had to be mechanically ventilated. When she became stable on 02/08/23, it was discovered the pin on her left femur was causing tension on her skin and she was taken back to surgery to place a left femoral nail. Although the Immediate Jeopardy was removed on 02/05/23, 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) until the deficiency was corrected on 02/08/23 when the facility implemented the following corrective actions: On 02/04/23, the DON, LPN #40, LPN #06 and LPN #46 provided education to direct care staff regarding proper procedure for bed mobility, how to identify staff assistance needed and how to pull the information from the care plan. On 02/05/23, the DON, LPN #40 LPN #06, and RCN #04 reviewed all bed bound residents that received two-person assistance with bed mobility to ensure care plans were accurate. On 02/05/23, the DON reviewed the incident and accident logs to ensure no similar instances were identified. On 02/06/23, the DON, and LPNs #40, #06, and #46 initiated audits to include direct care staff verbalizing where to find information regarding Activities of Daily Living (ADL) assistance requirement and be checked off on this process. Also, a return demonstration of pulling ADL assistance needs from plan of care especially bed mobility and demonstrate proper bed mobility and how to turn and reposition resident towards the caregiver correctly. All staff will verbalize and be checked off. On 02/07/23, the DON, and LPNs #40, #06, and #46 will conduct audits of direct care staff every shift daily, for one week and ongoing audits to consist of five direct care staff members five days a week, for four weeks. On 02/07/23, the DON, and LPNs #40, #06, and #46 placed a Kardex in the resident's closet and a binder at the nursing station for bed mobility information. The staff were educated on this information. All staff will be educated on this prior to working on the unit. On 02/07/23, the Administrator conducted a Quality Assurance and Performance Improvement (QAPI) meeting with the Interdisciplinary Team (IDT), COO #03, CRN #04, and the Medical Director (MD). During interviews on 02/09/23 from 1:41 P.M. to 1:51 P.M., STNAs #16, #27 and #172 stated they had been educated on two-person assistance and how to find it in the medical record, in a binder at the nursing station, and in the closet of the resident. Observation on 02/09/23 at 1:51 P.M. revealed there was a binder at the nursing stations and Kardex's in the closets of the residents so the staff could determine what kind of assistance a resident required for Activities of Daily Living (ADL). Findings include: Medical record review revealed Resident #01 was admitted to the facility on [DATE]. The resident had diagnoses including cerebral infarction, atrial fibrillation, coronary artery disease, and cerebrovascular attack with hemiplegia and hemiparesis to the left side. Review of Minimum Data Set (MDS) assessment, dated 11/30/22, revealed Resident #01 was cognitively intact. She required the assistance of two staff for bed mobility and personal hygiene. She was totally dependent on two staff for transfers. She had impairment on one side for upper and lower extremity. Review of the care plan dated 12/08/22 for Resident #10 revealed she had a physical functioning deficit related to requiring additional assistance due to left hemiplegia related to mobility impairment. Interventions were assistive devices, and bed mobility with two-person assistance. Review of progress notes dated 02/04/23 at 5:11 P.M. revealed STNA #05 was providing personal care to Resident #01 at 4:55 P.M. STNA #05 asked Licensed Practical Nurse (LPN) #07 to come into the room and stated the resident fell out of bed while she was changing her. LPN #07 went into the room and found Resident #01 laying on her back with her left leg bent and underneath her bottom. The right femur was protruding from of her right leg. Resident #01 stated she was in a lot of pain and was screaming. The nurse did not move the resident at all. The nurse called the on-call nurse to inform her of the situation. The nurse then called 911 for the Emergency Medical Transport (EMT) to come and transport the resident to the hospital. Review of the STNA #05 ' s written statement, dated 02/04/23, documented she was changing Resident #01 and had her rolled toward her and cleaned her back side. Resident #01 asked the aide to fix her pillow. When the aide moved to fix the pillow, the resident ' s legs slipped off the bed. When her legs slid, the aide was under her head and the top of the resident ' s body to protect her. The resident ' s left leg was under her Indian style. Review of the hospital records dated 02/04/23 revealed Resident #01 presented to the emergency room with complaints of falling from the bed approximately four feet while nursing home staff was attempting to change the resident. There was obvious deformity to the right femur. She was complaining of bilateral leg pain that was severe. She was in atrial fibrillation with rapid ventricular rate (RVR). She received multiple doses of intravenous Cardizem. She subsequently became hypotensive and required mechanical ventilation and vasopressors transiently. She was awake and agitated by the ventilator. Her final diagnoses included closed fracture of shaft of left and right femur. Review of hospital records dated 02/08/23 revealed Resident #01 had a left femur retrograde intramedullary nail insertion. Resident is with a history of bilateral distal femur fractures. Resident came in over the weekend on 02/04/2023 and on 02/05/2023 she was placed in bilateral femoral external fixators because she went into atrial fibrillation with RVR during the procedure. Over the last 2 days she was adequately resuscitated and when examining the pin sites earlier today the proximal pin was putting tension on the skin on the left femur so decided to take her back to the operating room for retrograde femoral nail for definitive fixation of the left femur. She had been adequately resuscitated in respect to her last acid level and base deficit under the care of her critical care team and trauma team. The hospital will continue to monitor her electrolytes and vital signs over the next couple of days and if the resident was amendable, the hospital will fix her right femur with a retrograde femoral nail and removal of external fixator on 02/10/23. During an interview on 02/09/23 at 10:51 A.M., LPN #07 stated STNA #05 asked her to come to Resident #01 ' s room. When she arrived in the room, Resident #01 was lying on the floor next to the heater that sits on the wall by the window. The resident ' s right leg was extended out and the left leg was underneath the resident to where she couldn ' t see her foot. She also observed the femur protruding out of her right leg. She stated she didn ' t move her at all. She knew she was fractured and knew she needed to get the resident to the hospital as soon as possible and made the calls and sent her out to the hospital. She revealed Resident #01 was a two-person assistance and STNA #05 provided the care by herself and didn ' t ask her to help. She said the hall was fully staffed on this day. During interview on 02/09/23 at 3:17 P.M., STNA #05 stated she had taken care of Resident #01 many times before at another facility and was comfortable with the resident. She said she was changing her on 02/04/23 and had the bed up to her waist. She turned the resident toward her to clean her bottom and kept the resident toward her when the resident asked to have her pillow readjusted. She reached up to straighten the pillow and when she repositioned the pillow the resident ' s legs started to slip off the bed. She tried to protect the resident ' s head and the upper half of the resident ' s body, but basically the resident fell on top of her. She stated the resident didn ' t hit the ground very hard, and the resident ' s left leg was Indian style, and the resident was screaming in pain. She stated she didn ' t know the resident was a two-person assistance and had provided the care by herself many times and never had a problem. She stated the hall was short staffed on this day. She stated she didn ' t look at the Kardex before her shift but knew how to look at it to determine the bed mobility of a resident. Review of policy titled Fall Prevention Program, dated 09/29/22, revealed each resident would be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. This deficiency represents non-compliance investigated under Complaint Numbers OH00140117 and OH000140154.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, staff interview, policy review, and review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, the facility failed to ensure timely and adequate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#03) of three residents reviewed for wound prevention. The census was 84. Findings include: Review of Resident #03's closed medical record revealed an admitted [DATE]. Resident #03 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed the resident discharged to another facility on 05/17/22. Review of a care plan with the revision date of 02/06/21, revealed Resident #03 had altered skin integrity related to impaired mobility. Interventions included: complete a Braden scale per policy, conduct weekly skin inspection, provide pressure reducing wheelchair cushion, provide pressure reduction mattress, provide thorough skin care after incontinent episode, and apply barrier cream, skin assessment to be completed per policy, turn and reposition schedule per assessment, and weekly wound assessment. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #03 had no pressure ulcers/injuries, no venous and arterial ulcers, and no other ulcers, wounds, or skin problems. Skin and ulcer/injury treatments included pressure reduction device for chair and pressure reduction device for bed. The resident required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of a quarterly data collection tool dated 04/26/22, revealed Resident #03 was non-ambulatory, demonstrated poor bed mobility or difficulty moving to a sitting position on the side of bed, had difficulty with balance, and/or poor trunk control. The resident risk for pressure was identified as a total score of 12, which indicated a high risk for the development of pressure sores. Review of the physician orders, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nurse progress note dated 05/16/22 at 11:53 A.M., for Resident #03 revealed the resident had an unstageable pressure ulcer located on the bottom right foot. Measurements were length 10.3 cm, width 7.5 cm, and depth 0.1 cm. Drainage was identified as a moderate amount of thick green drainage with no odor. No tunneling or undermining was present. Review of a nurse progress note dated 05/16/22 at 4:58 P.M., revealed the Director of Nursing (DON) followed up with Resident #03's representative about a request to send Resident #03 to the hospital for evaluation and treatment. Documentation revealed measures had been put into place to address the resident's right foot (sole) wound. The progress note revealed the representative continued to ask what exactly was on the resident's foot. The DON explained that the investigation had not been completed. Documentation revealed an x-ray of the right foot was to be ordered to rule out [CONDITION(S)], a culture of the wound to the right foot was to be ordered to rule out infection due to drainage noted upon cleansing wound, STAT (immediate) laboratory test to be ordered today included a comprehensive metabolic panel (CMP), complete blood count (CBC), hemoglobin (HGB) A1C, and [CONDITION(S)] stimulating hormone (TSH)), and treatment in place along with assessment of area completed. Documentation revealed the wound consultant and physician/nurse practitioner to follow up once results were in. Documentation revealed bilateral foam foot boots put in place for protection and a longer bed was ordered to prevent feet from connecting with foot board. Review of the progress note revealed the foot wound had no redness or temperature noted. Review of a discharge return not anticipated MDS assessment dated [DATE] revealed Resident #03 had severe impaired cognition. The assessment revealed the resident had an unstageable pressure ulcer. Review of Nurse Practitioner (NP) #800's progress note dated 05/17/22 at 6:21 P.M., revealed Resident #03 was assessed today per nursing request for right foot wound. The arch of the resident's foot does have an open area in the center. It is surrounded by dry scaly skin with small area of black eschar at the edge of the wound closest to the heel. Staff reports thinking it occurred at the foot of the resident's bed. Documentation revealed the resident was a very tall man that does have to have the head elevated secondary to feeding tube. A conversation with the management team as well as the resident's daughter regarding diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was currently on no medications for diabetes and hospital records from prior to admission state that diabetes was diet controlled. Documentation revealed a new order for the medication [MEDICATION(S)] (antibiotic) secondary to foot wound. Review of the progress note revealed family was requesting the resident be transferred to another facility closer to the family member's house and arrangements were being made per the request. Review of a progress note titled, Weekly Skin Review dated 05/19/22, (late entry for 05/11/22) revealed a wound assessment for Resident #03 which identified an unstageable pressure wound located on the bottom of the right foot. Measurements were length of 10.3 centimeters (cm), width of 7.5 cm, and depth of 0.1 cm. The assessment revealed a moderate amount of thin, bloody drainage with no odor and no tunneling or undermining. The treatment documented on the weekly skin review was to cleanse with wound wash, pat dry, cover with calcium alginate and abdominal (ABD) pad, then wrap with gauze every day and as needed. Review of the progress note revealed there was no complaint/evidence of pain related to the pressure area. Review of a care plan with a revision date of 05/25/22 (after discharge), revealed Resident #03 had a pressure ulcer to right heel and was at risk due to assistance required in bed mobility and skin desensitized. Interventions include Braden scale per policy, conduct weekly skin inspection, provide pressure reducing wheelchair cushion, and provide pressure reduction mattress. Interview on 07/13/22 at 12:23 P.M., with Licensed Practical Nurse (LPN) #70 revealed on 05/11/22 State tested Nurse Aide (STNA) #20 notified LPN #70 of the resident having some bleeding located on the bottom of the right foot. LPN #70 reported it was a busy night and the LPN stopped current activity and went to assess the resident. LPN #70 revealed Resident #03's right foot was up against the foot board. LPN #70 further reported the area was white, macerated in appearance, kind of like fingers look when they have been wet for a while. LPN #70 revealed the wound was cleansed with normal saline, then calcium alginate was applied, and the foot wrapped with gauze. LPN #70 then reported being unable to recall for sure if calcium alginate was applied. Further interview with LPN #70 revealed the nurse then got busy with other nursing duties and forgot to notify the primary care provider, forgot to notify the family, and forgot to place an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #70 further verified the medical record contained no evidence of wound care being completed for Resident #03 from 05/11/22 to 05/16/22. Interview on 07/13/22 at 12:45 P.M., with NP #800 revealed the wound located on the arch of Resident #03's foot appeared to come from sliding down in the bed and the way the resident foot was on the footboard. NP #800 revealed it was questionable to whether the area was an injury from hitting the foot board or if it was true pressure. NP #800 revealed the resident used an air mattress and the pump from the air mattress hung over the footboard by two metal hinges. When seeing the resident in bed, the area in which the resident foot touched the foot board was the area in which the air mattress hinge was hanging on the foot board. Interview with NP #800 revealed NP #800 was made aware of the foot wound on 05/16/22 and assessed the wound on 05/17/22. NP #800 revealed the wound was because the resident received a continuous tube feed, and the head of the bed was to be elevated at all times. Any time the resident moved in the bed the resident would go down in the bed and that was enough movement to put feet onto the footboard. NP #800 reported the antibiotic was prophylactic because the resident representative was concerned with the wound. NP #800 further reported green drainage was dried on the old dressing but after the wound was cleaned there was no active drainage. Further interview with NP #800 revealed the nurse practitioner should have been notified immediately of the wound located on Resident #03's foot. NP #800 verified the first notification of the foot wound for Resident #03 occurred on 05/16/22. Review of the undated policy titled Wound Prevention Program, revealed all open areas will be identified and documented on the appropriate forms. Resident with wounds will have appropriate treatments. Document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter. Enter the current treatment plan at the initiation of the pressure ulcer and the date of the last physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the NPIAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [CONDITION(S)], and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for [CONDITION(S)] (redness of the skin) was the first component of every skin inspection. Skin redness and tissue [CONDITION(S)] resulting from capillary occlusion was a response to pressure. Further review revealed an unstageable pressure injury is obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage three or Stage four pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Review of the facility's corrective action revealed the following actions were implemented and the deficiency was corrected as of 07/09/22. · On 05/16/22, the Director of Nursing (DON) initiated an investigation into the wound and wound dressing located on Resident #03's right foot per family request. LPN #70 was interviewed and verified Resident #03 had a wound located on the bottom of the right foot that was discovered on 05/11/22. LPN #70 verified the primary care provider and resident representative were not notified of the wound and no treatment order was obtained. The primary care provider was notified of the resident's wound and a treatment order was obtained. · On 05/16/22, LPN #70 was disciplined and educated on following the policy upon finding a wound. The education was provided by the DON. · On 05/16/22, the DON educated all nursing staff regarding the wound program policy, notification of change, and documentation. Review of in-service sign-in sheet revealed all nursing staff were educated on the wound program. · On 05/16/122, a skin sweep was conducted for all residents with no significant findings, like residents plan of care were reviewed and updated as needed. · Skin monitoring for random residents was conducted weekly for four weeks with the initial assessments taking place the week on 05/22/22 through 05/28/22 and the last assessments occurring the week of 07/03/22 through 07/09/22. Audits and monitoring were reviewed and were completed. · Review of two additional (#01 and #05) resident medical records revealed no concerns for pressure sores. · Interviews with LPN #70, LPN #100 and STNA #50 on 07/12/22 and 07/14/22 at random times, revealed staff verified education was provided and were able to verbalize the policy and procedure for pressure sore prevention and treatment. This deficiency substantiates Master Complaint Number OH 191, and Complaint Numbers OH 851, and OH 783.

Based on resident record reviews, staff interview, review of a personnel file, fall investigation review, Self-Reported Incident (SRI) review, and policy review, the facility failed to ensure a resident was provided adequate staff assistance with bed mobility. Actual harm occurred when one resident (#07) requiring two persons for bed mobility was rolled in bed and experienced a fall resulting in the fracture of the right knee and ankle. Additionally, the facility failed to ensure a second resident (#02) was provided adequate assistance during a mechanical (Hoyer) lift transfer that did not result in harm, but had the potential for more than minimal harm. This affected two (#02 and #07) of four residents reviewed for falls. The census was 84. Findings include: 1. Review of Resident #07's medical record revealed an admitted [DATE]. Diagnoses for Resident #07 included: [CONDITION(S)] ([CONDITION(S)]), muscle weakness, seizures, [CONDITION(S)], and cognitive communication deficit. Review of a care plan dated 12/17/20, revealed Resident #07 had a physical function deficit related to mobility impairment and self-care impairment. Interventions include bed mobility: two-person extensive assist, and toileting assistance required two-person maximum assist. Review of a care plan dated 12/04/21, revealed Resident #07 was at risk for falls. Interventions include bariatric bed, bed in low position, and call light or personal items in easy reach. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #07 had moderately impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and hygiene. Review of a progress note dated 07/11/22 at 9:12 P.M., revealed at 4:35 P.M., State tested Nurse Aide (STNA) #300 reported Resident #07 had been lowered to the floor from the bed. Documentation revealed the resident was turned on his/her side in the bed and then started sliding out of the bed. STNA #300 then went to the other side of bed and lowered Resident #07 to the floor. Documentation revealed Resident #07 was observed lying on his/her back, on the floor. Resident #07 complained of bilateral knee pain. Resident #07 was able to move both legs and feet to best of the resident's ability. Further review of the progress note revealed the resident was assisted to bed via Hoyer lift and assistance of three staff. Documentation revealed the Nurse Practitioner was notified and new orders were received for STAT x-ray of left ankle and bilateral knees two views. The resident representative was notified and requested the resident be sent to the hospital. Review of the progress note revealed transportation was arranged for the resident to be evaluated at the hospital. Further review of the progress note revealed at 6:20 P.M., a mobile imaging company arrived at the facility to complete the x-rays. After the technician completed an x-ray of left ankle, the x-ray suggested possible left tibia fracture. The resident was sent to the hospital for evaluation and treatment. Review of a document titled, Patient Report dated 07/11/22, revealed the x-ray results for Resident #07's right knee imaging. The findings were acute mildly displaced fracture proximal tibial metaphysis. Acute mildly displaced impact fracture of lateral femoral condyle. The patella, distal femur, and fibula are intact. There is no deep sulcus to suggest anterior cruciate ligament tear. The bony mineralization is severely decreased. There is no joint effusion. The impression: Acute mildly displaced fracture proximal tibial metaphysis, acute mildly displaced impact fracture of lateral femoral condyle, no joint effusion, and severe [CONDITION(S)]. Review of a fall investigation dated 07/12/22 revealed the facility completed an investigation of Resident #07's fall that occurred on 07/11/22. Documentation revealed the appropriate number of staff assistance and proper technique was not used. Review of the SRI date of discovery 07/13/22, revealed on 07/13/22, the facility received a call from the representative for Resident #07 verbalizing a concern/allegation with resident's care specific to weight loss and fractures. The Administrator submitted the report to the state agency and initiated an investigation. The investigation included STNA #300 being suspended, staff interview, and clinical chart review. The SRI revealed the resident is a [AGE] year-old female with mild cognitive impairment and diagnoses to include but not limited to severe [CONDITION(S)], [CONDITION(S)], major depressive disorder, anxiety disorder and dysphonia. The resident required assistance from staff for activities of daily living (ADL), limited assistance with bed mobility as resident can participate in helping staff move side to side. Resident's weight is 208 pounds and uses a bariatric mattress. On 07/12/22, the resident required a total bed change due to incontinence. STNA #300 was providing care to resident. Per STNA #300 interview and re-enactment, resident rolled over in bed swiftly and threw her leg off the side of the bed. STNA #300 noted that resident was sliding off the bed and climbed in bed to lower resident onto the floor. The resident complained of right knee pain, x-ray obtained with family and physician notification. Resident #07 presented with fracture of right knee and ankle along with severe [CONDITION(S)]. Resident #07's weight is currently 208 pounds and upon review of clinical record, there is no significant weight loss. Upon review and completion of the investigation, it is our professional opinion that neglect and/or abuse did not occur. The SRI was unsubstantiated. Review of the personnel file for STNA #300 revealed a hire date of 11/22/21. The annual performance review dated 02/28/22, revealed STNA #300 meets expectations with satisfactory job knowledge: understands and performs most phases of job well, occasionally requires assistance or instruction. Review of a document titled, Employee Progressive Action Memorandum dated 07/18/22, revealed STNA #300 failed to review the kardex/care plan for a resident who required two-person assistance. While performing care by self, the resident rolled out of bed. The employee was terminated. There were no other progressive action memorandums in the file. Interview on 07/21/22 at 8:36 A.M., with the Director of Nursing (DON) revealed Resident #07 had a fall out of bed while the resident was being assisted with incontinence care and other resident care from one staff member (STNA #300). The DON verified Resident #07 required assistance of two staff for resident care. 2. Review of Resident #02's medical record revealed an admitted [DATE]. Diagnoses for Resident #02 included Alzheimer's disease, muscle weakness, [CONDITION(S)], metal disorder, and dementia. Review of a care plan revised 01/20/20, revealed Resident #02 had a physical function deficit related to impaired mobility. Interventions included transfer assistance dependent of two per Hoyer. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 had impaired cognition. The assessment revealed the resident had short and long-term memory problems and was unable to recall the current season, location of own room and of being in a nursing home, and staff names/faces. The resident was assessed to have severely impaired cognitive skills for daily decision making. Continued review of the assessment revealed the resident required extensive assistance of two staff for bed mobility, transfers, locomotion on and off the unit, dressing, personal hygiene, and toilet use. Review of a progress note dated 07/02/22 at 6:09 A.M., revealed Resident #02 was being transferred to the wheelchair via Hoyer lift. Documentation revealed the Hoyer lift was tipped and the resident was lowered to the ground by an aide controlling movement onto floor. Resident was assessed and range of motion was noted to be within normal limits. Vital signs were blood pressure systolic 164 millimeters of mercury (mmHg) and diastolic 63 mmHg and pulse 74 beats per minute. Review of a fall investigation dated 07/02/22 revealed the appropriate number of staff was not used during the Hoyer lift transfer for Resident #02. The investigation revealed the resident sustained no injury. The resident was sent out to the hospital for evaluation and treatment per the resident representative request. The intervention was to use two people assistance for all Hoyer transfers. Review of hospital documentation dated 07/02/22, revealed Resident #02 was sent to the hospital for evaluation and treatment post fall into the bed during a Hoyer lift transfer. Documentation revealed the fall was reported to be a controlled fall onto the bed as the resident was over the bed at the time of the occurrence. Review of the documentation revealed the resident displayed no obvious injuries and was pleasantly confused upon arrival. Further review of the documentation revealed upon physician evaluation no external evidence of head trauma was noted. There was no midline cervical, thoracic, or lumbar spine tenderness, no rib or chest pain upon palpation, and full range of motion was noted for arms and legs with good strength throughout. The final impression was no identified injuries at this time. Resident to be discharge back to the facility. Interview on 07/12/22 at 12:44 P.M., the DON verified the correct number of employee assistance was not used during the Hoyer lift transfer for Resident #02 which resulted in a fall on 07/02/22. The DON revealed the resident was assessed by the nurse and found to have no injury. The DON further revealed the resident representative requested Resident #02 be sent to the hospital for evaluation and treatment. The DON revealed the resident went out to the hospital for evaluation on 07/02/22 and returned to the facility the same day without injury. Review of a policy titled, Low Lift revised 01/20, revealed two staff members are required when using a mechanical lift. Review of the undated policy titled, Fall Prevention Program, revealed the assigned certified nurse aide on all shifts needs to hold accountable to ensure that the care plan to eliminate falls is being implemented. This deficiency substantiates Master Complaint Number OH 191, and Complaint Numbers OH 096, and OH 851.

Based on observation, medical record review, staff, physician and podiatrist interview, pressure ulcer policy review and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure pressure relieving interventions were implemented for Resident #2 and #3 who were identified at risk for skin breakdown and also failed to monitor Resident #2's posterior right thigh pressure ulcer. This resulted in harm when Resident #3's pressure ulcer declined from a Stage Two to a Stage Three with an increase in drainage, the presence of a foul odor with an infection and the facility failed to notify the physician to seek alternative treatments/interventions to treat the wound appropriately. This also resulted in harm when the facility failed to implement physician ordered pressure ulcer treatments to Resident #2's coccyx wound resulting in deterioration of the Stage four pressure ulcer. Harm also occurred when the facility failed to ensure pressure ulcer preventative measures were in place resulting in the development of an avoidable Unstageable pressure ulcer to Resident #2's right heel. This affected two (#2, #3) of three residents reviewed for pressure ulcers. The facility census was 105. Findings include: 1. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired, was dependent for bed mobility and toileting and required extensive assistance for all other activities of daily living. Review of nursing note dated 11/14/17 at 4:47 P.M. revealed an aide notified Licensed Practical Nurse (LPN) #121 the resident had an area on their left foot great toe. The nurse assessed the resident's toe and determined a Stage two pressure ulcer was present. treatment of [REDACTED]. Review of physician order [REDACTED]. Review of Treatment Administration Record (TAR) for November and December 2017 revealed the treatment was not changed or updated with the decline of the wound until 12/07/17. Review of facility weekly skin checks revealed on 11/21/17 the wound was a Stage Three and now measured 2 cm by 2 cm by 0.2 cm. Review of Podiatry note dated 11/21/17 revealed the resident had the ulcer of the great toe. Documentation revealed the physician completed sharp debridement to the ulcer present on the left great toe. Upon removal of the bandage, a thin layer of white fibrous tissue was present in the center of the wound. The ulcer measured 1.5 cm in diameter and had limited depth to the dermis. The base had an excellent granulating tissue with no signs of infection. There were also two orders noted one to use two pillows under the legs to suspend/float the feet to prevent feet from coming into contact with the bed mattress in order to prevent further tissue loss; secondly for PSO ([MEDICATION NAME] ointment) and dry dressing every other day. Further noted the resident was a high-risk due to a history of a previous ulcer, [MEDICAL CONDITION], and foot deformity. Review of the physician order [REDACTED]. There was no indication in the medical record the order for the PSO was clarified and/or implemented. Review of physician progress notes [REDACTED].#1) revealed there were no documented skin conditions noted. Review of wound observation by Registered Nurse (RN) #143 on 11/22/17 and 11/28/17 (documented on 12/07/17) revealed the wound to the left great toe was measured at 2 cm by 2 cm and 2 cm of tunneling and was now a Stage Three with no exudate (fluid seeping). Review of facility weekly wound tracking indicated on 12/05/17, the resident's wound to the left great toe was a Stage three measuring at 2 cm by 2 cm and was 0.2 cm in depth. No further information was documented. Review of wound observation by RN #143 documented on 12/07/17 revealed the wound to the left great toe was 2 cm by 2 cm and 2 cm of tunneling and was now a Stage Three with a moderate amount of exudate (fluid seeping). Review of Resident #3's Pressure Ulcer Care Plan initiated on 12/07/17 showing a problem start date of 11/14/17 included the resident had an alteration in skin integrity. Interventions included to monitor the effectiveness of my treatments, follow physicians orders, report changes in my skin to my physician. There were no other care plans implemented or available prior to that date that included the risk of skin break down. Review of nursing note late entry for 12/07/17 dated 12/11/17 revealed the resident's physician (#1) was made aware of the resident's toe and the treatment increased to change twice daily. Review of new physician order [REDACTED]. Review of lab report regarding a wound culture dated 12/08/17 included the resident had heavy growth of staphylococcus aureus and moderate growth of proteus mirabilis. An order from the Medical Director Physician (MDP) #99 was written on the laboratory report with his initials. There was no further documentation noted in the medical record indicating where the order originated from or why it was obtained. Review of nursing note and physician order [REDACTED].M. revealed an order for [REDACTED]. Review of the TAR indicated the treatment for [REDACTED].M. to 7:00 P.M. shift. Interview on 12/11/17 at 2:19 P.M. with Physician #1 stated he could not recall being notified regarding the pressure ulcer to Resident #3's left great toe. He explained due to the resident's diagnosis, when the wound went from a stage two to a Stage three with tunneling he would have ordered a wound clinic consultation. Further interview at 3:24 P.M., revealed he had no faxed communication from the facility regarding any related wound orders. Observation on 12/11/17 at 2:41 P.M. with LPN #290 revealed she explained the procedure to the resident and pulled back the blanket and sheet, and there was an odor. The bottom of Resident #3's left foot was resting directly on the pillow, her wound was covered and it was pressing on the footboard. There was blood on the dressing which had seeped and was dried on the linen on the bed. LPN #290 confirmed the resident's left foot wound was pressed on the footboard. LPN #290 cut the kerlix and removed the dressing. Pieces of the calcium alginate remained stuck on the resident's foot. There was a strong foul odor present. The nurse used three vials of normal saline to try and loosen the calcium alginate. The foot was resting on a pillow on top of the footboard. The wound was bleeding and LPN #290 was able to remove the calcium alginate. At 3:01 P.M., LPN #290 verbally described the wound as being a large open wound on the left great toe with a moderate amount of coagulated blood, granulation, slough, irregular shape and a depth which was unable to be obtained. The would measured at 1.8 cm in length and the width at 2.5 cm. Also noted during the dressing change was the left third toe which was observed to be macerated, measuring at 1.1 cm by 1.4 cm and a depth was unable to determined. LPN #290 placed the calcium alginate on the wound, covered with an abdominal pad and secured it with tape. At 3:22 P.M. after leaving the room LPN#290 confirmed the treatment administered, and confirmed there was a very strong foul odor. LPN #290 was upset and stated she had previously routinely worked with the resident and was not expecting the wound to be in that condition. Interview at 5:08 P.M. with the MDS nurse LPN #178 explained that on 12/07/17 she received notification from LPN #156 and RN #143 that Resident #3's wound had more drainage and to notify the physician they were increasing the order to twice a day. She stated she left a message and she had forgotten to document that in the medical record. She further confirmed that on 12/07/17 she realized Resident #3 did not have a care plan in place for the pressure ulcer so she initiated one with a noted problem start date of 11/14/17. Interview on 12/11/17 at 5:47 P.M. with the Director of Nursing (DON), Administrator, LPN #156 and RN #143 all confirmed they would notify the resident's physician if there was a concern or a decline in the condition of the wound. They all confirmed the resident's wound declined when it went from a Stage two to a Stage three with tunneling on 11/22/17 and remained that way. They all confirmed the physician, either the resident's or the medical director was not notified when the change of condition (Stage three and tunneling) was noted or until 12/07/17 when the wound team decided to change the dressing order due to the dressing having drainage increase from minimal to moderate. The DON confirmed Resident #3 had a foul odor coming from her wound prior to 12/06/17, however confirmed there was no indication of that in the medical record. The DON explained Resident #3 did see the podiatrist the day prior to the facility's findings of the change of the wound (11/21/17), also the Medical Director (#99)'s nurse practitioner was going to see the resident's wound but would not due to the resident having Physician #1. The DON stated they were not getting timely responses from Physician #1 which was why they involved physician #99. Interview on 12/13/17 at 12:21 P.M. with Podiatrist #999 explained he saw the resident on 11/21/17 as a routine visit and no one prearranged the visit due to the resident's pressure ulcer. He explained he had written orders for [MEDICATION NAME] ointment and dry dressing every other day after the area was debrided. He explained the wound to her left great toe was limited to the dermis, but felt the area was a gray Stage 2 on that date, and the way the resident's foot was formed, the great toe would rest directly on the mattress if not suspended. Podiatrist #999 explained he did not speak with any staff while at the facility. He explained he would have expected the staff to implement his order and/or clarify the order if they had questions or felt there was a more appropriate treatment. He confirmed he was not aware there was a decline in the wound, but confirmed that a physician should have been notified. He also stated he had not been further consulted regarding the wound. He further explained the resident would need aggressive repositioning every two hours to ensure she was positioned correctly to protect her due to being high risk for break down. He explained the order he left included the feet should be suspended and to not have contact with the bed, but also should not be resting on the pillows as that would still create pressure. He further explained the resident should not have a footboard and her feet should never be directly resting on it. 2. Review of the medical record revealed Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the timeline completed by the DON revealed Resident #2 initially developed an in-house pressure ulcer to the coccyx on 08/04/17. Review of readmission physician orders [REDACTED]. Apply Magic Butt Cream to intact skin around wound. Maintain area as clean as possible. Review of Wound Clinic documentation measurements dated 11/20/17 revealed pressure ulcers included Wound #1 on the coccyx, measuring at 8 cm by 5 cm by 2 cm at a Stage 4 and the right posterior thigh, Wound #8, measuring 2.3 cm by 3.6 cm by 0.1 cm at a Stage 3. Progress note from the visit included the sacrococcygeal wound was more extensive than previous. There was now palpable bone in the base causing this to be a stage IV ulceration. There was a good deal of slough material in the base also. The area was debrided to remove necrotic tissue to allow more appropriate placement of the wet-to-dry dressings. Further review of the documentation revealed to continue the Dakin's solution as a wet to dry dressing, twice a day and apply barrier cream around the other wounds. A family member was with the resident and it was noted he wanted to take an aggressive approach to the wound, and the physician felt at the time, to utilize a [DEVICE]. Review of internal facility weekly skin assessment dated [DATE] revealed Resident #2 had two areas one to her right buttock that measured 4 cm by 2 cm by 0.1 cm and one to the coccyx that measured 16 cm by 10 cm by 4 cm that were both a Stage Two. Review of internal facility weekly skin assessment dated [DATE] included the resident had a Stage four pressure ulcer on the coccyx that measured 7 cm by 7 cm by 4.5 cm and was a Stage Four pressure ulcer. Review of physician order [REDACTED]. Dakin's 0.25% twice daily and as needed to coccyx wound. Pack wound with gauze soaked with Dakin's secure with dressing. Review of internal facility weekly skin assessment dated [DATE] included Resident #2 had an area on her coccyx that measured 12 cm by 10 cm by 5 cm and was a Stage Four pressure ulcer. Review of Pressure Ulcer Care Plan implemented 12/07/17 with a noted problem start date of 07/27/17 revealed to float the heels with pillows to relieve pressure on the heels. Perform dressing changes as ordered and follow up with the wound physician. Conduct systemic skin inspection weekly skin checks. Review of nursing note dated 12/08/17 at 11:09 A.M. revealed during morning rounds the nurse noted a 3.0 cm by 2.5 cm pressure ulcer of the resident ' s right heel. There was a new order for skin prep twice a day and keep heels elevated at all times. There was no staging of the pressure ulcer. Observation with interview on 12/07/17 at 11:50 A.M. revealed LPN #389 and STNA #897 entered the room to complete a wound dressing change. LPN #389 removed the old treatment and confirmed it had no date and there were no initials documented on the dressing. LPN #389 removed the packing from the wound, squirted normal saline on the wound and described the wound as having a whole bunch of slough. It was beefy red with a black center and was a Stage four wound with an additional wound on her right thigh. LPN #389 packed kerlix soaked in Dakin's to the coccyx wound. She covered with an abdominal dressing. Interview and Review of December TAR on 12/07/17 at 4:30 P.M. with the DON confirmed the treatment for [REDACTED]. Also, there was no documented evidence on 12/03/17, 12/04/17, and 12/05/17 that the treatment was completed at all. Interview on 12/08/17 at 9:43 A.M. with the DON, RN #45, RN #143, LPN #156, LPN #178, and the Administrator, explained they complete wound rounds on Tuesdays and complete their internal pressure ulcer tracking and then document their findings in the resident's medical record on Thursdays. They stated there was no expectation of when they are supposed to document in the medical record. Both RN #143 and RN #156 confirmed they were unaware of any pressure ulcer to Resident #2's right thigh as described by the wound clinic or from the hospital upon readmission. When asked to all present why Resident #2 was last hospitalized all stated [MEDICAL CONDITION]. When asked if Resident #2 had [DIAGNOSES REDACTED] all stated they were not aware until hospital documentation which was in the resident's medical record as part of the hard chart were they aware. No one was able to explain the specifics of the site identified, but stated they would obtain more hospital information. The DON felt that the facility staff were doing their treatments and preventative measures as often as the family of Resident #3 would allow. The DON presented documented records in the nursing notes of when care was refused and by whom, but confirmed refusal was not all day every day. The DON felt the non-compliance has led to the wound's decline. RN#45 stated she felt that the facility was providing care they just don't have the documentation, and the issue was more of a documentation concern. The DON confirmed the wound had declined in the past few weeks, and was unable to explain who was responsible for communicating with the wound clinic and monitoring their measurements and findings. The facility stated at times the wound clinic does send back a summary with wound orders, however actual measurements and the physician's wound notes were obtained later when the wound clinic would fax over the information. Directly after the meeting all present with the exception of RN #45 and LPN #178 went to Resident #3's room to observed the wounds. A new area was noted to the right heel measuring at 1.9 in length by 1.5 in width described as scabbed yellow outer light brown perimeter with the surrounding skin healed (Unstageable). Additionally there was the large coccyx wound, and a wound to the back of the Resident's right thigh. LPN #156 stated she had not seen the area to the thigh previously and staff should notify her if there was a new area. After observations of the wound, the resident was repositioned with pillows under her head, right and left arm and two pillows under her legs by RN #45. Her right heel remained on the bed. At 11:42 A.M., the resident was repositioned. LPN #156 was asked to pull back the sheets and blanket. At this time, at 11:51 A.M., LPN #156 confirmed that both the residents' heels were resting directly on the bed. Interview on 12/08/17 at 11:55 A.M. with LPN #121 revealed she had already completed Resident #2's treatment for [REDACTED].#121 stated she did not use Dakin's when she completed her treatment today because it was not available in the facility. The nurse verified there was no Dakin's in the medication cart or treatment cart. The nurse verified there was no order to use normal saline in place of the Dakin's solution on Resident #2's wound. Review of physician order [REDACTED]. Interview at 5:08 P.M. with LPN (MDS) #178 confirmed that on 12/07/17 she realized Resident #2 did not have a care plan in place for the pressure ulcer. LPN #178 initiated the care plan on 12/07/17 with a problem start date of 07/27/17. Review of Skin Care Policy and Procedure dated 10/01/15 included residents with [MEDICAL CONDITION]/wounds will be monitored and documented by the charge nurse, director of nursing, or designee. Documentation of skin conditions must occur upon identification and at least once each week. Assessment must include characteristics, treatment and response to treatment, and prevention techniques. Review of Treatment and procedures policy for Dressing Change: Clean dated 02/2016 included the nurse would document any abnormal observations or changes in the wound as appropriate. Review of Preventative Skin Care Policy dated 04/16 included when a pressure area is identified an accurate assessment will be completed; a treatment program will be initiated and maintained. The physician is to be notified when a pressure sore develops. If there is no improvement noted after a reasonable amount of time (2-3 weeks) and/or upon signs of deterioration. Signs of infection include undermining and abnormal odor. Update the resident's care plan as needed. The DON/designee are to make pressure sore rounds every week and discus each resident's progress and make necessary changes. Review of information from the NPUAP revealed a Stage 3 Pressure Ulcer is full-thickness skin loss in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. A Stage 4 Pressure Ulcer is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. An Unstageable Pressure Ulcer is full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. The NPUAP further instructed to ensure heels are free from the bed to prevent pressure ulcer development and to consider using heel offloading devices or [MEDICATION NAME] foam dressings on individuals at high-risk for heel ulcers. The NPUAP further instructed to avoid positioning an individual on an area of [DIAGNOSES REDACTED] and avoid positioning the individual on body areas with pressure injury. This deficiency substantiates Complaint Number OH 901.