Every finding on record at Fairlawn Haven

Based on observation, medical record review, interview, and review of the facility policy, the facility failed to ensure Enhanced Barrier Precautions (EBP) was ordered, and proper Personal Protective Equipment (PPE) was worn when providing care for a resident with wounds. This affected one (#13) of three residents reviewed for EBP and had the potential to affect 16 residents that the facility identified requiring EBP. The census was 94.Findings include:Review of the medical record for Resident #13 revealed an admission date of 04/17/26. Diagnoses included Parkinson's disease without dyskinesia, anxiety, major depressive disorder, and lymphedema. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had intact cognition. Further review of the MDS revealed Resident #13 required supervision for activities of daily living (ADLs). Review of the care plan dated 08/31/25 revealed Resident #13 was at risk for skin breakdown due to decreased mobility and lymphedema. Interventions included bilateral knee-high ted hose on in the morning and off at night, observing skin condition with ADL care daily and report abnormalities, and weekly skin assessments. Additional review of the care plan dated 08/07/26 revealed Resident #13 exhibited lymphedema wound as evidence by frail fragile skin to left foot. Interventions included providing treatment per physician orders and monitor for signs of infection until healed and report changes. Further review of the care plan dated 05/26/26 revealed Resident #13 was to receive medications and treatments from staff. Interventions included giving medication and treatments as ordered. Review of the physician's orders dated 07/03/26 revealed and order to wash lymphedema wound to left foot with soap and water or normal saline, pat dry, apply Lortisone 1 percent (%) with 0.05% to entire distal foot and in between toes, apply alginate with calcium with silver between the toes and wrap.Review of the progress note dated 07/30/26 revealed Resident #13 left food lymphedema wound had improved but continued with moderate serous drainage.Review of the progress note dated 08/11/26 revealed at 4:00 P.M. when the technician arrived to do Resident #13's treatment for his lymphedema, there were open areas noted to the resident's right lateral calf. The open areas were multiple, close together, and seeping serosanguineous drainage.Observation on 08/12/26 at 9:04 A.M. of Resident #13 revealed no EBP sign on the door or in the room, and there was no PPE available inside or outside of his room. Resident #13 stated that he was having treatments completed to both legs for wounds.Observation on 08/12/26 at 9:10 A.M. of Licensed Practical Nurse (LPN) #384 completing wound care for Resident #13 revealed the nurse wore gloves when assessing the resident's wounds and when completing the wound treatments. Interview on 08/12/26 at 9:10 A.M., during the observation, with LPN #384 revealed Resident #13 had lymphedema, and weekly she comes in to assess the resident's wounds and complete the wound treatments. LPN #384 further confirmed she did not wear a gown when completing Resident #13's lymphedema wound treatments. LPN #384 stated that Resident #13 was not on EBP.Interview on 08/13/26 at 11:06 A.M. with the Director of Nursing (DON) confirmed Resident #13 was not on EBP, and any resident with open wounds should be placed on EBP.Interview on 08/13/26 at 11:26 A.M. with LPN #234 who serves as the facilities wound nurse revealed Resident #13 had the wound to the left leg for a couple months, and that the right leg opened on 08/11/26. LPN #234 further confirmed Resident #13 should have been on EBP.Review of the facility policy titled Enhanced Barrier Precautions, dated 07/2025, revealed an order for enhanced barrier precautions will be obtained for residents with wounds. Make gowns and gloves available immediately near or outside of the resident's room.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure foods were stored in a manner to prevent spoilage and spoiled foods were discarded. This had the potential to affect all residents receiving food from the kitchen with the exception of one (#244) resident the facility identified that received nothing by mouth. The facility census was 90. Findings include: Observation on 04/07/25 from 7:50 AM to 8:10 A.M. revealed the walk-in cooler contained four containers of fresh strawberries with a whitish fuzzy growth on them, a bag of baby carrots that were open, unlabeled, and undated, and a tray of pastries and brownies that were uncovered, unlabeled, and undated. The tray of pastries and the tray of browns were thrown away and were hard when they were moved on the tray to throw in the garbage can. Interview on 04/07/25 at 7:56 A.M. with Assistant Dietary Manager (ADM) #700 verified strawberries contained mold, and confirmed the opened, unlabeled, and undated bag of baby carrots and the tray of pastries and brownies. ADM #700 further stated the pastries and brownies were from meals the previous day. Review of the facility policy titled, Food and Supply Storage, revised January 2025, revealed staff must cover, label, and date unused portions or open packages, and sort produce daily and remove spoiled pieces.

Based on observation and staff interview, the facility failed to ensure garbage cans in the kitchen were properly covered to contain waste. This had the potential to affect all residents receiving food from the kitchen with the exception of one (#244) resident the facility identified as receiving nothing by mouth. The facility census was 90. Findings include: Observation on 04/07/25, during the initial kitchen tour from 7:50 A.M. to 8:10 A.M., revealed all the garbage cans in the kitchen had no lids in place. The total number of garbage can in the kitchen was four. Interview on 04/07/25 at 8:05 A.M. with [NAME] #695 verified there were no lids for any of the garbage cans in the kitchen. Interview on 04/10/25 at 11:00 A.M. with the Administrator verified the facility did not have a policy for lids on garbage cans in the kitchen.

Based on observation, medical record review, and resident and staff interview, the facility failed to ensure residents were provided a dignified dining experience. This affected one (#5) of three residents reviewed for dignity. The facility census was 90. Findings Include: Review of Resident #5's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, dysphagia, borderline personality disorder, restlessness and agitation, pseudobulbar affect, major depressive disorder, conduct disorder, convulsions, type II diabetes, dysphagia, and anxiety disorder. Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #5 was rarely or never understood. A Staff Interview for Mental Status was completed and Resident #5 had short and long term memory problem. Resident #5 was severely cognitively impaired. Resident #5 displayed wandering behaviors daily. Review of Resident #5's care plan revised 02/24/25 revealed supports and interventions for risk for falls, potential for pain, risk for elopement, self-care deficit, cognitive loss, and nutritional status. Nutritional status interventions included provide diet as ordered, Resident #5 preferred to eat food with her fingers although silverware was provided, at times Resident #5 would eat very fast, pocket food, then spit out the food and would attempt to re-eat it again. Resident #5 would also take food off other resident's plates at times. The care plan did not include interventions for Resident #5 to be seated at an overbed table instead of a regular table like the other residents on the secured memory unit. Observation on 04/07/25 at 11:52 A.M. of Resident #5 found her seated in the dining room at a overbed table in the dining room. There were six square dining room tables where 10 other residents were seated at square dining room tables. There was one square dining table off to the right side of the dinning area with a singular chair and boxes of puzzles on top. An interview was attempted with Resident #5 at the time of the observation, with the resident not able to be interviewed but stated she was hungry. Interview on 04/07/25 at 11:55 A.M. with Licensed Practical Nurse (LPN) #597 verified Resident #5 was seated at a overbed table in the dining room and not at a dining room table like the other residents. LPN #597 reported Resident #5 would spit her food out and was seated at the overbed table so she would not spit on others. Review of Resident #5's care plan revised on 04/08/25, after questions were asked regarding Resident #5 wearing gloves and being seated at a bedside table separate from other residents, revealed Resident #5 was to be provided diet as ordered, gloves were to be worn with meals, at times Resident #5 would eat very fast, pocketed food, then would then spit out the food, and attempt to re-eat again. Resident #5 sat by herself at a bed side tray table due to she would take food off other residents' plates at times. Observation on 04/08/25 at 12:23 P.M. of Resident #5 found her seated at a overbed table off to the side in the dining room. An empty dining room table continued to be off to the right side of the dining room with one chair and activity items stacked on it. Interview on 04/08/25 at 2:31 P.M. with the Director of Nursing (DON) verified Resident #5's care plan was edited on 04/08/25 to include Resident #5 being seated at bedside table for dining. The DON provided a progress note dated 11/22/23 indicating Resident #5 did not mind where she sat. The progress note did not include information on where Resident #5 was seated at the time of the progress note. The DON also confirmed Resident #5 was severely cognitively impaired. The concern for Resident #5 not being provided a dignified dining experience by being provided her meals at a overbed table when all others in the memory care unit were eating at tables was presented to the DON.

Based on medical record review, resident and staff interview, resident family interview, and policy review, the facility failed to provide a resident and the resident representative a written bed-hold notice at the time of hospitalization. This affected one (#44) of one resident reviewed for hospitalization. The facility census was 90. Findings included: Review of Resident #44's medical record revealed an admission date of 03/07/25. Diagnoses included complication of left knee internal orthopedic prosthetic devices, left artificial knee joint, and multiple sclerosis. Review of Resident #44's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an intact cognition. Review of Resident #44's most recent care plan revealed the resident may need assistance to coordinate community resources for discharge planning. Interventions included to provide written and verbal instructions at the resident's level of understanding, verbally explain instructions to the resident and family prior to discharge, and provide the resident/family with a written copy. Review of Resident #44's contact information revealed the resident was her own responsible party. The resident's wife was the first emergency contact and representative for care conferences, and Resident #44's sister was the second emergency contact. Review of Resident #44's hospital notes dated 03/19/25 revealed the resident had worsening necrotic tissue of her lower extremity and would require a debridement the following week of the left knee. The resident was admitted to the hospital on [DATE]. Review of Resident #44's progress note dated 03/26/25 revealed the nurse received a telephone call from Resident #44's sister indicating the hospital was admitting the resident until 03/28/25, and the resident would be returning with a wound vacuum to the left knee. Review of Resident #44's social service note dated 03/31/25 revealed telephone contact was made with the resident, and she wanted to confirm her room would be held until her return from the hospital. The Social Worker responded that Resident #44 would return to the same room as her sister agreed to a bed hold. The resident would sign the bed hold form at that time. Review of Resident #44's late entry social service progress note, written by Assistant Heath Care Administrator #658 and dated 04/03/25, revealed on 03/26/25 he spoke with Resident #44's sister in regard to completing a bed hold and the sister stated she would do anything they have to keep her room. Review of Resident #44's bed hold agreement document dated 03/26/25 revealed a telephone interview with the resident's sister revealed the sister agreed to the bed hold policy and expenses. Review of a social service note dated 04/03/25 revealed Resident #44 returned to the facility. Interview with Resident #44 on 04/07/25 at 10:04 A.M. revealed she was not notified she was past her 20 days of paid care and was paying out of pocket. The resident was hospitalized and stated she had to have a wound vacuum applied to her knee. Her sister called the facility and spoke to Assistant Health Care Administrator #658 and was never informed of the expenses incurred in a bed hold. Resident #44 stated she was never informed verbally nor in writing of the bed hold policy and had incurred a large amount of out-of-pocket money owed to the facility. The resident stated she was her own person, and her sister was not the one to make financial decisions for her. Interview with Resident #44's sister on 04/07/25 at 10:04 A.M. verified she was not informed of the bed hold policy. Interview with the Administrator on 04/07/25 at 1:25 P.M. verified the facility failed to inform Resident #44 in writing of the bed hold policy on 03/26/25. Review of the undated facility policy titled, Out of Residence Policy, revealed the facility will ascertain from the resident or responsible party either prior to or during the absence if the resident intends to return to the facility.

Based on observation, resident family member and staff interview, medical record review, review of staff meeting documents and education materials, facility policy review, and review of a facility job description for certified medication aides (CMAs), the facility failed to ensure staff were working within their scope of practice related to CMAs administering as needed medications. This affected one (#64) of two residents reviewed for pain. The facility census was 90. Findings include: Review of the medical record for Resident #64 revealed she was admitted on [DATE] with diagnoses of congestive heart failure (CHF), diabetes mellitus type two, anxiety, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #64 revealed she was cognitively impaired. At the time of medical record review for Resident #64 an MDS assessment was in progress for a significant change for admission to hospice services. Review of the care plan initiated April 2025 for Resident #64 revealed a care plan for pain with interventions to assess affects of unrelieved pain and notify the physician for pain medication adjustment, assess complaints of sudden/unusual/worsening pain and report to physician, assess the need to change as needed pain medication to a routine if resident was having difficulty anticipating pain medication needs, assist with position changes for comfort, and non-pharmacological methods of comfort. Review of the current physician orders dated April 2025 for Resident #64 revealed she was prescribed the pain medication Tylenol 650 milligrams (mg) every six hours pro re nata (PRN, meaning as needed) for pain or fever. The order was prescribed and in place since admission and admission to hospice services on 04/07/25. Review of Resident #64's nursing progress notes dated 04/04/2025 at 10:54 A.M. revealed the resident was crying out in pain and PRN Tylenol was administered and the overseeing nurse was notified. Review of the pain assessment documentation for Resident #64 revealed she had documented pain on 04/04/25 at 10:55 A.M. Further review of the pain assessment documentation for Resident #64 revealed following administration of Tylenol her pain was rated as a seven and the Tylenol was ineffective. Review of the nursing note dated 4/4/2025 at 10:55 A.M., generated by the electronic medication administration record (eMAR) for Resident #64 revealed Tylenol was administered for pain and the pain was rated at a six. Review of the nursing progress note dated 4/4/2025 at 2:28 P.M., generated by the eMAR for Resident #64, revealed the Tylenol was not effective and the follow-up pain was rated at a seven. Observation on 04/07/25 at 10:18 A.M. of Resident #64 revealed she was laying in bed on her back, moaning, and her breathing had a gurgling sound. Resident #64's daughter-in-law was at the bedside. Concurrent interview with Resident #64's daughter-in-law stated Resident #64 had been declining and the family was asked to consider hospice care. Resident #64's daughter-in-law stated the resident's family decided yesterday (04/06/25) and notified the facility on which hospice provider they chose, and were now waiting for hospice to come for their assessment and possible admission. Resident #64's daughter-in-law further stated she arrived at approximately 9:15 A.M. on 04/07/25 and the nurse communicated the nurse practitioner had been in to evaluate Resident #64 earlier that morning and ordered medication for comfort. Observation on 04/07/25 at 11:49 A.M. of Resident #64 revealed she was laying in bed, with the head of bed elevated, and had a wash cloth to her forehead. Resident #64 moved her head side-to-side and was breathing out of her mouth with non-labored shallow breaths with continued gurgling sound during breathing. Resident #64 had continuous oxygen running at two liters by way of nasal cannula and her family remained at the bedside. Interview on 04/08/25 at 2:52 P.M. with Licensed Practical Nurse (LPN) #612 stated if a certified medication aide (CMA) reported ineffective pain control the expectation would be for the overseeing nurse to conduct an assessment and attempt non-pharmacological methods of pain control such as repositioning. LPN #612 verified there was no documentation for a nursing assessment for pain control, no further treatment for pain, and no notification to the physician for uncontrolled pain for Resident #64. Further interview with LPN #612 stated the CMA that provided care on 04/04/25 for Resident #64 was CMA #584 and LPN #597 was assigned to oversee CMA #584 on 04/04/25. Interview on 04/08/25 at 3:35 P.M. with LPN #597 verified she worked on 04/04/25 and was not notified of uncontrolled pain for Resident #64 by CMA #584. Interview on 04/09/25 at 10:39 A.M. with the Director of Nursing (DON) stated on 04/04/25 the Tylenol administered to Resident #64 was by CMA #584 and it was out of her scope of practice to assess for pain. The DON further stated when a CMA was working and PRN medication was warranted, the CMA was required to notify the overseeing nurse for an assessment and direction for administration of the PRN medication. The DON further stated she interviewed the staff, and LPN #597 reported she was not notified of Resident #64's uncontrolled pain; and interview with CMA #584 reported she administered Resident #64 Tylenol before notifying the overseeing nurse. Further interview with the DON stated the CMA regulations were recently updated and included duties CMAs could now practice which included administration of insulin via an insulin pen only, administration of narcotics, and administration of PRN medications. The DON further stated the facility reviewed these updated regulations for CMAs, and the facility chose to allow for CMAs to administer insulin by way of insulin dial pen only with training and the facility policy continued to prohibit CMAs from administering narcotic medications and PRN medications without the assessment from the overseeing nurse first. Review of the staff meeting conducted on 03/17/25 for all nurses and CMAs to review the expectation of the nurse and the CMAs and update on the facility policy regarding the recent regulation changes for CMAs. Review of the sign-in sheet of this meeting revealed CMA #584 was present at the meeting and received the updated facility policy. Review of the presentation material revealed CMAs, per facility policy, were not permitted to administer PRN medications without a nurse assessment and narcotics continued to not be permitted for administration by a CMA. Interview on 04/10/25 at 7:54 A.M. with CMA #584 verified she was working on 04/04/25 and caring for Resident #64 when she was in calling out in pain and was different than her usual behavior of yelling. CMA #584 verified she administered the PRN Tylenol to Resident #64 on 04/04/25. Review of the undated facility job description for CMA revealed a certified medication aide will have their tasks delegated by their supervising LPN or registered nurse (RN). In addition to passing medication, CMAs will also monitor resident conditions, document, and report any condition changes, and monitor for drug reactions. CMAs are only allowed to observe and notify the nurse of any change in condition, and may not administer any PRN medication without notifying a nurse of the observation and need and the nurse completing the assessment and giving verbal consent to administer a PRN medication. Review of the facility policy titled, Pain Management, dated June 2024, revealed staff will observe for non-verbal and verbal indicators which may indicate the presence of pain and report to the overseeing nurse. The facility will use the pain assessment tool. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team such as nurse practitioners, physicians, nurses, or pharmacists. Review of the facility policy titled, Provision of Quality of Care, dated January 2023, revealed the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice. All employees are responsible for following established policies and procedures.

Based on observation, medical record review, staff interview, and standing lift device instructions for use, the facility failed to ensure lift equipment was utilized safely. This affected one (#23) of one residents observed during transfers. The facility census was 90. Findings include: Medical record review revealed Resident #23 admitted to the facility on [DATE] with the diagnoses including, Alzheimer's disease, dementia, coronary artery disease, hypertension, anxiety disorder, chronic pain, osteoporosis, anemia, major depression, type II diabetes mellitus, atrial fibrillation, and chronic kidney disease stage four (4). Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had moderately impaired cognition, utilized a walker and wheelchair for mobility, required supervision or touching assistance with activities of daily living (ADLs) including transfers, was continent of bowel and bladder, received a mechanically altered diet, was not a risk for development of pressure ulcers, and received insulin injections, antipsychotic medication, antidepressant medication, anticoagulation medication, and diuretic medication. Review of a nurse plan of care dated 07/31/24 revealed a problem area was implemented to address Resident #23's risk for adverse effects and/or side effects of anticoagulation therapy. Interventions included to administer medication per physician (MD) orders; monitor for side effects/adverse reaction and notify the physician if these are suspected or observed; if on Coumadin (an anticoagulant) or other medication having a direct impact on the laboratory results, have Vitamin K or Protamine available for emergent use and administer per MD orders; monitor administration of medications with other medications for contraindication, dosage timing, or drug-to-drug reactions; monitor for and report adverse effects (i.e. blood in the urine/stool, bruising of unknown origin, bleeding gums/nose bleeding, or any other abnormal bleeding) and notify the MD if these are suspected; monitor laboratory values and report results to the physician; observe for signs/symptoms of abnormal bleeding; and physician consult as needed. Further review revealed no interventions were implemented to prevent or limit potential bruising or bleeding. Further review of Resident #23's medical record revealed a nursing plan of care was implemented on 07/31/24 to address Resident #23's risk for falls due to weakness. Interventions included to assist the resident in getting in and out of bed with two person assist; mechanical (Hoyer) lift as needed, and staff to refer to color chart by weight for sling color; and may use Sara Steady (a sit-to-stand transfer aid that helps residents move from a seated position to a standing position, and vice versa) for transfers as needed. Observation on 04/08/25 at 9:29 A.M. noted Resident #23 in bed and the resident was noted with two purple bruises to the right upper arm and one to the left upper arm. On 04/09/25 at 8:44 A.M. Certified Nurse Aide (CNA) #900 and CNA #533 were observed to place Resident #23 in a mechanical stand lift sling. CNA #533 fastened the sling to the standing lift and proceeded to lift the resident. Resident #23 did not attempt to bare weight and was observed to remain dependent in the sling (dangling). CNA #900 and CNA #533 propelled Resident #23 in the lift to the toilet. Interview with CNA #900 and CNA #533 at the time revealed they were unaware Resident #23 received a anticoagulant medication which placed the resident as increase risk of bleeding or bruising. The CNAs were unable to indicate if any safety interventions were implemented to prevent injury or bruising. Both CNAs verified Resident #23 dangled in the lift sling and did not bare weight or participate in the transfer. The CNAs also confirmed Resident #23 had bruising to both upper arms. Review of the CNA care Kardex at the time also lacked information to address Resident #23 risk of bruising or bleeding. On 04/09/25 9:10 A.M. interview with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) Unit Manager #612, during review of Resident #23's medical record, verified no interventions in place to prevent bruising and were unaware staff used a stand-up lift for dependent residents. The DON and LPN Unit Manager #612 also confirmed there was no documentation contained in the medical record documenting the bilateral upper arm bruising to the resident. Review of the health status notes on 04/09/25 at 10:54 A.M. the DON reported to the nurse that bruises were reported to Resident #23's bilateral arms. The writer assessed and noted two dark purple bruises to the resident's left upper arm with the superior bruise measuring 4.0 centimeters (cm) wide by (x) 1.5 cm long. The inferior bruise measured 6.0 cm wide x 2.5 cm length. The right upper arm also had a yellowish bruise measuring 2.0 cm wide x 3.0 cm long. On 04/10/25 at 9:31 A.M., additional interview with the DON, during a review of Resident #23's medical record, verified the use of the standing lift required the resident to participate with the standing process and not hang dependent in the transfer sling. In addition, CNAs were not aware Resident #23 was receiving an anticoagulant medication or interventions to prevent bruising or bleeding. Review of standing lift (Sara Steady) manufacturer instructions for use, dated December 2022, revealed before use, the caregiver should always consider the patients/residents, medical condition as well as physical and mental capabilities. In addition, the patient/resident must have the ability to stand unaided or stand with minimal assistance and be able to sit on the edge of the bed. When transferring the patient from a bed, encourage the patient to achieve the standing position. The patient's knees should stay in contact with the kneepad, and the patient should sit back on seat halves during transfer.

Based on medical record review, resident and staff interview, and facility policy review, the facility failed to ensure physician orders for pain were maintained to provide effective pain management. This affected one (#86) of two residents reviewed for pain. The facility census was 90. Findings included: Review of Resident #86's medical record revealed an admitted [DATE]. Diagnoses included malnutrition and acute renal disease. Review of Resident #86's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact. The resident required scheduled pain medication and opioid use for pain control daily. Review of Resident #86's current care plan revealed she had the potential for pain related to chronic pain, osteoarthritis, and low back pain. Interventions included listening to the resident's concerns, advise the resident to request pain medication before pain becomes severe, and assess complaints of pain and report to the medical doctor. Review of Resident #86's nurses note dated 03/16/25 revealed she was readmitted to the facility after a laminectomy (a surgical procedure on the spinal cord). Review of Resident #86's physician order dated 03/16/25 revealed the resident was ordered the pain medication acetaminophen oral tablet 325 milligrams (mg) with instructions to give two tablets by mouth every four hours as needed for pain. Review of Resident #86's physician order dated 04/01/25 revealed the resident was ordered hydrocodone-acetaminophen (opioid pain medication) tablet 5-325 mg to be administered as needed for pain once daily related to diseases of the spinal cord. The end date for the order was indefinite. Review of Resident #86's skilled evaluation dated 04/07/25 at 12:05 A.M. revealed the resident complained of pain in her medial back (spine) with a level of seven on a 10-point pain scale. Relaxation techniques were encouraged and the resident's position was changed. Further review revealed non-medication interventions were not effective and as needed medication was provided. Review of Resident #86's medication administration record (MAR) for April 2025 revealed acetaminophen 325 mg was administered on 04/08/25 at 1:15 A.M. and at 8:43 A.M. for a pain rating of seven. Hydrocodone-acetaminophen was administered not administered on 04/08/25. Interview with Resident #86 on 04/08/25 at 7:20 A.M. revealed the resident had requested pain medication at 5:15 A.M. on 04/08/25 and received no medication. She rated her back pain as eight to nine out of 10. The resident stated staff informed her they could not obtain the medication from the locked medication dispensing system. Interview with Licensed Practical Nurse (LPN) #594 on 04/08/25 at 7:25 A.M. revealed Resident #86 did receive acetaminophen on 04/08/25, but there was not a current order for hydrocodone-acetaminophen. LPN #594 stated the physician was due to round anytime and they would ask for an updated prescription at that time. Review of the facility policy titled, Pain Management, dated June 2024, revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Based on observation, medical record review, and staff interview, the facility failed to ensure interventions were implemented to address dementia care and treatment. This affected one (#23) of one residents reviewed for dementia related daily care and stimulation. The facility census was 90. Findings include: Review of Resident #23's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including Alzheimer's disease, dementia, coronary artery disease, hypertension, anxiety disorder, chronic pain, osteoporosis, anemia, major depression, type II diabetes mellitus, atrial fibrillation, and chronic kidney disease stage four. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was assessed with moderately impaired cognition, utilized a walker and wheelchair for mobility, required supervision or touching assistance with activities of daily living (ADLs), was continent of bowel and bladder, received a mechanically altered diet, was not at risk for development of pressure ulcers, and received insulin injections, antipsychotic medication, antidepressant medication, anticoagulation medication, and diuretic medication. Review of a nursing plan of care dated 08/11/24 was revised to address Resident #23's risk for fluctuating cognitive state/progressive cognitive deficit related to dementia and Alzheimer's disease. Interventions included to administer medication to help address the resident's cognitive deficit per physician order; monitor for side effects/adverse reaction and notify the physician if these are suspected or observed; encourage the resident to attempt simple tasks unassisted as able; encourage to speak about pleasant memories as needed; gently redirect the resident in the event that he/she makes an inappropriate choice; give cues/supervision for daily decision-making; give medications as ordered; intervene for unsafe decisions; monitor for changes in cognitive status and notify the physician if these are observed or suspected; notify family for material needs; physician consultation as needed; provide reorientation as needed during daily care activities; and provide simple explanations prior to initiating or assisting with care and reminders as needed. Further review revealed no resident individualized or specific interventions were documented. In addition on 08/12/24 a plan of care was initiated to address Resident #23's psychosocial well-being and activities which noted Resident #23 had a need for interpersonal interaction, established own goals, had a strong identification with past roles, lost roles, new to the facility, and withdrawal from activities of interest. The resident voiced she it was more difficult to do some activities she once enjoyed, such as reading and baking. Interests include reading when feeling up to it, watching television, and resting. She voiced having little pleasure or interest in doing things. Interventions included to allow the resident to vent/express thoughts, needs, and feelings; talk with the resident during care to provide socialization and reorient as needed; encourage the resident to attend activities and praise for doing so; and encourage the resident to maintain current level of independence in all simple choices. There were no resident specific points of interest were listed or alternative examples of sensory stimulation were provided. Observation on 04/08/25 at 9:29 A.M. noted Resident #23 in bed with the lights off, eyes closed, and the room quiet. There was no stimulation or activity was being provided. At 11:51 A.M., Resident #23 was seated in a recliner at the bedside with no radio, television, books, or stimulation observed. On 04/09/25 at 10:26 A.M., Resident #23 was seated in a recliner with her feet to the floor. There was no meaningful stimuli or activity being provided and the room was silent with the lights off. At 12:07 P.M., the resident was in her room and reclined in a chair with her eyes closed. There was no meaningful stimuli or activity engagement provided. On 04/10/25 at 8:00 A.M., Resident #23 was observed in bed with her eyes closed and the room was quiet with the lights off. On 04/08/25 at 1:50 P.M., interview with Activity Assistant (AA) #622 stated Resident #23 spent much of her time in her room, sleeping. AA #662 stated the resident was provided with one-on-one visits once weekly and was not aware of any residents specific activity or stimulation engagement for Resident #23. On 04/10/25 at 8:10 A.M. interview with Activity Director (AD) #626, during a review of Resident #23's activity interest, verified no documentation was available indicating activities or related engagement that were provided. On 04/10/25 at 9:22 A.M., additional interview with AD #626 stated Resident #23 was spoken to following the previous interview and noted Resident #23 had interest in various types of music, movies, reading, and the walls in the resident's room also lacked pictures or visual stimuli.

Based on observation, staff interview, medical record review, review of a menu, review of a meal ticket, and review of the facility policy, the facility failed to offer alternate food choices when the resident did not eat well from the offered meal. This affected one (#42) of three residents reviewed for dining observation. The facility census was 90. Findings include: Review of the medical record for Resident #42 revealed an admitted [DATE] with diagnoses of Alzheimer's disease and dysphagia (difficulty swallowing). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #42 revealed the resident was severely cognitively impaired and required set-up for eating. Review of the current physician orders dated April 2025 for Resident #42 revealed she was ordered a fortified regular diet and for staff to check the refrigerator for homemade meals provided from family, and if food was available from family, please offer the homemade food during mealtime. Review of the care plan revised March 2025 for Resident #42 revealed she was at risk for poor oral intake with interventions in place for a fortified regular diet and needed assistance with eating. Review of the menu for 04/07/25 revealed the lunch served was Salisbury steak, roasted potato wedges, and peas and carrots. Review of the meal ticket for Resident #42 revealed no documented dislikes. Observation on 04/07/25 at 12:28 P.M., during dining observation, revealed Resident #42 was not offered substitute foods when she did not eat well for lunch. Continued observation during lunch for Resident #42 revealed she was assisted by Certified Nurse Aide (CNA) #530 and CNA #541, and neither of them offered a substitute when Resident #42 did not eat well. Review of the certified nurse aide (CNA) documentation for Resident #42 dated 04/07/25 revealed her meal intake for lunch on 04/07/25 was documented as zero percent (0%), which indicated Resident #42 ate between 0 and 25 of her meal. Interview on 04/07/25 at 1:06 P.M. with CNA #541 verified she did not offer an alternate meal or tried any other source of intake for Resident #42 for lunch. CNA #541 verified Resident #42 ate less than 25% of her meal for lunch. Review of the facility undated staff guidelines titled, Dining Room Expectations, revealed staff are to offer substitute meals for any unwanted items or food uneaten.

Based on observation, staff interview, review of visitor screening logs, review of resident vaccination status, and review of facility policy, the facility failed to ensure proper infection control practices and procedures were followed for visitor screening and source control to prevent the spread of COVID-19 with the potential to affect 13 (#1, #6, #11, #13, #15, #17, #24, #29, #31, #50, #58, #67 and #76) of 13 residents in the Special Care Unit (memory care). Additionally, the facility failed to ensure clean linen was transported in a sanitary manner with the potential to affect 10 (#40, #70, #177, #178, #179, #180, #182, #183, #184 and #187) of 10 residents on the rehabilitation unit. Lastly, the facility failed to ensure sanitary conditions for one Resident (#61) of three residents reviewed who had a catheter. The facility census was 77. Findings include: 1. Interview on 08/01/22 at 8:00 A.M. of the Administrator revealed the facility was in COVID-19 outbreak status until 08/07/22. Observation on 08/02/22 at 11:33 A.M. of the Special Care Unit dining room revealed Resident #11 sitting at a table with three visitors, a male, a female and a toddler who was sitting on Resident #11's lap. The male visitor had his facemask hanging from his left ear, the female visitor had her facemask below her chin, and the toddler was unmasked. Each visitors' mouth and nose were exposed. Resident #6 approached the table and sat with Resident #11 and the three visitors. Both residents and all visitors were within arms reach of each other. Neither Resident #11 or Resident #6 were wearing facemasks. Additional observation revealed Residents #1, #13, #17, #24 and #50 were also sitting in the dining room, unmasked, and at adjacent tables from Resident #11, Resident #6 and the three visitors. Review of the facility resident COVID-19 vaccination list revealed Resident #11 was not vaccinated for COVID-19 and Resident #6 was not up-to-date with COVID-19 vaccinations. Review of the facility COVID-19 kiosk screening log, dated 08/02/22, revealed Resident #11's three visitors did not screen for signs and symptoms of COVID-19 prior to visiting the Special Care Unit on 08/02/22. Interview on 08/02/22 at 11:35 A.M. with State tested Nurse Aide (STNA) #434 confirmed visitors were to wear facemasks during visits and were to social distance to potentially limit transmission of COVID-19 to residents. STNA #434 stated the visitors were family of Resident #11. STNA #434 verified the visitors were not properly wearing facemasks to cover their mouth and nose and Residents #1, #6, #11, #13, #17, #24 and #50 were in the dining room with the visitors, in close proximity, and the residents were also unmasked. STNA #434 stated she had asked the family many times to put their facemasks on correctly but they refused and she was not sure what else she could do about it. Interview on 08/02/22 at 12:20 P.M. with the Administrator confirmed visitors were expected to wear facemasks, especially in common areas of the facility. If visitors refused to wear the proper personal protective equipment (PPE) staff were expected to contact someone in administration for assistance. Interview on 08/04/22 at 10:31 A.M. with the Administrator and Director of Nursing (DON) verified on 08/02/22 Resident #11's three visitors were not screened for COVID-19 signs and symptoms on the facility kiosk prior to visiting the Special Care Unit. The Administrator stated the visitors may have screened in through the connected assisted living entrance, which was a paper screening. Follow-up interview on 08/04/22 at 11:38 A.M. with the Administrator revealed a family member of Resident #11 screened for signs and symptoms of COVID-19 through the assisted living entrance. The paper screening document was dated 08/01/22 and 08/02/22. Each specific visitor entry was undated, including the date Resident #11's family member screened for signs and symptoms of COVID-19. Review of the facility assisted living paper COVID-19 screening log, dated 08/01/22 and 08/02/22 revealed Resident #11's three visitors in the facility on 08/02/22 did not screen for signs and symptoms of COVID-19 prior to visiting the Special Care Unit on 08/02/22. Interview on 08/04/22 at 11:40 A.M. with STNA #434 confirmed Resident #11's family member who screened for signs and symptoms of COVID-19 on the assisted living paper screening log dated 08/01/22 and 08/02/22 was not one of the three visitors observed visiting on the Special Care Unit on 08/02/22. STNA #434 identified the family member on the screening form to be Resident #11's daughter, who had visited at a different time. STNA #434 confirmed Resident #11's visitors on 08/02/22 were the Resident's son, granddaughter and great granddaughter. STNA #434 verified their names were not on the assisted living paper screening log. Follow up interview on 08/04/22 at 11:41 A.M. with the Administrator verified the facility had no evidence Resident #11's family, who were observed not practicing COVID-19 source control on 08/02/22, were screened by the facility for signs and symptoms of COVID-19. Review of facility policy titled COVID-19 Visitors-Vendors-Others, revised 06/22/22, revealed all individuals and personnel must be screened for COVID-19 each time they enter the facility. In addition to the screening questions, visitors were to wear masks before entering the facility or have the necessary PPE on. Unvaccinated residents, where possible, should wear a face covering during the visit. Staff will observe the visitors to ensure correct donning of PPE and appropriate hand hygiene. Additionally, visitations will not be allowed for those visitors who refuse to wear a face covering, whether visiting a vaccinated or unvaccinated resident, and all visitors are to facilitate social distancing. 2. Observation on 08/02/22 at 8:08 A.M. of the rehabilitation unit revealed a three tier cart sitting in the hall outside of Resident #180 and #183's rooms. Both Resident doors were closed, a PPE cart was placed outside of each door and signs were hanging on the room doors identifying Resident #180 and #183 were on transmission based precautions. Further observation revealed there were 14 folded personal clothing items on the top shelf of the uncovered cart. Continued observations on 08/02/22 at 8:22 A.M., 8:48 A.M. and 8:57 A.M. revealed the three tiered cart remained in the hall outside of Resident #180 and #183's rooms, with the personal clothing items on the top shelf, uncovered. Interview on 08/02/22 at 8:57 A.M. with Licensed Practical Nurse (LPN) #417 verified the uncovered cart located in the hall outside of Resident #180 and #183's rooms had uncovered resident personal clothing on the top shelf of the cart. LPN #417 stated the personal clothing was waiting to be delivered to residents. LPN #417 confirmed Residents #180 and #183 were on transmission based precautions due to being on COVID-19 quarantine. Additional observation on 08/02/22 at 9:06 A.M. revealed the three tier cart remained in the hall outside of Resident #180 and #183's room, with uncovered personal clothing on the top shelf. Interview on 08/02/22 with State tested Nurse Aide (STNA) #418 verified the cart had clean, uncovered, resident personal clothing on the top shelf. STNA #418 stated some of the clothing was labeled and other items were unlabeled so she would have to figure out who they belonged to. STNA #418 stated she did not know why the uncovered cart with clean clothing was left in the hall. STNA #418 moved the cart into the clean linen closet. Review of facility policy titled Handling Clean Linen, dated 05/31/22, revealed clean linens must be transported by methods that ensure cleanliness and protect from dust and soil during loading, transport and unloading. Guidelines for the storage of clean linen included clean linen shall be delivered to resident care units on covered linen carts with covers down. The facility identified 10 residents (#40, #70, #177, #178, #179, #180, #182, #183, #184 and #187) on the rehabilitation unit. 3. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set 3.0 assessment, dated 07/18/22, revealed Resident #61 had mild cognitive impairment and required extensive assistance with toilet use and personal hygiene. Resident #61 was continent of bowel and bladder and had a urinary tract infection in the last thirty days. Review of physician orders revealed an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of urine culture dated 07/06/22 revealed evidence of a urinary tract infection with pseudomonas greater than 100,000 colony forming units per milliliter (CFU/ml). Review of physician orders dated 07/14/22 included the antibiotic [MEDICATION(S)] 200 mg, one tablet twice a day for seven days. Additional orders written on 07/14/22 included catheter irrigation as needed for occlusion, catheter drainage bag to be changed weekly and the tubing changed weekly every Wednesday night, catheter leg bag when Resident #61 was up, and catheter care every shift. Observation on 08/02/22 at 2:13 P.M. revealed the catheter bag folded onto itself resting on the floor next to the right side of the bed. Interview on 08/02/22 at 2:23 P.M. with STNA #551 verified the catheter bag for Resident #61 was touching the floor. STNA #551 further added catheter bags are not to be on the floor. STNA #551 readjusted the catheter bag to ensure the catheter bag no longer sat on the floor. Observation on 08/03/22 at 2:05 P.M. revealed Resident #61's catheter bag hanging off the handle of the recliner, resting on the floor. Interview on 08/03/22 at 2:08 P.M. with STNA #390 verified Resident #61's catheter bag was resting on the floor and further verified the catheter bag should not touching the floor. STNA #390 repositioned the catheter drainage bag to prevent it from touching the floor. Review of the facility policy titled Catheter Care, dated 03/08/21, revealed residents with catheters should receive appropriate catheter care and further stated catheter drainage bags should be always covered when in use.

Based on observation, medical record review, and staff interview, the facility failed to assisted residents with dining in a dignified manner. This affected three (#2, #21, and #28) of eight residents observed eating in the South dining room. The census was 77. Findings include: 1. Review of Resident #2's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment, completed 07/12/22, revealed Resident #2 was assessed as cognitively intact and required extensive one person physical assist with eating. Review of a nutritional care plan dated 12/02/19 revealed an intervention Resident #2 needed assistance with eating. 2. Review of Resident #21's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent MDS assessment, completed 05/14/22, revealed Resident #21 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nutritional care plan dated 07/17/15 revealed an intervention that Resident #21 needed assistance with eating. 3. Review of Resident #28's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent MDS assessment, completed 05/25/22, revealed Resident #28 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nutritional care plan dated 10/03/18 revealed an intervention that Resident #28 needed assistance with eating. Observation on 08/02/22 at 5:07 P.M. revealed State tested Nurse Aide (STNA) #413 was feeding three residents (#2, #21, and #28) in the South dining room. Further observation revealed all three residents were seated at the same table and STNA #413 was standing feeding one of the residents. There was one empty chair at the table not being used by anyone at this time. Continual observation was made, on 08/02/22 between 5:08 P.M. and 5:25 P.M., and revealed STNA #413 stood beside one of the residents and offered a bite of food or drink, and then walked to the next resident to offer food and drink, and walked to the last resident to offer food and drink. STNA #413 moved in a clockwise fashion from resident to resident seated at the table, while standing and when walking around the table. STNA #413 offered no more than one bite of food or one drink to each resident during each turn throughout the entire observation. STNA #413 walked around the entire table and offered food and drink to each of the three residents at least five times during this observation. Observation on 08/02/22 at 5:26 P.M. revealed 14 empty chairs in the South dining not being utilized by any resident, visitor, or staff member. Interview on 08/02/22 at 5:28 P.M. with STNA #413 verified the three residents she was assisting with feeding were Resident #2, #21, and #28 and verified they all required staff assistance with eating. STNA #413 stated she started feeding all three residents around 5:00 P.M. on 08/02/22 and verified she was standing, walking, and feeding all three residents at the same time.

Based on record review, policy review, staff interview, and resident interview, the facility failed to ensure residents were assessed for the appropriate use of a restraint and free from use of an unnecessary restraint. This affected one (#53) of six residents reviewed for falls. The facility census was 77. Findings include: Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #53 had mild cognitive impairment and exhibited no physical, verbal or wandering behaviors. Review of fall risk assessments dated 05/24/22, 07/06/22, and 08/06/22 revealed Resident #53 was at moderate risk for falls. Review of the care plan for Resident #53 revealed the risk for falls due to Resident #53's decreased safety awareness. Interventions for Resident #53 included the use of a chair alarm when resident in chair and a bed alarm when Resident #53 was in bed. Review of restrictive device consent, signed 05/28/22, revealed Resident #53 was to use a bed alarm when in bed and a chair alarm when in any chair. The consent was signed by family after the resident had a fall which required a hospital assessment during which a urinary tract infection was identified. Review of the social service notes dated 05/30/22 revealed Resident #53 mentioned she felt she had lost her independence because of the chair and bed alarms. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The record contained no assessment for the use of the bed and chair alarm. Interview with Resident #53 on 08/01/22 at 2:35 P.M. revealed Resident #53 felt she had lost independence due to the use of the chair and bed alarms. Observation on 08/02/22 at 9:06 A.M. Resident #53 ambulated to the bathroom with a wheeled walker and the chair alarm was sounding. Two staff responded immediately. Observation on 08/03/22 at 8:52 A.M. revealed Resident #53 was in her room sitting in the recliner with the chair alarm in place. At 1:51 P.M. Resident #53 standing with the walker in hand in front of the recliner with the chair alarm sounding. Staff in hallway outside of the room responded. Observations on 08/04/22 at 8:50 A.M., 12:07 P.M., and 4:08 P.M. revealed Resident #53 was her room sitting in the recliner with the chair alarm in place. Interview with the State tested Nursing Assistant (STNA) #431 on 08/04/22 at 8:50 A.M. revealed knowledge that Resident #53 did not like the chair alarm and did not want the alarms for either the bed or chair. Interview on 08/04/22 at 1:53 A.M. with Social Work #376 revealed the family for Resident #53 requested the use of the alarms due Resident #53's increased falls. Social Worker #376 stated Resident #53 was not afraid of the alarm and continues to get up without the assistance of staff. Interview on 08/04/22 at 3:50 P.M. with the Director of Nursing revealed no specific resident evaluations are completed either initially or ongoing for the use of bed alarms or chair alarms. If the family requests the use of an alarm the facility will place one on the resident. Review of the policy titled Restraint Free Environment, dated 10/12/21, revealed residents are to be treated with respect and dignity, which included the right to be free of any physical restraint imposed for the purpose of discipline or staff convenience and not required to treat the resident's medical symptoms. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interview, medical record review, and review of facility policies, the facility failed to ensure residents with hearing impairments were assisted with placement of hearing aides as care planned and as ordered. This affected one (#25) of one residents reviewed for vision and hearing. The facility identified 23 residents in the facility with hearing aides. The census was 77. Findings include: Review of Resident #25's medical record revealed an admitted [DATE]. Findings included Alzheimer's disease with late onset, [CONDITION(S)], diabetes mellitus type II, dementia without behavioral disturbances, [CONDITION(S)], anxiety, and [CONDITION(S)]. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Area Assessment (CAA) Summary for communication revealed Resident #25 had minimum hearing difficulty and staff were to assist with hearing aids, adjust the tone, and repeat as needed. The facility indicated Resident #25's communication deficits would be care planned. Review of the most recently completed MDS assessment dated [DATE] revealed Resident #25 continued to be assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan dated 03/19/20 revealed Resident #25 was alert with clear speech, and minimal hearing difficulty with hearing aids. Review of an intervention dated 03/19/20 revealed Resident #25 had bilateral hearing aids available and in use. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #25's hearing aids were to be stored in the nurse's cart. Review of the August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 08/01/22 between 9:00 A.M. and 2:30 P.M. revealed Resident #25 did not have her hearing aids in her ears throughout the day. Observation on 08/02/22 at 12:38 P.M., at 1:40 P.M., at 3:00 P.M., and at 5:08 P.M. revealed Resident #25 did not have hearing aids in her ears. Observation on 08/03/22 at 7:58 A.M. revealed Resident #25 sitting in her reclining chair in her bedroom eating breakfast. Resident #25 did not have her hearing aids in her ears at this time. Subsequent observations on 08/03/22 at 8:59 A.M. and at 9:48 A.M. revealed Resident #25 continued to not have her hearing aids in her ears. Interview on 08/03/22 at 10:34 A.M. with Licensed Practical Nurse (LPN) #417 verified she was the nurse providing care to Resident #25 on 08/03/22 and verified Resident #25's hearing aids were kept in the medication cart. Observation on 08/03/22 at 10:35 A.M., with LPN #417, revealed both of Resident #25's hearing aids were inside of a case and stored in the medication cart at that time. Interview on 08/03/22 at 10:35 A.M. with LPN #417 verified Resident #25 did not have her hearing aids in her ears and stated she thought Resident #25's family did not want her to have her hearing aids in unless they said to put them in, but could not identify where or when she discovered that information. Observation on 08/03/22 at 11:27 A.M. revealed Resident #25 remained with no hearing aids in her ears. Review of a facility policy titled Activities of Daily Living (ADLs), revised 11/22/21, revealed based on the resident's comprehensive assessment and consistent with the resident's needs and choices, the facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for all ADLs including using speech, language, or other functional communication systems. Review of a facility policy titled Care and Use of Hearing Aids, revised 03/29/22, revealed it is the practice of the facility to assist residents in using their hearing aides, and to provide care to the hearing aides to ensure they are clean and protected from loss and breakage when not being worn.

Based on observation, medical record review, staff interview, review of State tested Nurse Aide (STNA) bowel tracking documentation and review of facility policy, the facility failed to ensure residents who were dependent for care received assistance with nail care. This affected one (#177) of two residents reviewed for activities of daily living (ADLs). The facility census was 77. Findings include: Review of the medical record for Resident #177 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 07/29/22, revealed Resident #177 had short and long term memory problems, was severely cognitively impaired, and required extensive assistance with bed mobility, dressing, and personal hygiene. Additionally, Resident #177 was occasionally incontinent of bowel. Review of the plan of care, initiated 07/23/22, revealed Resident #177 had a potential/actual deficit with activities of daily living (ADLs). Interventions included allow ample time for participation, assist with ADLs as current needs required, encourage Resident #177 to participate in ADLs, encourage rest periods as needed, and monitor for changes in functional ADL ability. Review of STNA documentation from 07/24/22 through 08/04/22 revealed Resident #177 had bowel movements on 07/26/22, 07/30/22, 07/31/22 and 08/04/22. Review of a nursing progress note dated 07/31/22 revealed Resident #177 had a bowel movement and smeared feces over self and bed. Observation on 08/01/22 at 1:34 P.M. of Resident #177 revealed a dark substance was present under the Resident's left hand fingernails. Additional observations on 08/02/22 at 8:03 A.M. and 8:49 A.M. revealed Resident #177 had a dark substance was present his left hand fingernails. Interview on 08/02/22 at 9:00 A.M. of Licensed Practical Nurse (LPN) #417 verified Resident #177 had a dark substance was present under his left hand fingernails. Interview on 08/02/22 at 9:06 A.M., STNA #418 confirmed Resident #177 had a dark substance under his left hand fingernails. STNA #418 stated Resident #177 was incontinent of bowel and would remove the brief and get feces on his hands. STNA #418 stated she believed Resident #177 had feces under his left hand fingernails and she planned to clean them today. STNA #418 stated Resident #177 did not have a bowel movement yet today on her shift, which began at 6:00 A.M. STNA #418 confirmed resident's bowel movements were documented and tracked in the electronic medical record with the Resident's last documented bowel movement being 07/31/22. Additional observations on 08/02/22 at 10:36 A.M. and 12:07 P.M. of Resident #177 revealed the dark substance was remained under his left hand fingernails. Observation on 08/02/22 at 2:39 P. M. revealed Resident #177's fingernails had been cleaned. Observation on 08/04/22 at 8:37 A.M. of Resident #177 revealed a dark substance was present under the resident's left hand fingernails. Interview on 08/04/22 at 10:23 A.M., STNA # 390 revealed Resident #177 had a bowel movement that morning and the resident stuck his hand in the feces. STNA #390 stated he cleaned Resident #177 up after the bowel movement but did not clean his fingernails. Additional observations on 08/04/22 at 10:25 A.M., 11:19 A.M. and 1:07 P.M. revealed Resident #177 continued to have debris under his left hand fingernails. Follow up interview on 08/04/22 at 1:07 P.M., STNA #390 confirmed Resident #177 only had one bowel movement that day which was earlier in the morning. Interview on 08/04/22 at 2:45 P.M., STNA #424 verified Resident #177 had debris under his left hand fingernails. STNA #424 stated she would take care of cleaning the Resident's fingernails. Review of facility policy titled Activities of Daily Living (ADLs), dated 11/22/21, revealed a resident who was unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on medical record review, staff interview, and review of facility polices, the facility failed to ensure wounds were assessed and treated in a timely manner and failed to ensure compression garments were applied as ordered. This affected one (#62) of one residents reviewed for non-pressure skin impairments and one (#52) of one residents reviewed for [CONDITION(S)]. The facility identified three residents in the facility with non-pressure skin impairments. The census was 77. Findings include: 1. Review of Resident #62's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #62 was discharged on [DATE]. Review of an admission Minimum Data Set (MDS) assessment, completed 07/05/22, revealed Resident #62 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #62 was assessed at risk for pressure ulcers and was admitted with three stage four and two unstageable (obscured full-thickness skin and tissue loss) pressure ulcers on admission. Review of a risk for skin breakdown care plan dated 07/01/22 revealed Resident #62 was to be assessed for risk factors associated with pressure ulcer development, turn and reposition every two hours when in bed, and provide pressure reduction to the bed and chair. Review of an admission nursing assessment dated [DATE] revealed Resident #62 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2022 treatment administration record (TAR) revealed Resident #62 had the skin surrounding all wounds monitored every night shift for changes with no concerns noted and all pressure ulcers measured on 07/03/22. There was no other documentation of Resident #62 having any other wounds measured or assessed. Review of a nursing progress note dated 07/09/22 revealed a nurses aide informed the nurse there was a small amount of green fluid found in Resident #62's abdominal fold on the right side. The nurse aide showed the nurse the area, and when Resident #62's abdomen was lifted greenish-yellow fluid started coming out of a small opening in the skin. The nurse documented she continued to hold Resident #62's abdomen while it continued to drain. Review of a nursing progress note dated 07/10/22 revealed when Resident #62 was washed up there was more drainage from the small opening in Resident #62's skin. The area was cleaned and was not warm to the touch and no fever was present. There was no assessment of the new wound discovered in Resident #62's abdominal fold on 07/09/22, 07/10/22, or 07/11/22. Review of a nursing progress note dated 07/12/22 revealed the wound care physician was notified about the condition of Resident #62's wounds. Review of a nurse practitioner visit note dated 07/12/22 revealed the nurse practitioner noted a new wound in the right abdominal fold measuring approximately 2.0 cm long by 2.0 cm wide with a small amount of serosanguinous (thin and watery) fluid noted. Resident #62 voiced no complaints of pain or discomfort at that time. Review of a nursing progress note dated 07/12/22 revealed Resident #62 received orders to be sent to the hospital for evaluation and treatment and did not return to the facility. Review of hospital documents dated 07/12/22 revealed Resident #62 was admitted to the hospital in fair condition. Resident #62 was well known to the hospital having been seen there for the past eight years for treatment and evaluation of her sacral pressure wounds. Resident #62 underwent surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #62 was also noted to have a small wound and [CONDITION(S)] (redness) with a skin breakdown under the abdominal pannus (excess skin and fat that hangs over the pubic region) on the right. There were no treatments or further assessments completed on Resident #62's wound under the abdominal pannus. Interview on 08/03/22 at 1:41 P.M. with Licensed Practical Nurse (LPN) #391 stated she was the nurse that was working when Resident #62's wound in her abdominal wound was discovered. LPN #391 stated the wound was in Resident #62 abdominal fold and when pressure was applied yellowish-green fluid came out. LPN #391 stated the wound was about half the size of an eraser on a pencil and stated she notified the nurse practitioner (Nurse Practitioner #500) about the wound but could not remember if she documented the notification in the medical record. LPN #391 stated there was a calendar book that nurses sometimes used to document in, but the book could not be found. LPN #391 stated she could not remember if the nurse practitioner gave any orders to treat the wound, but stated she placed gauze over the wound. LPN #391 stated she could not remember if she documented the wound treatment in the medical record. Interview on 08/03/22 at 10:34 A.M. with Nurse Practitioner (NP) #500 stated she was not notified of Resident #62's abdominal wound and did not order any treatments for the wound. NP #500 stated the first time she knew about Resident #62's abdominal wound was on 07/12/22 when she physically assessed Resident #62 and it was observed. NP #500 stated the wound was approximately 2.0 cm long by 2.0 cm wide and stated she did not order any treatments for the wound because there were other issues with Resident #62's condition that required immediate attention. NP #500 stated Resident #62 needed to be seen for evaluation of her pressure ulcers and was sent to the hospital. Review of a facility policy titled Documentation of Wound Treatments, dated 11/24/21, revealed wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. Review of a facility policy titled Wound Treatment Management, dated 11/24/21, revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, of the assigned licensed nurse in the absence of the treatment nurse. 2. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed Resident #52 was cognitively intact and required extensive assistance with dressing. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 03/07/22 revealed the nurse was to measure Resident #52 for knee high compression stockings and the compression stockings were to be applied in the morning and removed at bedtime. an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress note dated 07/19/22 revealed chronic bilateral lower extremity [CONDITION(S)] with left lower extremity greater than the right lower extremity. Observations on 08/02/22 at 9:13 A.M., 08/03/22 at 8:29 A.M. and on 08/04/22 at 12:48 P.M. revealed swelling and [CONDITION(S)] to Resident #52's bilateral lower extremities with the [CONDITION(S)] to the left lower extremity greater than the [CONDITION(S)] to the right lower extremity. Compression stockings were not observed in place. Interview on 08/03/22 at 2:16 PM with State tested Nursing Assistant (STNA) #431 revealed Resident #52 was not wearing compression stockings. STNA #431 stated she was unaware Resident #52 was to wear compression stocking and added Resident #52 does not have compression stockings. Interview on 08/03/22 at 2:20 P.M. with Registered Nurse (RN) #443 verified Resident #52 did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #443 stated she measured and ordered the compression stockings. Review of facility policy titled Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders allow staff to provide essential care to the resident and provide information to maintain or improve the resident's functional status. This deficiency substantiates Complaint Number OH 422.

Based on medical record review, staff interview, and review of a facility policy, the facility failed timely assess pressure ulcers. This affected one (#62) of six residents reviewed for pressure ulcers. The facility identified 10 residents in the facility with pressure ulcers. The census was 77. Findings include: Review of Resident #62's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #62 was discharged on [DATE]. Review of hospital documents dated 05/20/22, prior to Resident #62's admission to the facility, revealed Resident #62 was admitted with chronic [CONDITION(S)] due to uncontrolled diabetes mellitus, had multiple extensive pressure ulcers with necrotizing fascitis (flesh-eating infection), and three separate infectious organisms discovered in her wounds. Resident #62's wound infections were treated with two antibiotics and consideration was made for a surgical consultation. Resident #62's wounds initially got better but then deteriorated rapidly to a necrotizing state. Review of a wound progress note dated 06/27/22 revealed Resident #62 had a stage three (full-thickness skin loss) pressure ulcer to the right heel which measured 3.0 centimeters (cm) long by 4.0 cm wide with no depth and 75 percent (%) to 100% of the wound covered with eschar (dead tissue); a stage four (full-thickness skin and tissue loss) to the right ischium (on the curvature of the posterior pelvic bone) measuring 9.0 cm long by 2.5 cm wide by 0.1 cm deep; and a stage four pressure ulcer to the coccyx (bone structure at the base of the spine) measuring 8.5 cm long by 14.5 cm wide by 1.0 cm deep. Review of a physician note dated 06/29/22 revealed Resident #62 would be discharged to a nursing facility within the next 24 to 48 hours and Resident #62 had arranged follow up with care with a plastic surgeon to look at the sacral and ischial wounds. Review of an admission Minimum Data Set (MDS) assessment, completed 07/05/22, revealed Resident #62 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #62 was assessed at risk for pressure ulcers and was admitted with three stage four and two unstageable (obscured full-thickness skin and tissue loss) pressure ulcers on admission. Resident #62 had interventions with pressure reduction to the bed and chair, turning and repositioning, pressure ulcer care, and application of non-surgical dressings. Review of the Care Area Assessment (CAA) Summary for pressure ulcer and injury revealed Resident #62 was able to voice needs and required extensive assistance with bed mobility to reduce friction. Resident #62's skin was observed with care and weekly skin checks completed. Staff provided treatments and monitored for changes as needed. Review of a care plan dated 07/01/22 revealed Resident #62 had actual skin breakdown with pressure ulcers on admission. Care plan interventions included provide treatments as ordered and monitor for changes, observe skin daily with care, and weekly wound management. Review of an assessment used to predict pressure ulcer development dated 07/01/22 revealed Resident #62 was assessed at moderate risk. Review of an admission nursing assessment dated [DATE] revealed Resident #62 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2022 treatment administration record (TAR) revealed Resident #62 had the skin surrounding all wounds monitored every night shift for changes with no concerns noted. Resident #62's pressure ulcers were assessed on 07/03/22 and were as followed: Resident #62's deep tissue injury to the right heel measured 3.8 cm long by 3.5 cm wide by 0.1 cm depth; Resident #62's deep tissue injury to the right lateral ischium measured 2.0 cm long by 2.0 cm wide by 0.2 cm deep; Resident #62's stage four pressure ulcer to the left ischium measured 3.5 cm long by 2.2 cm wide by 0.5 cm deep; Resident #62's stage four pressure ulcer to the right ischium measured 7.5 cm long by 3.5 cm wide by 2.0 cm deep; and Resident #62's stage four pressure ulcer to the sacrum measured 13.0 cm long by 9.0 cm wide by 4.0 cm deep. Review of the July 2022 TAR revealed Resident #62's deep tissue injury to the right heel was assessed on 07/10/22 and measured 3.5 cm long by 3.0 cm wide with no depth; however, none of Resident #62's other pressure ulcers were assessed or measured on 07/10/22. Review of nursing progress notes and assessments dated between 07/04/22 and 07/12/22 revealed no documentation of Resident #62's wounds on her right lateral ischium, left ischium, right ischium, and sacrum assessed or measured after 07/03/22. Review of a nursing progress note dated 07/11/22 revealed Resident #62's wound vacuum change and reapplication were held for day shift. The nursing note indicated with the complexity level it was felt it would take two staff to manage it appropriately and the unit manager was notified. Review of a nursing progress note dated 07/11/22 revealed Resident #62's wound vacuum was changed with the canister noted to have brownish-red drainage and a foul odor. The pressure ulcers were observed to be beefy red with increased necrotic tissue to the wound perimeter. There were no measurements obtained of these wounds and the wounds were not staged. The wound vacuum was applied and sealed with no leaks. Review of a nursing progress note dated 07/12/22 revealed the wound care physician was notified about the condition of Resident #62's wounds. Review of a nursing progress note dated 07/12/22 revealed Resident #62 received orders to be sent to the hospital for evaluation and treatment and did not return to the facility. Review of hospital documents dated 07/12/22 revealed Resident #62 underwent surgical debridement of the pressure ulcers on her left and right ischium and sacrum to remove necrotic tissue. Resident #62's wounds were not significantly bigger and did not change stages. Interview on 08/04/22 at 4:55 P.M. with Director of Nursing (DON) verified Resident #62's wounds were assessed in the facility on 07/01/22, on admission, and on 07/03/22. DON stated Resident #62's wounds were scheduled to be assessed on 07/10/22; however, the wound vacuum was in place and the wounds could not be observed. DON verified Resident #62's wound vacuum was changed on 07/11/22 and verified Resident #62's wounds wound have been visible and able to be assessed at that time but the facility did not assess them. DON verified Resident #62's pressure ulcers on her right lateral ischium, left ischium, right ischium, and sacrum were not assessed after 07/10/22 as Resident #62 was sent to the hospital on 07/12/22. Review of a facility policy titled, Documentation of Wound Treatments, dated 11/24/21, revealed wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. This deficiency substantiates Complaint Number OH 422.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure fall interventions were implemented as care planned. This affected one (#13) of six residents reviewed for falls. The facility census was 77. Findings include: Review of the medical record revealed Resident #13 was admitted on [DATE]. Diagnoses included Alzheimer's disease, history of falling, major depressive disorder, [CONDITION(S)], [CONDITION(S)], and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was severely cognitively impaired, required extensive assistance with bed mobility, transfers, and locomotion, and had two or more falls. Review of the plan of care, revised 10/29/20, revealed Resident #13 was at risk for falls. Interventions included assist resident getting in and out of bed, a scoop mattress to bed to define bed parameters, and keep wheelchair at bedside while in bed for safety. Review of the Fall Risk Assessment, dated 06/10/22, revealed Resident #13 was at moderate risk for falls. Review of a physician order, dated 02/01/22, revealed a scoop mattress to bed to define bed parameters due to resident's decreased awareness of own physical limitations. Observation on 08/01/22 at 3:01 P.M. revealed Resident #13 in bed. Resident #13 did not have a scoop mattress on the bed and the wheelchair was located on the wall opposite the Resident's bed, in front of the window. Observation on 08/02/22 at 7:30 A.M. revealed Resident #13 in bed. Resident #13 did not have a scoop mattress on the bed and the wheelchair was located on the wall opposite the Resident's bed, in front of the window. Interview on 08/02/22 at 11:18 A.M. with State tested Nurse Aide (STNA) #434 confirmed Resident #13 did not have a scoop mattress to the bed. Additionally, STNA #434 stated it was not typical for Resident #13's wheelchair to be left at bedside when the Resident was in bed. STNA #434 was unaware of the fall interventions for Resident #13 to have a scoop mattress or for her wheelchair to be placed bedside when Resident #13 was in bed. STNA #434 stated Resident #13 did attempt to get up on her own sometimes and had a history of falls at the facility. STNA #434 confirmed Resident #13 was dependent on staff for all care, including safe transfers. Observation on 08/03/22 at 8:08 A.M. revealed Resident #13 in bed. Resident #13 did not have a scoop mattress and her wheelchair was located on the wall opposite her bed, in front of the window. Review of facility policy titled Fall Prevention Program, revised 06/23/22, revealed each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care and staff were to be aware of interventions in the electronic medical record and plan of care.

Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure physician ordered fluid restrictions were followed and failed to ensure appropriate mechanisms were used to alert staff to residents on fluids restrictions per the policy. This affected one (#45) of one residents reviewed for hydration. The census was 77. Findings include: Review of Resident #45's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #45's most recently completed basic metabolic panel (a laboratory test that measures electrolyte balance) revealed Resident #45's sodium and potassium levels were within normal range. Review of a nutrition care plan dated 10/05/21 revealed Resident #45 had an intervention for no water pitcher at the bedside. Review of a consulting dietician recommendation document dated 07/07/22 revealed Resident #45 was ordered a regular diet with small portions and a fluid restriction consisting of no water pitcher at the bedside. Review of a physician order dated 07/12/22 revealed Resident #45 was ordered a fluid restriction with no water pitcher at the bedside. There was no physician order to monitor Resident #45's fluid intake. Review of a dietary communication form dated 07/1/522 revealed Resident #45 was to have no water pitcher at the bedside. Review of nurse aide documentation dated between 07/10/22 and 08/08/22 revealed only one fluid intake documented on 07/10/22 and revealed Resident #45 had 20 milliliters of fluid intake. Observation on 08/02/22 at 3:10 P.M. and 5:11 P.M. revealed Resident #45 sitting in her reclining chair in her bedroom with a large white Styrofoam cup sitting on the bedside table, with fluid in the cup, to the right of Resident #45 within her reach. There was no signage to identify Resident #45 was on a fluid restriction outside or inside the room. Observation on 08/03/22 at 7:22 A.M. revealed Resident #45 was up sitting in her reclining chair eating breakfast. There was a large white Styrofoam cup on the bedside table near her food tray that contained fluids with the date of 08/03/22 written on the outside of the cup. Resident #45 was eating and drinking independently. Subsequent observations on 08/03/22 at 9:03 A.M. and 9:48 A.M. revealed Resident #45 remained in her reclining chair with a large white Styrofoam cup with fluid inside with her reach on the beside table. There remained no signage indicating Resident #45 was on a fluid restriction outside or inside the room. Interview on 08/03/22 at 7:48 A.M. with Resident #45 stated she was not aware she was on a fluid restriction and when asked what she drank from when she was thirsty, Resident #45 lifted her large white Styrofoam cup full of fluid. Interview on 08/03/22 at 10:02 A.M. with State tested Nurse Aide (STNA) #456 stated residents received large white Styrofoam cups as their water pitchers and the third shift staff were responsible for getting the residents new cups every day and filling them with fresh ice water. STNA #456 stated each Styrofoam cup could hold 20 ounces of water. Observation on 08/03/22 at 10:25 A.M., with STNA #456, verified Resident #45 had a large white Styrofoam cup within her reach that contained fluid and no signage identifying Resident #45 was on a fluid restriction. Interview on 08/03/22 at 10:25 A.M. with STNA #456 stated she was not aware Resident #45 was on a fluid restriction and was not to have a water pitcher at the bedside. A telephone interview was completed on 08/08/22 at 8:49 A.M. with Dietician #550 who verified Resident #45 was ordered to have no water pitcher at the bedside. Dietician #550 stated Resident #45 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Dietician #550 stated Resident #45 was moderately to severely cognitively impaired and was physically capable of drinking independently, and by having no water pitcher at the bedside, it eliminated the readily available source of water for Resident #45 to drink. Review of a a facility policy titled Hydration, last revised 08/03/22, revealed the resident's goals and preferences regarding hydration will be reflected in the resident's plan of care. Interventions will be individualized to address the specific needs of the resident. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. Signage will be placed in individual resident rooms alerting staff to resident specific needs, such as thickened liquids, no water at bedside, etc.

Based on medical record review, staff interview, and review of a facility policy, the facility failed to timely notify the physician when a resident experienced a change in condition that required a new treatment. This affected one (#62) of two reviewed for changes in condition. The census was 77. Findings include: Review of Resident #62's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #62 was discharged on [DATE]. Review of an admission Minimum Data Set (MDS) assessment, completed 07/05/22, revealed Resident #62 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #62 was assessed at risk for pressure ulcers and was admitted with three stage four and two unstageable (obscured full-thickness skin and tissue loss) pressure ulcers on admission. Review of a risk for skin breakdown care plan, dated 07/01/22, revealed Resident #62 was to be assessed for risk factors associated with pressure ulcer development, turn and reposition every two hours when in bed, and provide pressure reduction to the bed and chair. Review of an admission nursing assessment, dated 07/01/22, revealed Resident #62 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2022 treatment administration record (TAR) revealed Resident #62 had the skin surrounding all wounds monitored every night shift for changes with no concerns noted and all pressure ulcers measured on 07/03/22. There was no other documentation of Resident #62 having any other wounds measured or assessed. Review of a nursing progress note dated 07/09/22 revealed a nurses aide informed the nurse there was a small amount of green fluid found in Resident #62's abdominal fold on the right side. The nurse aide showed the nurse the area, and when Resident #62's abdomen was lifted greenish-yellow fluid started coming out of a small opening in the skin. The nurse documented she continued to hold Resident #62's abdomen while it continued to drain. Review of a nursing progress note dated 07/10/22 revealed when Resident #62 was washed up there was more drainage from the small opening in Resident #62's skin. The area was cleaned and was not warm to the touch and no fever was present. There was no documentation of a physician or nurse practitioner being notified of the new wound discovered in Resident #62's abdominal fold on 07/09/22, 07/10/22, or 07/11/22. Review of a nursing progress note dated 07/12/22 revealed the wound care physician was notified about the condition of Resident #62's wounds. Review of a nurse practitioner visit note, dated 07/12/22, revealed Resident #62's wound vacuum was in place and functioning with no concerns. The nurse practitioner noted a new wound in the right abdominal fold measuring approximately 2.0 cm long by 2.0 cm wide with a small amount of serosanguinous (thin and watery) fluid noted. Resident #62 voiced no complaints of pain or discomfort at that time. Review of a nursing progress note dated 07/12/22 revealed Resident #62 received orders to be sent to the hospital for evaluation and treatment and did not return to the facility. Review of hospital documents dated 07/12/22 revealed Resident #62 was admitted to the hospital in fair condition. Resident #62 was well known to the hospital having been seen there for the past eight years for treatment and evaluation of her sacral pressure wounds. Resident #62 underwent surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #62 was also noted to have a small wound and [CONDITION(S)] (redness) with a skin breakdown under the abdominal pannus (excess skin and fat that hangs over the pubic region) on the right. There were no treatments or further assessments completed on Resident #62's wound under the abdominal pannus. Interview on 08/03/22 at 1:41 P.M. with Licensed Practical Nurse (LPN) #391 stated she was the nurse that was working when Resident #62's wound in her abdominal wound was discovered. LPN #391 stated the wound was in Resident #62 abdominal fold and when pressure was applied yellowish-green fluid came out. LPN #391 stated the wound was about half the size of an eraser on a pencil and stated she notified the nurse practitioner (Nurse Practitioner #500) about the wound but could not remember if she documented the notification in the medical record. LPN #391 stated there was a calendar book that nurses sometimes used to document in, but the book could not be found. LPN #391 stated she could not remember if the nurse practitioner gave any orders to treat the wound, but stated she placed gauze over the wound. LPN #391 stated she could not remember if she documented the wound treatment in the medical record. Interview on 08/03/22 at 10:34 A.M. with Nurse Practitioner (NP) #500 stated she was not notified of Resident #62's abdominal wound the first time she knew about Resident #62's abdominal wound was on 07/12/22 when she physically assessed Resident #62 and it was observed. NP #500 stated the wound was approximately 2.0 cm long by 2.0 cm wide and stated she did not order any treatments for the wound because there were other issues with Resident #62's condition that required immediate attention. NP #500 stated Resident #62 needed to be seen for evaluation of her pressure ulcers and was sent to the hospital. Review of a facility policy titled Review of the Notification of Changes, dated 03/30/22, revealed the facility must inform the resident, consult with the resident's physician and or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification included a need to alter treatment, this may include a new treatment or discontinuation of a current treatment, and a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status. This may include life-threatening conditions or clinical complications. Review of a facility policy titled Wound Treatment Management, dated 11/24/21, revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, of the assigned licensed nurse in the absence of the treatment nurse. This deficiency substantiated Complaint Number OH 4422.

Based on medical record review, observations, staff interview, review of the facility policy regarding missing/wandering residents, review of the ambulance report, review of the facility Self-Reported Incident (SRI) investigation, review of the alarm activation ticket, review of hospital documentation, and the "Weather Underground" report, the facility failed to provide adequate supervision for one (Resident #1) of fourteen residents identified for potential elopement of a total of three residents reviewed for elopement. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy for one (Resident #1) cognitively impaired resident with wandering behaviors who successfully eloped from the facility without staff knowledge. On 02/12/15 at 4:08 P.M., the Administrator, and Director of Nursing (DON) were notified Immediate Jeopardy began on 02/01/15 at approximately 10:00 A.M. when Resident #1 walked out of the facility through an alarm exit door which was disabled. The facility was not aware Resident #1 was missing until approximately 10:45 A.M. when the facility was notified by the Director of Independent Living #1. Resident #1 independently walked approximately 500 feet to a neighboring home within the retirement community. The resident was wearing a sweater, shirt, long pants, and tennis shoes. The resident was not wearing a winter coat, hat or gloves. According to the history report on "Weather Underground", the local weather forecast, the outside temperature in the area on 02/01/15 was 26 degrees Fahrenheit (F), with snow covered ground. Resident #1 was found by emergency services lying on the ground in landscape shrubbery at approximately 10:15 A.M., after notification by a resident of an independent living apartment, and taken to the hospital for evaluation. The resident was returned to the facility the same day at 3:15 P.M. The Immediate Jeopardy was removed on 02/13/15 at 12:00 P.M. when the facility implemented the following corrective actions: * On 02/01/15 at 10:30 A.M., the Chief Executive Officer ensured the alarming door was functioning properly. * On 02/01/15 at 3:15 P.M., Resident #1 was returned to the facility and the resident ' s chair pressure pad alarm was changed to a floor mat alarm to alert staff when the resident stood up from the bed or chair. * On 02/02/15 at 1:00 P.M., the facility implemented checks of all facility doors at the start and end of every shift to ensure proper functioning of the alarms. * On 02/12/15 at 4:50 P.M., the facility re-assessed all residents in the facility for elopement or wandering behaviors. On 02/13/15 at 7:00 A.M., the plans of care for all residents assessed to be at risk for elopement were reviewed for accuracy. * Between 02/12/15 at 4:01 P.M. and 02/13/15 at 12:00 P.M., the DON completed an all staff in-service for each shift, including nursing, activities, dietary, housekeeping, maintenance, and therapy on ensuring door alarms are functioning properly, visual checks of doors, and the new policy on the " Disengaging of Door Alarms. " * On 02/13/15, the facility completed the development of a new policy titled " Disengaging of Door Alarms. " This policy indicates staff will never disengage a door alarm for any reason. All staff will, on rounds throughout the day, visually check and verify doors are engaged at all times, noted by the red light indicating the door is locked. Staff will notify supervisor of any questions or concerns regarding alarmed doors immediately. * On 02/13/15 between 12:30 P.M. and 1:00 P.M., interviews with Licensed Practical Nurse (LPN) #22, State tested Nursing Assistant (STNA) #3, #4, and #5, Dietary Aide #1, and Housekeeper #1 revealed they were able to describe in detail the facility ' s " Disengaging of Door Alarms " policy and procedure. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing the new policy regarding the disengaging of door alarms and assessing the appropriateness of staff response to this newly developed policy. Findings Include: Review of Resident #1 ' s medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment completed 01/01/15 revealed the resident was identified to have impaired ability to make herself understood and to understand others, to have a visual impairment, and to have severe cognitive impairment. The resident was also assessed to express delusions, with wandering behaviors exhibited one to three days during a seven day period. The resident required extensive physical assistance of one person for locomotion on and off the unit and extensive physical assistance of two staff for transfers. The assessment identified the resident had unsteady balance while standing without staff assistance. Review of physician ' s orders revealed on 02/12/13 the physician ordered a Wander-guard bracelet (device which causes specific door alarms to sound and/or door to lock) to left ankle due to impaired cognitive ability. Review of Resident #1 ' s plan of care dated 03/20/13 revealed the resident had altered perception or awareness of surroundings and was an elopement risk. Interventions included staff intervention for unsafe decisions, give supervision for daily decision making, and monitoring the Wander-guard bracelet every shift and daily for function. Review of Resident #1 ' s comprehensive elopement assessment dated [DATE] noted the resident ' s elopement risk was unchanged and there was no change to the care plan. Review of nurses notes dated 02/01/15 at 10:45 A.M., entered as a late entry for an undetermined original time, documented the resident was sitting in a reclining chair in the south solarium with a sitter alarm in place. The resident had the alarm box in hand and turned the alarm off. The resident walked toward her room and walked out the exit door (southeast). At 10:30 A.M. the Director of Independent Living #1 reported the resident was found wandering on a community street and fell in a shrub. The resident ' s clothes were dry. The resident was wearing shoes, socks, pants and a long sleeve shirt. Emergency Medical Services (EMS) transported the resident to the hospital for evaluation. It was also noted the resident was toileted at 9:30 A.M. due to an incontinence episode. Review of the facility SRI investigation dated 02/01/15 revealed Resident #1 exited the building through an unalarmed door and sustained a fall. The resident was transferred to the hospital emergency room and no injuries were identified. Observation on 02/12/15 at 8:50 A.M. noted Resident #1 in her bed with an alarming floor mat alarm in place. The resident was unable to answer questions, utilizing head nods with inappropriate responses. The Wander-guard bracelet was observed in place to the ankle. Interview with Maintenance Director #1 on 02/12/15 at 9:00 A.M., revealed on 01/30/15 a contractor was completing testing of the facility alarm system. During this time it was suspected the exit door near Resident #1 ' s room was deactivated to complete testing, due to visual and audible alarms sounding. Maintenance Director #1 stated the facility does not have a monitoring policy or system in place to ensure the exit doors equipped with audible and visible alarms operate as designed. The only doors that are tested quarterly are the delay egress doors. Maintenance Director #1 then provided a fire alarm inspection report dated 01/30/15. The inspection report verified smoke detector testing was completed at the exit door by Resident #1 ' s room on 01/30/15. Interview with LPN #22 on 02/12/15 at 9:05 A.M. revealed on 02/01/15 she was assigned to care for Resident #1. LPN #22 recalled seeing the resident sitting in a recliner in the unit lounge between 9:45 A.M. and 10:00 A.M. At approximately 10:45 A.M. the Director of Independent Living #1 came into the facility and reported a family member of one of the independent living facility residents had observed Resident #1 fall into a bush outside an unoccupied independent living apartment. The resident had shut off a chair pressure alarm pad and left the building carrying the device. A count of residents at that time revealed Resident #1 was not found. LPN #22 went to the southeast door near the resident ' s room and proceeded outside. The exit door was equipped with an audible and visible alarm, which did not sound at the time. The sidewalks were covered with snow, and footprints were observed. LPN #22 verified the alarm on the exit door through which Resident #1 eloped had been deactivated at the time the resident was discovered missing. LPN #22 verified Resident #1 wore a Wander-guard bracelet due to her cognitive impairment and wandering/elopement behavior. Interview with the DON on 02/12/15 at 9:40 A.M., during a review of the investigation, revealed Resident #1 exited the building on 02/01/15 through the southeast door located near her room. The door was equipped with an alarm when opened, but was not a delay egress door. The door was not equipped to work with the Wander-guard bracelets. The DON indicated a contractor de-energized the alarming door on Friday 01/30/15. The DON verified the resident was found outside the facility near an independent living apartment. The DON verified Resident #1 was identified with severe cognitive impairment. Observation on 02/12/15 at 10:30 A.M. with Maintenance Director #1 noted the southeast exit door near the resident room was equipped with an audible and visible alarm. An attempt to exit the door to the outside activated an audible and visible alarm which sounded at the door and the cross corridor. A numbered key pad located next to the exit door indefinitely deactivated the door alarm when Maintenance Director #1 placed a specific number sequence into the key pad. The door was opened at that time and no alarm sounded or was visualized. The door alarm did not reset until Maintenance Director #1 reentered the numeric code on the control panel. Telephone Interview with Fire Alarm Contractor #1 on 02/12/15 at 12:15 P.M., verified he was in the facility conducting testing of the fire alarm system on 01/30/15. The contractor stated an unidentified staff member placed a code into the key pad next to the southeast exit door in order to de-energize the audible alarm. The contractor indicated once the testing of the fire alarm device (smoke detector) was concluded he went on to complete further testing through-out the facility. Fire Alarm Contractor #1 verified he did not observe a staff member re-activate the door alarm. Interview with Director of Independent Living #1 on 02/12/15 at 12:45 P.M., revealed on 02/01/15 at approximately 10:05 A.M., a resident in an independent living apartment activated his medical alert bracelet. It was reported a visiting family member of the resident in the Apartment was walking into the apartment and heard a noise. The family member observed a resident fall into shrubbery outside un-occupied Apartment #536, which was across the street. Director of Independent Living #1 then started from her home off campus to the site of the incident and instructed 911 to be contacted. Upon arrival at the scene, Independent Living Director #1 observed ambulance personnel arrive at the scene of Apartment #536 and they proceeded to take the resident into the unoccupied apartment. The resident was placed on the floor and assessed to have no visible injuries. The resident was dry, and dressed with shoes, socks, pants, shirt, and sweater. No coat, hat or gloves were observed on the resident. Director of Independent Living #1 verified on 02/01/15 at the time of the incident, snow had begun falling. An attempt to identify the resident at the time of the EMS transport was unsuccessful. The resident was subsequently transported by EMS to the hospital for evaluation. Director of Independent Living #1 then proceeded to the facility to communicate with facility staff what she observed. Review of the alarm activation ticket noted the independent living panic alarm pendent for the resident in the apartment was activated on 02/01/15 at 10:05:03 A.M. Review of EMS documentation dated 02/01/15 revealed the dispatch was notified of the incident at 10:08 A.M. and the EMS unit was on scene at 10:16 A.M. Narrative documentation noted EMS to be dispatched due to an individual falling at the residence and lying in bushes. The individual was confused, disoriented and unsure of her name. Upon arrival, the resident was confused and disoriented as to who, what, where, and why she was there. Resident #1 ' s skin was assessed to be cool and dry with no obvious sign of injury. At 10:36 A.M. the resident was loaded into the ambulance and transported to the hospital. The resident ' s identity was discovered while in route to the hospital. The ambulance arrived at the hospital at 10:54 A.M. Review of hospital emergency room documentation dated 02/01/15 at 10:57 A.M. noted comments stating the patient had wandered away from the skilled nursing facility (SNF) this morning. The patient was found at a nearby housing complex. She had fallen into the bushes without injury. A concern for hypothermia was noted. The resident ' s vital signs were temperature 97.5 degrees Fahrenheit, pulse 95, respirations 16, and blood pressure 132/74. No injury was identified with the patient ' s skin warm and dry. Further review of Resident #1 ' s medical record revealed the family was notified of the incident on 02/01/15 at 11:10 A.M. and the physician was notified of the event on 02/01/15 at 11:41 A.M. At 3:15 P.M. a nurses note documented the resident was returned to the facility and an assessment at that time identified no injuries. No new physician orders were received. Observation on 02/12/15 at 1:40 P.M. noted the distance from the southeast exit to the incident location was measured by car to be .10 of a mile (500 feet). The route traveled by Resident #1 was noted to be within a retirement community and along a residential street. Speed limit signage indicated the maximum speed limit to be 15 miles an hour. Review of the facility policy titled " Missing/Wandering Resident: Code Brown, " revised 04/19/11, revealed each exit door leading outside is equipped with an alarm. The alarm is triggered when an exit door is opened to alert staff to exiting persons. Interview with the DON on 02/12/15 at 2:00 P.M., verified Resident #1 was last observed on 02/01/15 at approximately 10:00 A.M. by LPN #22 in the lounge near the south dining room. The facility was made aware of the resident ' s status by Director of Independent Living #1 on 02/01/15 at approximately 10:40 A.M. The DON verified the alarm on the southeast exit door was de-activated on 01/30/15 and not re-activated until 02/01/15, following Resident #1 ' s unwitnessed elopement from the facility. The DON verified the facility elopement policy, revised on 04/19/11, indicated each exit door leading outside was equipped with an alarm. When an exit door was opened an alarm sounds to alert staff to an exiting person. The DON verified prior to 02/01/15, there was no monitoring of the alarms on the exit doors to ensure they were functioning properly. This deficiency substantiates Complaint Number OH 838.