Every finding on record at Fair Haven Shelby County

Based on staff interview, observation, policy review, and record review, the facility failed to ensure food was served and stored in a safe and sanitary manner. This had the potential to affect all 64 residents who receive food from the kitchen. The facility census was 64.Finding include:Review of food temperature logs from 01/10/26 through 02/26/26 with Dietary Manager (DM) #156 revealed the only meals with recorded temperatures during the review period were: 01/10/26 (breakfast, lunch, dinner), 01/10/26 (unspecified meal), 01/12/26 (dinner), 02/10/26 (lunch and dinner), 02/11/26 (lunch and dinner), 02/12/26 (breakfast, lunch, dinner), 02/13/26 (lunch), 02/14/26 (breakfast), 02/15/26 (breakfast), 02/16/26 (breakfast), 02/21/26 (breakfast, lunch, dinner, and one unspecified meal), and 02/22/26 (breakfast, lunch, dinner). All remaining required meal service times lacked documented food temperatures.Interview on 02/27/26 at 10:10 A.M. with DM #156 confirmed kitchen staff do not routinely check food temperatures as required. DM #156 confirmed she was unable to provide consistent and daily food temperature logs for each meal.Observation of the lunch meal service in the satellite kitchen on 02/27/26 from 11:18 A.M. through 11:58 A.M. revealed the food arrived in the satellite kitchen from the main kitchen at 11:18 A.M. At 11:21 A.M., a thermometer was observed above the stove; however, a temperature log could not be found and the steam table was set at 10 (maximum heat). At 11:28 A.M., the food remained uncovered without a lid and the plastic covering had been removed. At 11:42 A.M., the food continued to remain uncovered. Food service began at 11:48 A.M. At 11:49 A.M., [NAME] #163 picked up a thermometer and briefly looked at it; however, no food temperatures were taken or documented.Interview on 02/27/26 at 11:52 A.M. with [NAME] #172 and [NAME] #163 confirmed no food temperatures were taken upon arrival to the satellite kitchen prior to the initiation of meal service. Staff stated they were unsure whether the food had been held at safe temperatures.Interview conducted on 02/27/26 at 1:46 P.M. with DM #156 confirmed food temperatures should be taken upon arrival from the main kitchen and prior to meal service, and that food should remain covered to ensure it stays warm and free from contaminants.Review of the facility's Food Storage and Handling policy dated 2022 revealed employees are required to take food temperatures prior to serving food out to confirm products are at the required temperature. Once temperatures are checked, employees are required to document the temperatures on a temperature log for record keeping.This deficiency represents non-compliance investigated under Complaint Number 2712515.

Based on medical record review, staff interviews, review of a facility investigation, and review of facility policy, the facility failed to ensure a resident was properly transferred from a recliner chair to a bed by a Hoyer (mechanical Lift). This resulted in Actual Harm when the Hoyer lift tipped over during transfer by Certified Nursing Assistant (CNA) #200 and Resident #55 hit her face on the floor. Resident #55 sustained facial fractures, a subdural hematoma (bleeding between brain and outer covering), and a facial laceration that required medical transport by helicopter and hospital admission. This affected one (#55) of three residents reviewed for accidents. The census was 65. Findings include: Review of Resident #55's medical record revealed an admission date of 08/09/19. Diagnoses included hypertension, chronic fatigue, bladder cancer, osteoarthritis, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact and dependent on staff for transfers. Review of the care plan initiated 08/09/19 revealed Resident #55 was at risk for falls related to weakness, decreased mobility, and chronic fatigue. Resident #55 had impaired activities of daily living (ADLs) self-performance and required a Hoyer lift for all transfers. Review of physician orders revealed an order dated 03/12/25 for Hoyer lift for all transfers. Review of progress notes dated 06/26/25 at 4:00 P.M. revealed the nurse was notified by a CNA that she needed assistance. Upon entry, Resident #55 was observed laying on her back and bleeding from an unknown area. The nurse called out for help from other nurses and the nurse called emergency services (911). The nurse assisted Resident #55 to spit out blood. Resident #55's oxygen saturation level was checked until emergency services staff (EMS) arrived. Review of hospital documentation dated 06/26/25 through 07/02/25 revealed Resident #55 suffered multiple facial fractures, a subdural hematoma, and an eight centimeter (cm) facial laceration between eyes to nose requiring sutures. Resident #55 was transported by medical helicopter from a local hospital's emergency room (ER) to a trauma center where she remained until discharge on [DATE]. Review of the facility's investigation revealed per a written statement by CNA #200, CNA #200 was transferring Resident #55 back into bed without assistance on 06/26/25 at 3:42 P.M. when the Hoyer lift tipped over and Resident #55 landed on the floor. CNA #200 reported Resident #55 grabbed the top of the Hoyer lift during transport before it tipped. CNA #200 noticed Resident #55 was bleeding and went to get a nurse. Resident #55 was talking and alert. Resident #55 fell on her left side. Further review of the investigation revealed witness statements were taken from nursing staff that assisted with Resident #55's post-fall until EMS arrived. There was not any documentation of the Hoyer lift being inspected for any defects post Resident #55's fall. Observation on 08/12/25 at 4:29 P.M. of the Hoyer lift that was used by CNA #200 on 06/26/25 revealed a sticker dated last inspection of 04/06/22 and was due for inspection April 2023. The Director of Nursing (DON) was present during the observation and confirmed both dates. Interview with the DON on 08/13/25 at 9:23 A.M. revealed there is not a check-off for agency staff before they are able to use the Hoyer lifts. A maintenance slip was not filled out to check the Hoyer for any defects post Resident #55's fall. The DON was unsure if maintenance performed scheduled maintenance checks of Hoyer lifts. The cause of the Hoyer lift tipping over was not determined. CNA #200 reported that Resident #55 was grabbing the top of Hoyer during transfer. CNA #200 was not an employee of the facility and worked through a staffing agency. Interview with Resident #55 on 08/13/25 at 10:02 A.M. revealed she did not remember very much of the fall event. Resident #55 stated there should have been two people transferring her and there was only one. Resident #55 was told there was a lot of blood when she fell. Resident #55 had residual effects from the fall and reported sometimes it was like looking through a screen in her left eye. Observation of Resident #55 during the interview revealed a scar on the left side of her face between her left eye and nose. Interview with CNA #110 and CNA #150 on 08/13/25 at 1:13 P.M. revealed two staff members are required when transferring residents by a Hoyer. Interview with Environmental Service Director (ESD) #170 on 08/13/25 at 2:00 P.M. revealed he does not inspect Hoyer lifts on a regular schedule. ESD #170 does not inspect any medical equipment and was not certified in medical equipment inspection. ESD #170 looked at the Hoyer lift post Resident #55 fall on 06/26/25 and checked for any obvious concerns. ESD #170 did not check the Hoyer lift functions or stability. Phone interview with CNA #200 on 08/13/25 at 3:26 P.M. revealed she worked at the facility through a staffing agency. The facility had not given her any instructions on how to operate the Hoyer lift prior to transferring Resident #55 on 06/26/25. It was the first time using that Hoyer lift and it was her first time transferring Resident #55. CNA #200 did not have any other staff members assisting her transferring Resident #55. When transferring Resident #55 from a recliner to her bed the Hoyer lift tipped over and Resident #55 landed on the floor. Resident #55 was grabbing the top of the Hoyer. CNA #200 immediately noticed blood and went to get a nurse. Nursing staff attended to Resident #55 until EMS arrived. Review of the Hoyer lift user manual revealed do not use this product or any available optional equipment without first completely reading and understanding these instructions and any additional instructional material such as user manuals, service manuals or instruction sheets supplied with this product or optional equipment. If you are unable to understand the warnings, cautions or instructions, contact a healthcare professional, provider or technical personnel before attempting to use this equipment; otherwise, injury or damage may occur. Although (the manufacturer) recommends that two assistants be used for all lifting preparation and transferring-from and transferring-to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the healthcare professional for each individual case. During transfer, with the patient suspended in a sling attached to the lift, do not roll the caster base over uneven surfaces that could cause the patient lift to tip over. Use the steering handle on the mast at all times to push or pull the patient lift. After the first year of use, the hooks of the hanger bar and the mounting brackets of the boom should be inspected every three months to determine the extent of wear. If these parts become worn, they must be replaced. Casters and axle bolts must be inspected every six months to check for tightness and wear. After the first 12 months of operation, inspect the hanger bar and the eye of the boom to which it attaches for wear. If the metal is worn, the parts must be replaced. Repeat this inspection every six months thereafter. Regular maintenance of patient lifts and accessories is necessary to assure proper operation. Do not overtighten the mounting hardware. This will damage the mounting brackets. After the first six months of operation, inspect all pivot points and fasteners for wear. If the metal is worn, the parts must be replaced. Repeat this inspection every six months. Review the facility's undated Fall Policy revealed the Interdisciplinary Team will assess the factors contributing to the fall event, recommend interventions and changes to the plan of care to prevent falls, communicate and document any pertinent referrals/information. This deficiency represents non-compliance investigated under Complaint Number 2561938.

Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure prescription medication was stored in a locked secured location and not within reach of the residents. In addition, the facility failed to ensure medications were labeled for opening, labeled for expiration, disposed of when expired and stored only with medications. This had the potential to affect all 62 residents in the facility who received medications. The facility census is 62. Findings include: 1. Review of the medical record for Resident #26 revealed an admission on [DATE], with diagnoses that include but not limited to Parkinson's disease, syncope and collapse, pacemaker, bulbous pemphioid, orthostatic hypotension, acute kidney failure, anxiety disorder, atrial fibrillation, and neuromuscular dysfunction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 revealed an impaired cognition. Resident #26 required set up or clean up assistance for eating, dependent for oral hygiene, dependent for toileting, dependent for shaving, dependent for bed mobility and transfers. Review of the plan of care for Resident # 26 revealed impaired activities of daily living (ADL) self performance related to sepsis, Parkinson's disease, anxiety, and dementia. Interventions include assess/record self-care status changes, administer boost very high calorie as ordered, ensure that call light is kept within reach, monitor need for consultation and provide treatment as ordered for therapy, provide adaptive/safety equipment with wheelchair and report significant changes in ADL status to physician. Review of the active physician orders for Resident #26 revealed an order for ketoconazole 2% shampoo apply to scalp topically every night, every Tuesday and Friday for dry scalp. Observation on 06/03/25 at 8:15 A.M., of a bottle of ketoconazole shampoo with label from facility pharmacy in Resident #26 bathroom. Interview on 06/03/25 at 8:22 A.M. with Registered Nurse (RN) #262 verified the medicated shampoo should not be in the room but locked up in the treatment cart. 2. Medical record review for Resident #45 revealed an admission on [DATE] with diagnoses that include cardiac arrhythmia, asthma, dementia with behaviors, psychotic disorder with delusions, Alzheimer's disease with late onset, major depressive disorder with severe psychotic symptoms, type two diabetes, and persistent mood disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] for Resident #45 revealed severe cognitive impairment. Resident #45 requires set up or clean up assistance for eating, dependent for toileting, maximal assistance for bed mobility and dependent for transfers. Review of the plan of care for Resident #45 revealed has impaired cognitive function, decision making skills, memory and recall impairments, impaired thought process related to dementia. Interventions include administer medication as ordered, monitor for side effects, anticipate and meet needs in a timely manner, avoid constant noise. distractions, use calendars' clocks and other items that establish and confirm orientation. Review of the active physician orders for Resident #45 revealed an order for Desonide 0.05% cream apply to face topically every shift for dermitis dated 09/04/24 and an order for Ketoconazole 2% shampoo apply daily to scalp topically every night shift, on Wednesday, Friday and Sunday for seborrheic dermatitis dated 04/04/24. Observation on 06/02/25 at 10:32 A.M., of a two bottles of medication for Resident #45. Bottles were labeled with the facility pharmacy label and identified as Desonide 0.05% cream apply to face topically every shift for dermatitis and Ketoconazole 2% shampoo apply daily to scalp topically every night shift on Wednesday, Friday and Sunday for seborrheic dermatitis. Both bottles observed in Resident #45's bathroom contained warning labels to contact poison control if ingested. Interview on 06/02/25 at 3:46 P.M., with Licensed Practical Nurse (LPN) #217 verified the two bottles of medication located in the bathroom of Resident #45 should not be in the room unsupervised removed it LPN #217 verified that she did not put it in the room and that the resident was the night shift shower. Review of the undated policy titled, Storage of Medication, stated drugs and biologicals shall be stored in a safe, secure and orderly manner. 3. Observation on 06/04/25 at 12:40 P.M. of the Sycamore Medication Room with Registered Nurse (RN) #262 revealed there were two residents who are no longer in the facility, personal medications in the cabinet, that needed to be sent home with the resident's family. Observation also revealed the medication refrigerator contained three yogurts, a pudding cup, a bottle of coffee, and multiple supplements. There was a vial of Tuberculin solution in refrigerator with a delivery date of 01/13/25. The Tuberculin solution was opened, with no date documented when it was opened. Interview on 06/04/25 at 12:45 P.M. with RN #262 confirmed the Sycamore Medication Room had two residents who are no longer in the facility, personal medications in the cabinet, that needed to be sent home with the resident's family. Interview also confirmed the medication refrigerator contained three yogurts, a pudding cup, a bottle of coffee, and multiple supplements. Interview also confirmed there was a vial Tuberculin solution in the refrigerator with a delivery date of 01/13/25 and the Tuberculin solution was opened, with no date documented when it was opened. Interview also confirmed that the refrigerator was a medication refrigerator and should not have food items in the refrigerator. Observation on 06/04/25 at 1:09 P.M. with RN #261 of the Sycamore Medication Cart revealed a COVID-19 Test with an expiration date of 04/25/24, Resident #53 Latanoprost 0.005% opened, not labeled with a date opened or expiration date from when it was opened, Resident #35 Latanoprost 0.005% opened, not labeled with a date opened or expiration date from when it was opened, Resident #35 Artificial Tears, opened not labeled with a date opened or expiration date from when it was opened, Resident #32 Antacid / Antigas Liquid 400 mg with a expiration date of 05/2025, and stock Nitroglycerin 0.4 mg with an expiration date of 10/2024. Interview on 06/04/25 at 1:15 P.M. with RN #261 confirmed a COVID-19 Test with an expiration date of 04/25/24, Resident #53 Latanoprost 0.005% opened, not labeled with a date opened or expiration date from when it was opened, Resident #35 Latanoprost 0.005% opened, not labeled with a date opened or expiration date from when it was opened, Resident #35 Artificial Tears, opened not labeled with a date opened or expiration date from when it was opened, Resident #32 Antacid / Antigas Liquid 400 mg with a expiration date of 05/2025, and stock Nitroglycerin 0.4 mg with an expiration date of 10/2024 was on the Sycamore Medication Cart and still actively in use. Interview on 06/04/25 at 2:46 P.M. with the Director of Nursing (DON) confirmed night shift nurses are supposed to check the medications refrigerator nightly to ensure it is clean and only contains medications but expects all nurses to check it as well. Review of the undated policy titled, Storage of Medication policy, revealed no discontinued, outdated, or deteriorated drugs or biologicals are available for use in this facility. All such drugs are destroyed. Medications requiring refrigeration must be stored in the refrigerator located in the drug room at the nurses' station. Mediations must be stored separately from food and must be labeled drugs. Food and Drinks (except those to be used for patient drug administration assistance) should not be stored or placed in/on the med cart.

Based on observation, staff interview, and review of policy, the facility failed to ensure the kitchens were maintained in a clean and sanitary condition and foods were stored in a manner to avoid contamination and spoilage. The facility also failed to ensure the dishes were sanitized when using the dishwasher. Furthermore, the facility failed to maintain the ice machines in the smaller kitchen areas in a sanitary manner. This had the potential to affect all residents but one (#32) who received foods prepared in the kitchens. The facility census was 62. Findings include: A tour of the kitchen on 06/02/25, beginning at 8:20 A.M. and ending at 8:50 A.M., revealed the floors were dull with many food particles scattered everywhere. The aluminum hand sink is stained brown and no covered trash bin was near. Food particles were noted on most surfaces, the sugar bin had dried food splatters on the exterior and a paper bag of sugar with a scoop inside the bin. The oatmeal and flour bins also had dried food splatters on the exterior. The floors and walls in the back portion of the kitchen, near the walk-in refrigerators, have a buildup of splatters. A prep table to the right of the right-hand walk-in refrigerator had a moderate sized splatter of, what appeared to be ketchup, dried on the side. A cart with shelves, located near the back entrance, had a gallon bottle of vanilla extract without a lid. On the same set of shelves were various other, non-food items, and a container of powered oven cleaner. The right-hand walk-in refrigerator had approximately 20 dishes of fruit without a date, and the floors were scattered with various items and dried food splatters. In the left-hand walk-in refrigerator were five packages of meats, bologna, ham, sliced beef, and sliced turkey, without opened dates, as well as two boxes of hot dogs, opened and with dates, and a metal container of chicken cordon bleu was on a shelf without a date. The floor was strewn with numerous items and dried food splatters. The top shelf was either rusty or coated with food particles. The walk-in freezer floor was splattered with dried food particles. A bag of dried macaroni, opened and undated, was noted in the dry food storage area. The hot box was splattered with dried food particles on the interior. The sanitization log for the dishwasher, hanging beside the dishwasher, was dated 08-2024. No log was located for the three-compartment sink sanitization levels. A chemical check of the sanitization level in the dishwasher, performed by [NAME] #265, revealed no reaction on the strip while the unit was in operation. All of the previous findings were verified at the time of discovery with [NAME] #265. While speaking with Dietary Manager (DM) #214, the exterior surfaces of the oven, the deep fryer, and the range were noted to be covered with dried food particles and a large build-up of grease. DM #214 revealed the convection oven surfaces require a special cleaning agent and she is awaiting the delivery of that. She verified the surfaces could have been wiped with a regular cleaning agent. DM #214 stated would get a hold of the contracted company regarding the sanitization of the dishwasher. A second observation at 9:20 A.M., revealed the dishwasher was still being used. At this time this surveyor verified the facility was going to stop using the dishwasher until checked by the contracted company to ensure sanitization levels are being reached. Observation on 06/04/25 at 8:45 A.M., of the kitchen in the skilled nursing section revealed three small bowls, upside down, in a dishwasher tray. Food particles were also noted in the tray. Interview at the time, with FSW #274, revealed the bowl were clean and verified the bowls were being used for the breakfast meal and verified the presence of the food particles. The drain continued to have a thick film of scum. Review of the undated policy titled Food Storage, revealed cleaning compounds are stored in separate storage areas. Review of the undated policy titled Food Storage Policy, revealed all opened, refrigerated foods were to be tightly sealed and labeled with the open date and product name. All products in the dry storage area were to be labeled with the opened date. Review of the undated policy titled Sanitation, revealed the food service are shall be maintained in a clean and sanitary manner. All kitchen, kitchen areas, and dining rooms are to kept clean and free of insects. Dumbwaiters are to sanitized between use. Review of the policy titled Fair Haven [NAME] County Home Dishwashing Policy undated, revealed sanitizer testing should be completed three times a day, before every meal. Observation on 06/02/25 at 2:12 P.M., revealed the Arbor Hall ice machine at the far end of dining room observed with whitish brown build up down front of ice machine by the water and ice dispenser, and whitish / brown buildup on the flat section above the ice dispenser. A yellowish white blanket was observed on floor in front of the ice machine with dirt like residue present. Another towel was noted under the ice machine. The overflow tray was observed to be full of liquid. Interview on 06/02/25 at 2:20 P.M. with Registered Nurse (RN) #252 confirmed she only knows how to get ice or water out of it. Interview confirmed she doesn't know when it is cleaned or how to get the water tray out of it. Interview on 06/02/25 at 2:22 P.M. with Maintenance Employee #215 confirmed the ice machine in Arbor Hall at the back of the dining room was dirty and needed cleaned. The interview confirmed there was a whitish brown buildup down front of ice machine by the water and ice dispenser, and whitish / brown buildup on the flat section above the ice dispenser. Interview also confirmed a yellowish white blanket was on floor in front of the ice machine with dirt like residue present and another towel was under the ice machine. Interview also confirmed that the overflow tray had white rough looking material on it, and the bottom had black substance that rubbed off when rubbed with a cloth. Interview confirmed the white built up substance is calcium buildup from the iron water the facility uses. Observation on 06/04/25 at 10:12 A.M. revealed the ice machine at the back of Arbor Hall continues with whitish brown buildup down front of ice machine, with whitish / brown buildup on the flat section above the ice dispenser. Yellowish white blanket on floor in front of the ice machine with dirt like residue present. Review of the undated policy titled, Sanitation, revealed the food service area shall be maintained in a clean and sanitary manner. Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner.

Based on observation and staff interview, the facility failed to ensure a full-time Licensed Nursing Home Administrator was available at least sixteen hours weekly. This had the potential to affect all 62 residents in the facility. The faciltiy census was 62. Findings include: Observation on 06/02/25, 06/03/25, 06/04/25, 06/05/25, 06/06/25 and 06/09/25, from 8:00 A.M. through 5:00 P.M. revealed no Licensed Nursing Home Administrator (LNHA) available. Interview on 06/09/25 at 10:35 A.M., with the Director of Nursing (DON) confirmed there was not an active LNHA working in the facility. Interview also confirmed the current LNHA #6468 has been on medical leave since 05/21/25 and has not been in the facility since 05/21/25. Interview also confirmed she was not aware of a policy related to LNHA coverage and she was not aware of the regulation requiring a LNHA in the facility at least sixteen hours weekly.

Based on record review and staff interview, the facility failed to have a comprehensive Quality Assurance Performance Improvement Program (QAPI). This had the potential to affect all 62 residents in the facility. Findings include: Record review on 06/09/25 at 5:20 P.M. of the current QAPI information available revealed no current program information available. QAPI book available had no program information present. The book contained meeting information from November 2024. There was no participation documented in the book. Interview on 06/09/25 at 5:20 P.M. with the Director of Nursing (DON) at the time of observation confirmed no current program information available. Interview confirmed the QAPI book available had no program information present. The book contained meeting information from November 2024. There was no participation documented in the book.

Based on record review and staff interview, the facility failed to ensure the Quality Assurance Performance Improvement Program (QAPI) took action and investigated underlying causes and factors contributing to problems. This had the potential to affect all 62 residents in the facility. Findings include: Record review on 06/09/25 at 5:20 P.M. of the current QAPI information available revealed actions or investigations have been completed for problems. The QAPI book contained no documents with actions taken or investigations to find underlying causes for problems in the facility. meeting information from November 2024. There was no participation documented in the book. Interview on 06/09/25 at 5:20 P.M., with the Director of Nursing (DON) at the time of observation confirmed no current investigations or actions being taken for current problems.

Based on record review and staff interview, the facility failed to ensure the Quality Assurance Performance Improvement Program (QAPI) committee met on a regular basis. This had the potential to affect all 62 residents in the facility. Findings include: Record review on 06/09/25 at 5:20 P.M. revealed there was no current QAPI committee meeting information available. The QAPI book had meeting information available for November 2024. Interview on 06/20/25 at 5:20 P.M. with the Director of Nursing (DON) at the time of the observation confirmed there was no information available of QAPI meetings being held since November 2024.

Based on observation, staff interview, and policy review, the facility failed to maintain a pest-free environment. This had the potential to affect all residents (except Resident #32) who receive food served from the kitchen. The facility census was 61. Findings include: Observation on 06/02/25 at 10:50 A.M. revealed a moderate amount of gnats flying around the juice and soda dispensing machine located in the serving area of the dining room on the skilled nursing unit. Interview on 06/02/25 at 10:55 A.M. with Food Service Worker #274 revealed the gnats have been there for quite some time. A subsequent observation on 06/04/25 at 11:00 A.M. revealed the gnats to still be present. Review of the undated policy titled Integrated Pest Management, revealed the facility will follow guidelines for preventative procedures for pest management.

Based on observation, staff interview, review of the facility menu, and review of the policy, the facility failed to ensure all residents received a balanced and nutritious meal. This had the potential to affect six residents (#01, #02, #19, #31, #26, and #53) who receive a pureed diet and did not receive bread or the desert, as well as all of the residents, who did not receive the desert. Resident #28 was identified as not receiving anything by mouth and is not affected. The facility census was 62. Findings include: Observation on 06/04/25 at 10:00 A.M. revealed [NAME] #237 preparing the pureed foods. No bread was added to the beef patty, nor the roasted zucchini. Review of the menu served on 06/04/25 included beef pepper patty, mashed potatoes, roasted zucchini, choice of roll, and cherry crisp. Observation on 06/04/25 from 11:27 A.M. to 1:20 P.M., revealed [NAME] #265 served the meals and was assisted by Dietary Manager (DM) #214 preparing the trays for delivery. The meal consisted of a beef pepper patty, mashed potatoes with gravy, roasted zucchini, a dinner roll, margarine, and cherry crisp. As the meals were being plated for the residents receiving a pureed diet, no bread was added to the plate. No pureed desert was noted in any of the serving dishes. Neither DM #214, nor [NAME] #265 placed the desert, cherry crisp, onto any of the trays to be delivered to the units as well as to the residents eating in the dining room. No margarine was placed on the trays. Observation at 11:50 A.M. of the dining room revealed no margarine on any of the tables with residents seated. At 12:16 P.M., surveyor questioned Food Service Worker (FSW) #274 if any of the residents in the dining had been served the desert or had been offered margarine. FSW #274 replied no, and entered the kitchen and began dishing out the desert and grabbed a handful of margarine tubs to offer to the residents. FSW #274 verified a few of the residents had already left the dining room after finishing their meal. Interview at 1:20 P.M. with [NAME] #265 and DM #214 provided verification the desert had not been served with the room trays nor to the residents in the dining room before FSW #274 dished the desert and served it to the remaining residents. They both also stated pureed bread is not served as it is unappealing and none of the residents eat it. [NAME] #265 and DM #214 verified margarine should be on the carts, but when checked the carts did not have any on it. Review of the undated policy titled Menus, revealed menus shall provide a variety of foods and indicate standard portions. This deficiency represents non-compliance investigated under Complaint Number OH00162995.

Based on observation, staff interview, and review of the policy, the facility failed to ensure the refrigerator used by family to store foods brought in from outside for residents was maintained in a clean manner. This had the potential to affect 44 (#03, #04, #05, #06, #07, #08, #10, #11, #12, #13, #15, #16, #18, #20, #21, #22, #23, #26, #28, #30, #31, #33, #34, #35, #36, #38, #40, #42, #43, #45, #46, #47, #48, #49, #50, #52, #53, #54, #55, #57, #59, #115, #116, #165, and #215) of 44 residents who utilized the refrigerator The facility census was 62. Findings include: Observation on 06/02/25 at 2:34 P.M. revealed four plastic dishes in the resident refrigerator, located in the lounge area near room [ROOM NUMBER], without dates, one plastic dish dated 04/30/25, and one small dish of salsa dated 04/15/25. The floor of the refrigerator was covered in food particles. Interview at the time of discovery with Certified Nursing Assistant (CNA) #258 revealed all of the food dishes belonged to Resident #12, and verified the presence of the food particles on the floor of the refrigerator. Observation on 06/04/25 at 2:30 P.M. revealed the dishes were still in the refrigerator but now had dates, but all were past the three days specified in the policy. Review of the policy titled Sanitary Outside Food Policy updated August 2017, revealed any food brought in for the residents must be labeled with the resident's name and the date it was brought in. All perishable food will be removed after the third day of arrival in the facility.

Based on medical record review, staff interview, resident interview, observation, review of the Sani-Cloth Bleach wipes container instructions, review of glucometer manufacture's recommendations, review of the Centers for Disease Control and Prevention (CDC) website, and policy review, the facility failed to ensure hand hygiene was completed during a pressure ulcer dressing change for Resident #49; failed to ensure recommendations for enhanced barrier precautions (EBP) were initiated for Resident #26; failed to ensure gloves were worn during assistance with food for Resident #17 and #56; and failed to ensure glucometer was properly cleaned for Resident #115. This affected four residents (#17, #26, #49, and #56), with the potential to affect a limited number of resident who received assistance with meals, glucometer checks or were on enhanced barrier protection. The census was 62. Findings included 1. Medical record review for Resident #49 revealed an admission assessment dated [DATE] with diagnoses including methicillin resistant staphylococcus aureus infection (MRSA), fracture of superior rim of pubis, urinary track infection, cerebral infarction, chronic myeloproliferative disease, depression and hypothyroidism. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #49 revealed moderately impaired cognition. Resident #49 required set up or clean up assistance for eating, dependent for toileting, maximal assistance for bed mobility, and dependent for transfers. Resident #49 was coded with one unstageable pressure ulcer. Resident #49 was coded with infection on the foot. Review of the Care Area assessment dated [DATE] for Resident #49 revealed an unstageable pressure ulcer to R heel with current MRSA infection. Antibiotic therapy as ordered and isolation precautions in place. Resident #49 requires assistance with bed mobility, frequently incontinent of bladder and bowel and receives blood thinners which can increase risk for bleeding and bruising. Review of the plan of care for Resident #49 revealed an infection of the right heel wound dated 05/13/25. Interventions include administer antibiotic as ordered, maintain universal precautions when providing resident care, monitor temperature/pulse as clinically indicated, monitor/document/report signs and symptoms of delirium including changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness and agitation, altered sleep cycle. Review of the active physician's orders for Resident #49 revealed an order dated 05/30/25 for Doxycycline Hyclate oral tablet 100 milligram (mg) give 1 tablet by mouth two times a day for heel wound until 06/12/2025; an order dated 05/23/25 for right heel, cleanse with normal saline (ns) and pat dry, apply silver alginate to wound only, cover with silicone bordered foam and wrap with kerlix. change dressing daily; and moon boot to right foot when in bed or chair every shift for right heel wound dated 3/13/2025. Observation on 06/04/25 at 9:31 A.M., with Registered Nurse (RN) #262 complete right heel dressing change for Resident #49. RN #262 donned personal protective equipment just inside the door. RN #262 advised the resident what task she was going to complete and assessed for pain prior to dressing initiation. Bedside table was cleaned and clean barrier was applied to surface, dressing supplies were opened and arranged on table with packaging under each item. RN #262 removed the blue moon boot from resident right heel and used pillow used to elevated right heel. RN #262 unwrapped kerlix from right heel, removed old dressing using normal saline to soak areas of silver nitrate from wound, dressing removed. RN #262 placed dressing into gloved hand and removed glove over dressing discarding both items into a bag on the resident's bed. RN #262 donned new gloves from supply table and cleansed wound to right heel with normal saline. RN #262 applied silver alginate to wound bed, covered with silicone bordered dressing. Dressing was dated with correct date and initialed by nurse. Interview on 06/04/25 at 9:52 A.M. with RN #262 verified she removed the old dressing, placing it in a gloved hand and discarded both items. RN#262 verified she did not complete hand hygiene before cleansing and applying the new dressing and should have. 2. Review of the medical record for Resident #26 revealed an admission on [DATE] with diagnoses including Parkinson's disease, acute kidney failure, hematuria, infection and inflammatory reaction of urethral catheter, urinary retention, and neuromuscular dysfunction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 revealed an impaired cognition. Resident #26 required set up or clean up assistance for eating, dependent for toileting, dependent for bed mobility and transfers. Resident #26 was coded as having a indwelling catheter, and was incontinent of bowel. Review of the plan of care for Resident #26 dated 10/13/23 revealed use of indwelling supra catheter: urinary retention and hematuria, Interventions include check urinary tubing for kinks every two hours, and as needed (PRN) each shift, monitor and document intake and output as per facility policy, monitor and document for pain and discomfort due to catheter, and monitor/record/report to physician (MD) for signs and symptoms of urinary tract infections. Review of the active physician orders for Resident #26 revealed [NAME] oral tablet (Hyoscyamine Sulfate) give 0.125 mg by mouth three times a day for bladder spasms dated 05/20/25; change suprapubic catheter 16 French/10 milliliter every four weeks and PRN dated 10/17/24; provide suprapubic catheter care and cover site with dry dressing twice daily every shift for protection dated 10/1/24; change urinary drainage bag per facility protocol every night shift every Wednesday for Foley catheter dated 10/2/2024; irrigate Foley catheter with normal saline solution to maintain patency as needed for patency AND every night shift every Wednesday for patency dated 10/1/2024. Observation on 06/02/25 12:04 P.M. of Resident #26 door frame facing hallway contained a small yellow square without any directions/signage of what it meant. Directly inside the room was observed a small three drawer chest with personal protective equipment in each drawer and alcohol based hand gel on the top of the unit. The area did not have any directions to see the nurse prior to entrance to the rooms with the yellow squares on them. Interview with Resident #26 concurrently requested assistance from staff to be pulled up in chair. Observation on 06/02/25 at 12:07 P.M. revealed Licensed Practical Nurse (LPN) #217 and Certified Nurse Assistant (CNA) #209 enter the room and both staff members donned gloves prior to pulling the resident up in his wheelchair. LPN #217 and CNA #209 removed gloves, discarded them into garbage bin before exiting the room. Interview on 06/02/25 at 12:15 P.M. with Resident #26 stated staff only have to wear a gown when the are caring for his catheter. Resident #26 unable to recall receiving any education regarding why the staff wear them and when they are supposed to where them. Resident #26 stated staff usually wear gloves but has not seen gowns in a long time. Interview on 06/02/25 at 12:21 P.M. with LPN #217 verified that she or the CNA assisting with positioning did not wear gowns as they were just pulling him up in his chair and did not provide any direct care to the resident. Interview on 06/09/25 at 01:05 P.M. with Registered Nurse (RN) #283 stated the facility has an enhanced barrier precaution (EBP) policy in place. RN #283 stated a small yellow square outside of the room on the door frame alerts staff of that care to the specified resident requires personal protective equipment (PPE) for staff when providing care. RN #283 verified the square did not contain any guidance for staff or visitors of the specific actions to take or precautions needed to follow to care or have contact with resident. RN #283 further verified rooms did not have any instruction to see the nurse prior to entering rooms with the yellow squares. RN #283 had a large binder that contained the Centers of Disease Control one sheet signage regarding EBP, but stated the facility was concerned they would violate the residents protected health information. RN #283 stated she was unaware of any education given to residents and visitors in regarding to the meaning or instructions regarding the EBP policy. Interview on 06/09/25 at 2:25 P.M. with the Director of Nursing (DON), verified the facility uses the yellow squares on the doors to alert staff and do not have any signage to alert visitors to see the nurse prior to visiting residents with the identified yellow squares on the door frames. Review of the facility policy titled Enhanced Barrier Precautions, dated 04/01/24 stated signage is posted at all nurse's stations explaining EBP and notification of which residents require EBP. Rooms will have a marker outside the residents room as a way to alert staff that they require EBP. Review of the CDC website (cdc.gov) for long term care facilities state the implementation of EBP should include posting clear signage on the door or wall outside of the resident room indicating the type of precautions and required personal protective equipment (PPE) (e.g., gown and gloves), signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves, make PPE including gowns and gloves, available immediately outside of the resident room, ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room), position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room, incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education, and provide education to residents and visitors. 3. Review of the medical record for Resident #17 revealed an admission date of 05/06/25 with diagnoses of acute on chronic diastolic congestive heart failure and dementia. Review of the care plan dated 05/12/25 revealed resident had a nutrition problem with intervention of provide and serve diet as ordered. Observation on 06/02/25 at 12:36 P.M. revealed Certified Nursing Assistant (CNA) #207 unwrapped Resident #17's cookie with her bare hands, without gloves and placed the cookie on the resident's meal tray. 4. Review of the medical record for Resident #56 revealed an admission date of 02/04/25 with diagnoses of lumbago with sciatica, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the care plan for Resident #56 dated 02/17/25 revealed resident had a nutrition problem with intervention of provide and serve diet as ordered. Observation on 06/02/25 at 12:36 P.M. revealed Certified Nursing Assistant (CNA) #207 unwrapped Resident #56's cookie with her bare hands, without gloves and placed the cookie on the resident's meal tray. Interview on 06/02/25 at 12:39 P.M. with CNA #207 confirmed she opened and removed Resident #17 and Resident #56's cookies with her bare hands, without gloves and placed them on their meal trays. Interview also confirmed she did not know she could not touch resident's food with her bare hands. Review of the undated policy titled, Food Handling and Serving, revealed gloves are required to be worn when handling ready-to-eat foods. 5. Review of the medical record for Resident #115 revealed an admission date of 02/18/25 with diagnosis of type 2 diabetes, anxiety, and chronic kidney disease. Review of the Quarterly MDS dated [DATE] revealed resident was cognitively intact. Resident #115 require set- up assistance with toileting hygiene and personal hygiene. Resident was independent with all other activities of daily living. Review of the physician order dated 02/18/25 revealed an order for Accu-Check before meals (AC) and at bedtime (HS) four times daily for diabetes. Observation on 06/04/25 at 8:42 A.M. revealed Licensed Practical Nurse (LPN) #201 remove the Glucometer One Care from her scrub shirt right pocket. LPN #201 continued into Resident #115's room. LPN #201 washed her hands, applied gloves, cleaned Resident #115's finger with alcohol wipes and proceeded to check Resident #115's finger stick blood sugar with the Glucometer One Care she had removed from her scrub shirt pocket. LPN #201 removed her gloves, placed the Glucometer One Care on top of her medication cart and washed her hands. After washing her hands, LPN #201 picked up Glucometer One Care and placed it inside the medication cart. Interview on 06/04/25 at 9:00 A.M. with LPN #201 confirmed she did not clean the glucometer before using in on Resident #115. LPN #201 confirmed she had cleaned the glucometer prior to sticking it into her scrub top pocket with Sani-Cloth Bleach wipes. LPN #201 confirmed the Glucometer One Care should not have been placed onto the medication cart after use or placed inside the medication cart after use without using a Sani-Cloth bleach wipe. LPN #201 proceeded to clean the Glucometer One Care at this time with the Sani-Cloth bleach wipes, with an expiration dated of 08/2025, at the nurse's station. Interview on 06/05/25 at 12:43 P.M. with the DON confirmed it is the expectation of the nurses to clean the Glucometer One Care after each use with an approved Sani-Cloth bleach wipe. Review of the Sani-Cloth Bleach wipes container revealed an expiration date of August 2025 revealed instructions to wait 4 minutes after cleaning to use. Review of the undated Glucometer One Care manual revealed to disinfect the Glucometer One Care apply protective disposable gloves, remove an EPA-registered disinfecting wipe from its container, carefully wipe the outside of the meter avoiding saturating the test strip dock , data port or battery section. Discard the used disinfecting wipe. Allow the meter to remain wet according to the recommended contact time of the manufacturer of the disinfecting wipe. Allow the meter to dry completely. Please note that there are commercially available EPA-registered disinfecting wipes, 1:10 quaternary/alcohol wipes and bleach wipes from a variety of manufactures to clean and disinfect the One-Care Pro meter. o PDI Super Sani-Cloth Germicidal Disposable Wipes o PDI Sani-Cloth Bleach Germicidal Disposable Wipes o Clorox Healthcare Bleach Germicidal Wipes Review of the undated policy titled,Glucometer Disinfecting, revealed the facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus.

Based on medical record review, staff interview, and policy review, the facility failed to ensure the care plans were updated to reflect the current physician order, change in diagnosis and include interventions. This affected five (#9, #26, #41, #46, and #54) of 23 residents reviewed for care plans. The facility census was 62. Findings include: 1. Review of the medical record of Resident #46 revealed an admission date of 09/17/21. Diagnoses include cerebral infarction and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #46 was cognitively impaired and had impairment of upper extremities. Review of the physician order dated 09/27/24 revealed to gently open right fingers and place a pillow splint in palm with strap over knuckles. Keep in hand at all times, except during hygiene for contracture management. Review of the care plan initiated 11/02/22 revealed to apply the hand splint when in bed and remove in the morning. Interview on 06/09/25 at 8:00 A.M., with Director of Nursing provided verification of the inaccurate care plan, did not address the physician order. Review of the undated policy titled Care Plan Policy, revealed care plans will provide instructions needed to provide effective and person-centers care of the resident that meets professional standards of quality of care. 2. Review of the medical record for Resident #26 revealed an admission on [DATE] with diagnoses that include but not limited to Parkinson's disease, acute kidney failure, hematuria, infection and inflammatory reaction of urethral catheter, urinary retention, and neuromuscular dysfunction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 revealed an impaired cognition. Resident #26 required set up or clean up assistance for eating, dependent for toileting, dependent for bed mobility and transfers. Resident #26 was coded as having a indwelling catheter, and was incontinent of bowel. Review of the plan of care for Resident #26 dated 10/13/23 revealed use of indwelling supra catheter: urinary retention and hematuria, Interventions include check urinary tubing for kinks every two hours, and as needed (PRN) each shift, monitor and document intake and output as per facility policy, monitor and document for pain and discomfort due to catheter, and monitor/record/report to physician (MD) for signs and symptoms of urinary tract infections. Review of the active June 2025 physician orders for Resident #26 revealed [NAME] oral tablet (Hyoscyamine Sulfate) give 0.125 milligram (mg) by mouth three times a day for bladder spasms dated 05/20/25, change suprapubic catheter 16 French/10 milliliter every four weeks and pro re nata (PRN) dated 10/17/24, provide suprapubic catheter care and cover site with dry dressing twice daily every shift for protection dated 10/01/24, change urinary drainage bag per facility protocol every night shift every Wednesday for Foley catheter dated 10/02/24, irrigate Foley catheter with normal saline solution to maintain patency as needed for patency and every night shift every Wednesday for patency dated 10/01/24 Review of the physicians consult form dated 04/09/25 revealed the resident went to urologist and supra pubic catheter was changed. Interview and observation completed concurrently on 06/03/25 at 8:30 A.M., with Resident #26 stated he has had the urinary catheter for some time now as he was unable to urinate on his own. Resident #26 states he has spasms related to urinary catheter and follows with urologist. Resident #26 stated sometimes the physician changes it and sometimes the nurses change it. Interview on 06/04/25 at 1:19 P.M., with the Director of Nursing (DON) verified the plan of care did not include the size of the urinary catheter used, irrigation orders, drainage bag changes, dressing changes and medications for bladder spasms and should have. 3. Review of the medical record for Resident #54 revealed an admission on [DATE] with diagnoses including chronic obstructive pulmonary disease, displaced fracture of proximal phalanx of left ring finger, Alzheimer's disease, dementia with severe psychotic disturbances, and psychotic disorder with delusions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 revealed severe cognitive impairment. Resident #54 was not coded with any behaviors. Resident #54 was coded as independent for eating, set up or clean up assistance for toileting, independent for bed mobility and transfers. Resident #54 was coded with fall sustaining a major injury. Review of the plan of care dated 03/25/25 for Resident #54 revealed alteration in musculoskeletal status related to minimally displaced, impacted fracture of left ring finger. Interventions include anticipate and meet needs, ensure call light is within reach and respond promptly to all requests for assistance and give analgesics as ordered. Review of the plan of care for Resident #54 dated 10/13/23 revealed resident was at risk for falls due to confusion, urinary incontinence and psychotropic med use. Interventions include anticipate and meet needs. Review of the fall assessment dated [DATE] revealed Resident #54 was at moderate risks for fall. Review of the fall investigation dated 03/23/25 at 8:00 P.M., for Resident #54 revealed nurse from other unit called to say the resident had fallen. Went to Resident #54 room and resident was sitting on the commode bleeding from skin tears to left thumb and first finger. Resident #54 had bruising to left hand, right palm and thumb. Blood noted on floor beside the bed. Resident #54 was found sitting on the commode by the nursing assistant. Resident #54 stated she used to hands to break the fall. Resident #54 is ambulatory without assist or assistive device. Immediate intervention was documented neurological checks and areas cleaned and steri strips applied. Fall intervention included grip strips next to bed. Review of the fall assessment dated [DATE] revealed Resident #54 was a moderate risk for falls. Review of the discontinued orders for Resident #54 revealed an order for physical therapy evaluation and treat dated 03/24/25, an order dated 03/27/25 for physical therapy to include thirty sessions in 6 weeks to include therapeutic exercises, therapeutic activity, neurological reeducation for gait training, manual techniques and modalities as needed. an order to apply bunny tape to ring finger and middle finger and wrap around left hand due to swelling and healing for fracture dated 03/25/25 and radiology (X-ray) of left hand due to pain and swelling from fall dated 03/24/25. Review of the progress note dated 03/24/25 at 5:06 P.M. for Resident #54 revealed nurse from another unit brought resident over in chair from other hall way with a skin tear on upper left forearm. Resident is unsure what happened and is worried about what happened to her left hand/fingers. Resident is complaining of pain, Tylenol was administered. Resident also took wrap off of left hand/wrist and tape off fingers. Nurse called and left a voice mail for physician to call back to make aware of situation, and also to get something stronger for pain. Director of Nursing (DON) aware and power of attorney notified. Review of the progress notes dated 03/24/25 at 5:22 P.M. revealed nurse also offered resident ice through out the day for swelling of Left hand and fingers. Resident has refused ice due to not liking the cold or feeling of having ice on her. Observation on 06/03/25 at 10:06 A.M., of Resident #54's room revealed grip strips applied to floor on the side of the bed that is closest to the bathroom. Interview on 06/09/25 at 5:00 P.M., with DON verified the fall interventions were not on the care plan and should have been. Review of the undated policy titled Care Plan Policy, undated, stated each care plan will be reviewed and updated after each quarterly and comprehensive assessment. 4. Review of the medical record for Resident #9 revealed an admission date of 11/15/11, with diagnoses of unspecified dementia, unspecified severity, with agitation, bipolar disorder, peripheral vascular disease, major depressive disorder, and epilepsy, unspecified, not intractable, without status epilepticus. Review of the Annual Minimum Data Set, dated [DATE] revealed Resident #9 had severe cognitive impairment. Resident #9 had no mood behaviors, did not have indicators of psychosis, and had no behavioral symptoms. Resident #9 was independent with bed mobility, required set-up assistance with eating, and required substantial assistance with oral hygiene and ambulation. Resident #9 was dependent on staff assistance with toileting hygiene, bathing, dressing, personal hygiene, transfers, and wheelchair mobility. Resident #9 used high-risk drug of antipsychotics, antianxiety, antidepressant, and anticonvulsant. Review of the care plan with a revision date of 02/04/25 revealed Resident #9 was on prophylactic antibiotic therapy with interventions of administer medication as ordered, monitor for side effects, and report pertinent lab results to physician. Review of the monthly physician orders for June 2025 revealed Resident #9 was not currently taking an antibiotic. Further review of the physician orders revealed an order dated 03/29/25 for Cipro (antibiotic) Oral Tablet 500 milligrams (mg) one tablet two times a day for urinary tract infection (UTI) for 20 administrations. Review of the Medication Administration Record for April 2025 revealed Cipro Oral Tablet 500 mg administration was completed on 04/08/25. Interview on 06/05/25 at 4:09 P.M., with the Director of Nursing (DON) confirmed Resident #9 was not on an antibiotic and care plan is inaccurate. 5. Review of the medical record for Resident #41 revealed an admission date of 6/16/20 with diagnoses of anorexia, Alzheimer's disease with late onset, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Discharge Return Anticipated Minimum Data Set, dated [DATE] revealed Resident #41 had severe cognitive impairment. Resident was dependent on staff assistance with all ADLs. Review of the care plan dated 01/16/21 revealed Resident #41 was at risk for bowel elimination problems related to decreased mobility, and history of constipation. Further review revealed the care plan was not revised to include fecal Impaction. Review of the progress note dated 05/14/25 at 6:00 A.M., revealed Resident #41 found with dark brown liquid emesis. Abdomen slightly firm, bowel sounds noted in all four quadrants. Review of the progress note dated 05/14/25 at 2:40 P.M., revealed the physician examined Resident #41 and ordered resident to be sent to the emergency room for evaluation. Review of the progress noted dated 05/17/25 at 8:37 P.M., revealed Resident #41 returned from the hospital after being admitted to the hospital with fecal impaction, manually removed while at the hospital, and a urinary tract infection (UTI). Review of the care plan dated 01/16/21 revealed Resident #41 was at risk for bowel elimination problems related to decreased mobility, and history of constipation. Further review revealed the care plan was not revised to include fecal Impaction. Review of hospital record for 05/14/25 through 05/17/25 revealed resident was seen in the emergency room on [DATE] after having an emesis and then became unresponsive. Emergency notes revealed resident had abnormal urine and dehydration. Resident was started on IV fluids and IV Rocephin and admitted to the hospital. Examine revealed resident's abdomen was distended. Lab results showed urinary tract infection, bowel dilatation and possible stool in rectum. Resident discharged back to the skilled nursing facility on 05/17/25 with diagnosis of fecal impaction in the rectum, constipation, dementia, and urinary tract infection. Review of the facility tasks for bowel continence revealed on 05/08/25, Resident #41 had a medium bowel movement, on 05/09/25 had a small bowel movement, 05/10/25 had two small bowel movements, 05/11/25 had a small bowel movement, 05/12/25 had a small, medium, and large bowel movement, 05/13/25 resident did not have a bowel movement, and on 05/14/25 resident had a small and medium bowel movement. All bowel movements documented were of soft texture. Review of the Medication Administration for Resident #41 record for May 2025 revealed resident did not receive any medications for constipation. Interview on 06/09/25 at 10:19 A.M., with the DON confirmed Resident #41's care plan was not updated to include the new diagnoses of fecal impaction and UTI. Review of the undated policy titled, Care Plan, revealed each resident will have a comprehensive care plan written that incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, staff interviews, and policy review, the facility staff failed to sign out narcotics when administered. This affected seven (#4, #7, #11, #20, #22, #26, and #43) of 62 residents in the facility randomly observed during medication cart review. The facility census was 62. Findings include: Observation on 06/04/25 at 12:59 P.M., of Sycamore Hall medication cart with Registered Nurse (RN) #262 revealed Resident #7's Lorazepam 0.5 milligram (mg) one (1) tablet signed out during cart inspection and Oxycodone 5 mg 1 tablet signed out during cart inspection, and Resident #26's Alprazolam 0.5 mg 1 tablet signed out during cart inspection. Observation on 06/04/25 at 1:05 P.M., of Sycamore Hall medication cart with RN #262 revealed Resident #7's Lorazepam 0.5 mg count sheet revealed 11 tablets remaining, medication card shows 10 tablets present. Interview on 06/04/25 at 1:05 P.M., with RN #262 confirmed Resident #7's Lorazepam 0.5 mg and Oxycodone 5 mg was signed out during cart inspection, and Resident #26's Alprazolam 0.5 mg was signed out during cart inspection. RN #262 confirmed Resident #7's Lorazepam 0.5 mg count sheet revealed 11 tablets remaining and there was only 10 tablets left on the medication card. RN #262 also revealed it is the expectation of the facility that narcotics are to be signed out when pulled from the cart at time of administration. RN #262 stated the narcotic count was correct at the start of the shift. Observation on 06/04/25 at 3:19 P.M., with Licensed Practical Nurse (LPN) #201 of Walnut Lane medication cart revealed Resident #20 Alprazolam 0.5 mg 1 tablet signed out during cart inspection, Resident #4's Pregabalin 100 mg 1 tablet signed out during cart inspection, Resident #11's Tramadol 50 mg 1 tablet signed out during cart inspection, Resident #22's Tramadol 50 mg 1 tablet signed out during cart inspection, and Resident #43's Hydrocodone / APAP 5/325 mg 1 tablet signed out during cart inspection. Interview on 06/04/25 at 3:29 P.M., with LPN #201 confirmed she failed to sign out Resident #20 's Alprazolam 0.5 mg, Resident #4's Pregabalin 100 mg, Resident #11's Tramadol 50 mg, Resident #22's Tramadol 50 mg, and Resident #43's Hydrocodone / APAP 5/325 mg, until during cart inspection. LPN #201 stated it is the expectation of the facility that narcotics are to be signed out when pulled from the cart at time of administration. Interview also confirmed the narcotic count was correct at the start of the shift. Interview on 06/04/25 at 2:40 P.M. with the Director of Nursing (DON) confirmed it is the expectation of the facility that all narcotics are signed of at the time of the narcotic being pulled out of the medication cart. Interview also confirmed RN #262 has been pulled off the floor. Review of the undated policy titled, Medication Administration Systems And Scheduled Medication Administration Times, revealed all medications are safely and accurately administered and documented by appropriately trained and authorized personnel in accordance with applicable state and federal regulations.

Based on medical record review, observations, staff interviews, review of medication inserts, and policy review, the facility failed to ensure medication were administered per physician orders and medications were documented when administered. This affected 16 (#4, #6, #7, #11, #15, #17, #18, #22, #26, #31, #32, #35, #43, #53, #61, and #115) of 62 residents in the facility. The facility census was 62. Findings include: Observation on 06/04/25 at 12:59 P.M. of Sycamore Medication Cart Narcotic Count Sheets with Registered Nurse (RN) #262 revealed Resident #7's Lorazepam 0.5 mg narcotic count sheet was off by two, one tablet signed out at time of observation. Resident #7's Oxycodone 5 mg narcotic count sheet was off by one, one table signed out at time of observation. Resident #26's Alprazolam 0.5 mg narcotic count sheet was off by one, one tablet signed off at time of observation. Interview on 06/04/25 at 1:05 P.M., with Registered Nurse (RN) #262 confirmed Resident #7's Lorazepam 0.5 mg narcotic count sheet was off by two, one tablet signed out at time of observation. Resident #7's Oxycodone 5 mg narcotic count sheet was off by one, one table signed out at time of observation. Resident #26's Alprazolam 0.5 mg narcotic count sheet was off by one, one tablet signed off at time of observation. RN #262 confirmed Resident #7 Lorazepam 0.5 mg tablet is one tablet short, the count sheet says 11, the card shows 10. RN #262 confirmed that all narcotics are to be signed out of the narcotic log sheets when the medications are pulling from the narcotic drawer. Interview confirmed she did not follow the procedure to sign the narcotic out on the narcotic log when she pulled the narcotics on this date. Observation on 06/04/25 at 1:09 P.M., with RN #262 of Sycamore Medication Cart revealed a COVID-19 test with an expiration date of 04/25/24. Latanoprost 0.005% for Resident #53 that was opened and not dated when opened or when expired. Latanoprost 0.005% and Artificial Tears for Resident #35 that was opened and not dated when opened or when expired. Antacid / Anti-gas Liquid 400 mg for Resident #32 with an expiration date of 05/2025. Stock Nitroglycerin 0.4 mg tablets with an expiration date of 10/2024. Interview on 06/04/25 at 1:15 P.M., with RN #262 confirmed Sycamore Medication Cart had a COVID-19 test with an expiration date of 04/25/24. Latanoprost 0.005% for Resident #53 that was opened and not dated when opened or when expired. Latanoprost 0.005% and Artificial Tears for Resident #35 that was opened and not dated when opened or when expired. Antacid / Anti-gas Liquid 400 mg for Resident #32 with an expiration date of 05/2025. And stock Nitroglycerin 0.4 mg tablets with an expiration date of 10/2024. Interview also confirmed medications should be discarded when expired. Interview on 06/04/25 at 2:40 P.M. with the Director of Nursing (DON) confirmed it is the expectation of the facility that all nurses sign out narcotics when pulled from the narcotic drawer and sign the medication administration record when given. Observation on 06/04/25 at 3:19 P.M. with Licensed Practical Nurse (LPN) #201 of Walnut Lane medication cart revealed Resident #20 Alprazolam 0.5 mg 1 tablet signed out during cart inspection, Resident #4 Pregabalin 100 mg 1 tablet signed out during cart inspection, Resident #11 Tramadol 50 mg 1 tablet signed out during cart inspection, Resident #22's Tramadol 50 mg 1 tablet signed out during cart inspection, and Resident #43 Hydrocodone / APAP 5/325 mg 1 tablet signed out during cart inspection. Interview on 06/04/25 at 3:29 P.M. with LPN #201 confirmed she failed to sign out Resident #20 Alprazolam 0.5 mg 1 tablet during cart inspection, Resident #4 Pregabalin 100 mg 1 tablet during cart inspection, Resident #11 Tramadol 50 mg 1 tablet during cart inspection, Resident #22 Tramadol 50 mg 1 tablet during cart inspection, and Resident #43 Hydrocodone / APAP 5/325 mg 1 tablet during cart inspection. Interview also revealed it is the expectation of the facility that narcotics are to be signed out when pulled from the cart at time of administration. Interview also confirmed the narcotic count was correct at the start of the shift. Observation on 06/04/25 at 3:32 P.M. with LPN #201 of Walnut Lane Medication Cart revealed a bottle of A Reds with an expiration date of 03/2025 was present in the cart, observation also revealed Resident #6's Lispro Insulin 100 units / ml was opened and not dated when opened, Resident #15's Sodium Chloride 5% eye drops was opened and not dated when opened, Resident #18's Brimodine 0.2% eye drops was opened and not dated when opened, Resident #18's Timolol 0.5% eye drops was opened and expired on 04/07/25, Resident #22's Novolog 100 units / ml expired 05/29/25, Resident #31's Lantus Insulin 100 units / ml expired 05/29/25, and Resident #31 Albuterol 0.83%/ml expired 12/2024. Interview on 06/04/25 at 03:36 P.M. with LPN #201 confirmed a bottle of Areds with an expiration date of 03/2025 was present in the cart, Resident #6's Lispro Insulin 100 units / ml was opened and not dated when opened, Resident #15's Sodium Chloride 5% eye drops was opened and not dated when opened, Resident #18's Brimodine 0.2% eye drops was opened and not dated when opened, Resident #18's Timolol 0.5% eye drops was opened and expired on 04/07/25, Resident #22's Novolog 100 units / ml expired 05/29/25, Resident #31's Lantus Insulin 100 units / ml expired 05/29/25, and Resident #31 Albuterol 0.83%/ml expired 12/2024. Interview also confirmed all of the expired medications and the medications not labeled in the Walnut Lane Medication Cart were active and still in use. Observation on 06/04/25 at 7:31 A.M. with LPN #290 revealed Resident #61 was administered Aspirin Enteric Coated (EC) 81 mg 1 tablet. Physician order was for Aspirin 81 mg 1 tablet. Observation also revealed Trelegy Eilipta 200-62.5-25mcg 1 puff was administered by having Resident #61 take a deep breath prior to administering, then had the resident to inhale the medication, LPN #290 did not advise resident to hold the medication in prior to exhaling. LPN #290 did not advise Resident #61 to rinse and spit after the inhalation of Trilogy Elipta 200-62.5-25 mcg. Observation on 06/04/25 at 7:43 A.M. with LPN #290 revealed Resident #17 was administered Aspirin EC 81 mg 1 tablet. Physician order was for Aspirin Chewable 81 mg 1 tablet. Observation on 06/04/25 at 8:42 A.M. with LPN #201 revealed Resident #115 was administered Farxiga 10 mg 1 tablet. Physician order was for Farxiga 5 mg 1 tablet. Observation also revealed Vitamin C 500 mg 1 tablet was administered. The physician order was for Vitamin C 1000 mg 1 tablet. Interview on 06/04/25 at 9:55 A.M. with LPN #201 confirmed Resident #115 was administered Farxiga 10 mg 1 tablet and the physician order was for Farxiga 5 mg 1 tablet. Interview also confirmed Resident #115 was administered Vitamin C 500 mg 1 tablet and the physician order was for Vitamin C 1000 mg 1 tablet. Observation and interview at 9:55 A.M. with LPN #201 confirmed the Farxiga pharmacy box for Resident #115 read Farxiga 5 mg on the label, but the tablets inside the box were labeled Farxiga 10 mg tablets. Interview on 06/04/25 at 10:06 A.M. with LPN #290 confirmed she administered Resident #61 Aspirin Enteric Coated 81 mg 1 tablet and that the physician order was for Aspirin 81 mg 1 tablet. Interview on 06/04/25 at 10:17 A.M. with LPN #290 confirmed she administered Resident #17 Aspirin Enteric Coated 81 mg 1 tablet and that the physician order was for Aspirin 81 mg 1 tablet. Review of the undated titled, Medication Administration revealed all medications are safely and accurately administered and documented. Review of the Trelegy Ellipta important safety information at trelegy.com/copd/why-trelegy-for-copd revealed TRELEGY can cause serious side effects, including fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using TRELEGY to help reduce your chance of getting thrush.

Based on record review and staff interview, the facility failed to ensure the comprehensive assessment was completed accurately to include a diuretic for one (Resident #9) and included falls without injury for one (Resident #40). This affected two (#9 and #40) of five residents reviewed for comprehensive assessments. The facility census was 62. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 11/15/11, with diagnoses of unspecified dementia, unspecified severity, with agitation, bipolar disorder, peripheral vascular disease, major depressive disorder, and epilepsy, unspecified, not intractable, without status epilepticus. Review of the Annual Minimum Data Set, dated [DATE] revealed Resident # 9 had severe cognitive impairment. Resident used high-risk drug of antipsychotics, antianxiety, antidepressant, and anticonvulsant. There was no diuretic use indicated. Review of the physician orders revealed an order dated 09/17/24 for Furosemide 20 milligram (mg) give one tablet by mouth one time a day related to heart failure. Review of the care plan with a revision date of 06/03/15 revealed Resident #9 was on a diuretic related to hypertension and edema with interventions of administer medications as ordered, physician to review medication for possible dose reduction every three months, monitor for interactions and adverse consequences with other drugs, and report pertinent lab results to the physician. 2. Review of the medical record for Resident #40 revealed an admission date of 05/20/20, with diagnoses of inflammatory disease of prostate, Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly MDS dated [DATE] revealed Resident #40 was cognitively intact. Resident #40 has had no falls since admission / entry or reentry or prior assessment without injury. Review of the care plan for Resident #40 revealed a risk for falls with interventions of every two-hour toileting, anti-roll backs on wheelchair, ensure room is free from clutter, and grip strips on floor beside bed. Review of the Unwitnessed Fall report dated 01/15/25 at 3:30 P.M. revealed Resident #40 had a fall without injuries. Review of the Unwitnessed Fall report dated 01/25/25 at 5:50 P.M. revealed Resident #40 had a fall without injuries. Review of the Unwitnessed Fall report dated 03/17/25 at 10:00 P.M. revealed Resident #40 had a fall without injuries. Interview on 06/05/25 at 4:09 P.M. with the Director of Nursing (DON) confirmed the Annual MDS, dated [DATE] for Resident # 9, did not include the use of a diuretic. Interview also confirmed the Quarterly MDS, dated [DATE] for Resident #40 did not include resident had falls without injuries. Interview on 06/09/25 at 5:00 P.M., with the DON confirmed there is not a policy on a comprehensive assessment being completed accurately.

Based on record review, staff interviews, and policy review, the facility failed to ensure medication administered was for an appropriate diagnosis. This affected one (#9) out of five residents reviewed for unnecessary medications. The facility census was 62. Findings include: Review of the medical record for Resident #9 revealed an admission date of 11/15/11, with diagnoses of unspecified dementia, unspecified severity, with agitation, bipolar disorder, peripheral vascular disease, major depressive disorder, and epilepsy, unspecified, not intractable, without status epilepticus. Review of the Annual Minimum Data Set, dated [DATE] revealed Resident #9 had severe cognitive impairment. Resident #9 had no mood behaviors, did not have indicators of psychosis, and had no behavioral symptoms. Resident was independent with bed mobility, required set-up assistance with eating, and required substantial assistance with oral hygiene and ambulation. Resident #9 was dependent on staff assistance with toileting hygiene, bathing, dressing, personal hygiene, transfers, and wheelchair mobility. Resident #9 used high-risk drug of antipsychotics, antianxiety, antidepressant, and anticonvulsant. Review of the monthly Physician Order for June 2025 revealed a start date of 09/17/24 for an order of Quetiapine (Seroquel) 50 milligram (mg) give 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with agitation and an order for Quetiapine 100 mg give 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with agitation. Review of the Care Plan dated 01/18/18 revealed Resident #9 was on psychotropic medications including Effexor, Seroquel, Klonopin, Buspar for Anxiety, Psychosis, Bipolar Disorder, dementia with behaviors with interventions to administer medications as ordered, consult with pharmacy, physician to consider dosage reduction when clinically appropriate, and to discuss with physician and family about ongoing need for use of medication. Review of the Pharmacy Reviews dated 06/23/24 through 05/31/25, revealed no recommendations made to discontinue Quetiapine due to improper use for Dementia. Interview on 06/05/25 at 9:43 A.M., with Registered Pharmacist (RPh) #292 stated he does not make recommendations for diagnosis changes on medications. Interview on 06/05/25 at 12:43 P.M., with the Director of Nursing (DON) confirmed Resident #9 is on Quetiapine (Seroquel) 50 mg 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with agitation and Quetiapine 100 mg 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, with agitation. Interview also confirmed dementia is not an appropriate diagnosis for the use of Quetiapine. Review of the undated policy titled, Use of Psychotropic Medication(s), revealed when a psychotropic is used for a diagnosis not indicated, the medication use will be subject to the requirements of psychotropic medications.

Based on observations, resident and staff interviews, and review of the policy, the facility failed to maintain a homelike environment for the residents. This directly affected two (#28 and #115) of 62 resident rooms observed. The facility census was 62. Findings include: 1. Observation on 06/03/25 at 8:00 A.M., revealed Resident #115 seated in a recliner in her room. The wall to the left, behind the back of the recliner, and to the left of the window, revealed an area round area approximately seven inches, with exposed plaster and a small pile of plaster dust on the floor below it. Interview with Resident #115, at the time of the observation, stated the wall had been like since her admission. 2. Observation on 06/03/25 at 8:55 A.M., revealed both walls in the small hallway leading into the room of Resident # 28 revealed large areas repaired but unpainted to match the wall coloring. Interview on 06/04/25 at 3:10 P.M., with Maintenance #215 revealed he had just finished repairing the walls, and they need sanded and repainted again. Maintenance #215 stated the walls need repaired often. Review of the policy titled Accommodation of Needs and Preference revised March 2020, revealed the facility staff will patch and paint walls between occupancy and updates were completed to damaged room areas as soon as possible.

Based on observations, staff interviews, and policy review, the facility failed to ensure residents were treated with dignity, when staff stood over residents while providing assistance with eating. This affected three (#2, #37, and #41) of three residents reviewed for feeding assistance. The facility census was 62. Findings include: Review of the medical record for Resident #2 revealed and admission date of 11/12/20, with diagnoses of Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident has a memory problem and cognitive skills were severely impaired. Resident #2 was dependent on staff assistance with all activities of daily living (ADL)s. Review of the care plan dated 12/04/23 revealed the facility will provide and serve meals as ordered and provide adaptive equipment to improve self-feeding skills. Review of the medical record for Resident #37 revealed and admission date of 07/06/20, with diagnoses of Alzheimer's disease with late onset, anorexia, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly MDS dated [DATE] revealed the resident has a memory problem, and cognitive skills were severely impaired. Resident #37 was dependent on staff assistance with all ADLs. Review of the care plan dated 07/07/20 revealed resident had a nutritional problem with intervention to provide and serve diet as ordered. Review of the medical record for Resident #41 revealed and admission date of 06/16/20, with diagnoses of anorexia, Alzheimer's disease with late onset, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Discharge Return Anticipated MDS, dated [DATE] revealed the resident had a memory problem, and cognitive skills were severely impaired. Resident #41 was dependent on staff assistance with all ADLs. Review of the care plan dated 06/22/20 revealed resident had a nutritional problem with intervention to provide and serve diet as ordered. Observation on 06/04/25 at 8:08 A.M., revealed Licensed Practical Nurse (LPN) #290 standing over Resident #37 feeding her. Observation on 06/04/25 at 8:15 A.M., revealed LPN #290 standing over Resident #41 feeding her. Observation on 06/04/25 at 8:16 A.M., revealed Certified Nursing Assistant (CNA) #204 standing over Resident #2 feeding her Interview on 06/04/25 at 8:20 A.M., with LPN #290 confirmed she was standing over Resident #37 and #41 feeding them breakfast. Interview with LPN #290 confirmed staff should sit down while feeding Resident #37 and #41. Interview on 06/04/25 at 8:20 A.M with CNA #204 confirmed she was standing over Resident #2 feeding her. Interview with CNA #204 confirmed staff should sit down while feeding residents. Review of the undated policy titled Fair Haven Meal Supervision and Assistance, revealed staff should assist with meal feeding as needed to prevent accidents. This deficiency represents the noncompliance investigated under Complaint Number OH00162995.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure the comprehensive care plan was initiated to include contractures. This affected one (#32) of 23 residents reviewed for comprehensive care plans. The facility census was 62. Findings include: Review of the medical record for Resident #32 revealed an admission date of 03/11/22 with diagnoses of encephalopathy, post traumatic seizures, neuromuscular dysfunction of bladder, post-traumatic stress disorder, and personal history of traumatic brain injury. Review of the Annual MDS dated [DATE] revealed resident was cognitively impaired. Resident #32 is dependent on staff assistance with all Activities of Daily Living (ADLs), except resident does not eat. Review of the care plan dated 03/24/22 revealed had an alteration in musculoskeletal status related to fibromyalgia, muscle spasms, and right below the knee amputation with interventions of Resident #32 will remain free from pain or at a level of acceptable discomfort through the review date. Facility staff will give analgesics as ordered by the physician. Observation on 06/03/25 at 8:26 A.M. revealed Resident #32 laying in bed with right hand contracture noted. No brace or cloth present in resident's right hand. Interview on 06/09/25 at 10:19 A.M., with the Director of Nursing (DON) confirmed Resident #32 does not have a contracture care plan in place. Review of the undated policy titled, Care Plan, revealed each resident will have a comprehensive care plan written that incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure the physician was notified during a three month period of the necessity to change or alter treatment to the wound and also failed to notify the physician when the pressured ulcer worsened. This resulted in actual harm when Resident #66 developed an avoidable unstageable pressure ulcer to the coccyx. This affected one (#66) of 38 residents reviewed for notification during Stage 2. The facility census was 91. Findings include: Review of Resident #66's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set ((MDS) dated [DATE], revealed the resident had a stage two pressure ulcer present on the coccyx since 07/12/14. Review of the resident's MDS dated [DATE], revealed the resident had an unstageable pressure ulcer. Resident #66's functional status was total dependence for bed mobility, transferring, locomotion, dressing, toileting, and personal hygiene. The resident's cognition was identified as impaired. Review of a document titled, Altered Skin Integrity/Bruise Event Report, dated 07/12/14, revealed Resident #66 had a 3.0 centimeter (cm) x 1.5 cm x less than 0.1 cm macerated area to the coccyx. It was also noted she had a 1.5 cm x 2.0 cm x 0.1 cm open red area to the coccyx with no drainage that was a possible abrasion. Review of the resident's physician orders [REDACTED]. Continued review of the physician orders [REDACTED]. On 11/03/14, an order was written to discontinue [MEDICATION NAME] treatment to the coccyx and the order was changed to cleanse the coccyx wound with normal saline, pat dry, apply Santyl, Collagen, foam, secure with tape daily and as needed. Review of Resident #66's nurses notes revealed an entry on 08/10/14, describing the coccyx wound as open superficially with a moist wound bed. An entry on 10/27/14, revealed the resident's coccyx wound measured 7.0 cm x 8.0 cm x 0.1 cm and described the wound bed as moist, pink with yellow eschar noted and a foul odor. Review of the nurses notes from 07/12/14 through 10/30/14, revealed no further description of the coccyx wound. There was no documentation of notification to the physician of wound changes with the exception of 10/16/14 and 11/03/14. Review of the weekly skin measurements for Resident #66 revealed weekly measurements were listed from 07/21/14 through 10/06/14, with description of pink/red and stage two only. On 07/21/14, the wound measurements were 0.6 cm x 0.2 cm x 0 cm. On 08/04/14, and increase in size was noted of 2.0 cm x 0.5 cm x 0 cm. On 08/18/14, the wound size had increased further to 3.5 cm x 4.5 cm x 0 cm. There were no measurements or wound descriptions from 10/06/14 through 10/27/14. On 11/03/14, the measurements were 5.5 cm x 6.0 cm and staff were unable to determine the depth. The description of the wound was documented as a black/red area and was an unstageable pressure ulcer. Review of Resident #66's physician progress notes [REDACTED]. Continued review of the physician's progress notes revealed no mention of the open area to the resident's coccyx until 10/18/14. The note indicated the resident had an open wound at the coccyx area and a swab culture was obtained and the organism isolated was proteus mirabilis. The resident was started on [MEDICATION NAME] (an antibiotic). Review of the resident's wound care specialist progress notes, revealed an initial assessment of the coccyx wound was completed on 11/14/14. The note indicated the resident had an unstageable facility acquired pressure ulcer to the coccyx with moderate exudate measuring 5.0 cm x 7.0 cm with undetermined depth. The periwound tissue was fragile and macerated. A new treatment order was initiated to cleanse the wound with normal saline, apply Santyl (a wound [MEDICATION NAME] agent), apply Calcium Alginate to the area, and cover with non-bordered foam and tape twice daily. Continued review of the wound care specialist progress notes, revealed a wound VAC (vacuum assisted closure) (a device that promotes healing in wounds via negative pressure wound therapy) was initiated on 03/17/15, to help promote healing and granulation. The wound VAC remains in place currently and was changed on Monday, Wednesday, Friday, and as needed. Interview with Licensed Practical Nurse (LPN) Wound Nurse #202 on 07/08/15 at 3:12 P.M., revealed she was asked to observe Resident #66's coccyx wound on 11/03/14. She felt it was an unstageable pressure ulcer at that time due to eschar in the wound bed and notified the physician and received a new treatment order and an order to refer the resident to the wound care specialist. She stated the wound was being monitored by the unit nurses and unit manager from 07/12/14 through 11/03/14, and verified there was not an adequate wound assessment documented from 07/12/14 through 10/27/14. LPN Wound Nurse #202, also verified there was no documentation of physician notification from 07/12/14 through 10/16/14 or from 10/16/14 through 11/03/14, regarding wound changes. She further verified there were no wound measurements or wound descriptions documented from 10/06/14 through 10/27/14.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure one (#66) resident received an adequate assessment and timely intervention to prevent the worsening of a pressure ulcer. This resulted in actual harm when Resident #66 developed an avoidable unstageable pressure ulcer to the coccyx. This affected one (#66) of two residents reviewed for pressure ulcers. The facility identified five current residents with pressure ulcers. The facility census was 91. Findings include: Review of Resident #66's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set ((MDS) dated [DATE], revealed the resident had a stage two pressure ulcer present on the coccyx since 07/12/14. Review of the resident's MDS dated [DATE], revealed the resident had an unstageable pressure ulcer. Resident #66's functional status was total dependence for bed mobility, transferring, locomotion, dressing, toileting, and personal hygiene. The resident's cognition was identified as impaired. Review of a document titled, Altered Skin Integrity/Bruise Event Report, dated 07/12/14, revealed Resident #66 had a 3.0 centimeter (cm) x 1.5 cm x less than 0.1 cm macerated area to the coccyx. It was also noted she had a 1.5 cm x 2.0 cm x 0.1 cm open red area to the coccyx with no drainage that was a possible abrasion. Review of the resident's physician orders [REDACTED]. Continued review of the physician orders [REDACTED]. On 11/03/14, an order was written to discontinue [MEDICATION NAME] treatment to the coccyx and the order was changed to cleanse the coccyx wound with normal saline, pat dry, apply Santyl, Collagen, foam, secure with tape daily and as needed. Review of Resident #66's nurses notes revealed an entry on 08/10/14, describing the coccyx wound as open superficially with a moist wound bed. An entry on 10/27/14, revealed the resident's coccyx wound measured 7.0 cm x 8.0 cm x 0.1 cm and described the wound bed as moist, pink with yellow eschar noted and a foul odor. Review of the nurses notes from 07/12/14 through 10/30/14, revealed no further description of the coccyx wound. There was no documentation of notification to the physician of wound changes with the exception of 10/16/14 and 11/03/14. Review of the weekly skin measurements for Resident #66 revealed weekly measurements were listed from 07/21/14 through 10/06/14, with description of pink/red and stage two only. On 07/21/14, the wound measurements were 0.6 cm x 0.2 cm x 0 cm. On 08/04/14, and increase in size was noted of 2.0 cm x 0.5 cm x 0 cm. On 08/18/14, the wound size had increased further to 3.5 cm x 4.5 cm x 0 cm. There were no measurements or wound descriptions from 10/06/14 through 10/27/14. On 11/03/14, the measurements were 5.5 cm x 6.0 cm and staff were unable to determine the depth. The description of the wound was documented as a black/red area and was an unstageable pressure ulcer. Review of Resident #66's physician progress notes [REDACTED]. Continued review of the physician's progress notes revealed no mention of the open area to the resident's coccyx until 10/18/14. The note indicated the resident had an open wound at the coccyx area and a swab culture was obtained and the organism isolated was proteus mirabilis. The resident was started on [MEDICATION NAME] (an antibiotic). Review of the resident's wound care specialist progress notes, revealed an initial assessment of the coccyx wound was completed on 11/14/14. The note indicated the resident had an unstageable facility acquired pressure ulcer to the coccyx with moderate exudate measuring 5.0 cm x 7.0 cm with undetermined depth. The periwound tissue was fragile and macerated. A new treatment order was initiated to cleanse the wound with normal saline, apply Santyl (a wound [MEDICATION NAME] agent), apply Calcium Alginate to the area, and cover with non-bordered foam and tape twice daily. Continued review of the wound care specialist progress notes, revealed a wound VAC (vacuum assisted closure) (a device that promotes healing in wounds via negative pressure wound therapy) was initiated on 03/17/15, to help promote healing and granulation. The wound VAC remains in place currently and was changed on Monday, Wednesday, Friday, and as needed. Review of Resident #66's care plan revealed a care plan was initiated on 10/16/12, for a risk of pressure ulcer development. This care plan was not updated to reflect the resident had an actual pressure ulcer with accompanying interventions until 11/04/14. Interview with Licensed Practical Nurse (LPN) Wound Nurse #202 on 07/08/15 at 3:12 P.M., revealed she was asked to observe Resident #66's coccyx wound on 11/03/14. She felt it was an unstageable pressure ulcer at that time due to eschar in the wound bed and notified the physician and received a new treatment order and an order to refer the resident to the wound care specialist. She stated the wound was being monitored by the unit nurses and unit manager from 07/12/14 through 11/03/14, and verified there was not an adequate wound assessment documented from 07/12/14 through 10/27/14. LPN Wound Nurse #202, also verified there was no documentation of physician notification from 07/12/14 through 10/16/14 or from 10/16/14 through 11/03/14, regarding wound changes. She further verified there were no wound measurements or wound descriptions documented from 10/06/14 through 10/27/14. LPN Wound Nurse #202 also verified there were no updates to Resident #66's care plan regarding her pressure ulcer until 11/04/14. Interview with MDS Nurse #203 on 07/08/15 at 4:55 P.M., revealed she coded Resident #66's coccyx wound as a stage two pressure ulcer on the 07/17/14 MDS due to the nursing staff documentation of an open area over the resident's bony prominence (coccyx). Surveyor was unable to make an observation of Resident #66's pressure ulcer due to wound VAC orders to be changed on Monday, Wednesday, Friday, and as needed. The resident's wound VAC was changed on Wednesday, 07/08/15, prior to surveyor arrival and was not due to be changed again until Friday, 07/10/15. Review of a facility policy titled. Decubitus Ulcer-Prevention, revised 03/20/09, revealed nursing responsibility included recording treatments in the nursing chart/treatment administration record (TAR), including all pertinent observations.