Every finding on record at Falls Village Skilled Nursing & Rehabilitation

Based on observation, interview, and facility policy review, the facility failed to maintain a clean and sanitary kitchen area and maintain kitchen equipment in good working order. This had the potential to affect all residents receiving meals from the kitchen. The facility identified four residents (#1, #17, #78, and #98) as on a nothing by mouth (NPO) diet who did not receive food from the facility's kitchen. The facility census was 87.Findings include: Observation on 08/03/26 at 8:30 A.M. revealed the walk-in freezer had significant ice buildup on two boxes of nutritional supplement drinks. The ice buildup was below the freezer condenser unit. The main kitchen stove had dried drips and food debris on the front and sides. The floor surrounding the kitchen stove also had notable debris. Interview on 08/03/26 at 8:35 A.M. with [NAME] #573 confirmed findings in the freezer and on the kitchen stove and surrounding floor. Observation on 08/03/26 at 8:37 A.M. revealed a low-temperature dish machine in the main kitchen area. Dietary Aide #583 reported the dish machine was coming up to temperature however it was not running the sanitizer. Dietary Aide #583 reported he first noticed this issue the previous week on Wednesday. Dietary Aide #583 stated he had reported the issue to Dietary Manager #535 however the machine was still not working appropriately. Dietary Aide #583 reported he had been using the dish machine to wash dishes and had not been using an alternative method to sanitize. Dietary Aide #583 was observed to be actively using the dish machine to wash dishes from the morning's breakfast meal. Observed a container of chlorine sanitizer under the machine with the sanitizer hose connected. A chlorine sanitizer test strip was used to test sanitizer level with no reading of any sanitizer present. A follow up observation on 08/03/26 at 9:14 A.M. with Registered Dietitian (RD) #624 confirmed the dish machine sanitizer level was not within an acceptable range.Observation on 08/03/26 at 9:23 A.M. with RD #624 of the second-floor pantry area revealed a refrigerator with a dried spill that was brown in color. RD #624 confirmed the refrigerator was not kept in a clean manner and it needed cleaned.Review of facility policy Food Safety and Sanitation dated 2023 revealed food would be stored in a manner to be protected from contamination.Review of facility policy Cleaning Dishes/Dish Machine dated 2023 revealed all dishes and cookware would be cleaned, rinsed, and sanitized after each use. The dish machine would be checked prior to meals to assure proper functioning and appropriate cleaning and sanitizing. The low temperature dish machine shall reach a wash temperature of 120 degrees Fahrenheit and a final sanitization level of 50 parts per million (PPM) hypochlorite.This deficiency represents non-compliance investigated under Complaint Number 2973237.

Based on resident record review, resident interview, staff interviews, and facility policy review, the facility failed to implement resident care plans. This affected three residents (Resident #5, #15, #93) of four residents reviewed for care planning. The facility census was 87. 1. Review of the medical record for Resident #93 revealed she was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement, other specified disorders of synovium, left knee and chronic pain syndrome. Review of the facility dental summary treatment list dated 02/11/26 through 06/17/26 revealed Resident #93 was not listed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 had a Brief Interview for Mental Status (BIMS) score of 12 that indicated she was alert and oriented to person, place and time. Review of the MDS assessment revealed Resident #93 was impaired on both upper extremities, impaired on one side of lower extremities and dependent on staff for activities of daily living (ADLs). Review of the physician orders dated 06/17/25 revealed Resident #93 had in order in place to receive dentist services as needed. Review of the care plan dated 06/20/25 revealed Resident #93 had potential for discomfort related to oral status with interventions that included being free of mouth pain and arrange for dental consults as needed. Review of the progress note dated 06/24/26 at 7:17 P.M. revealed Resident #93 reported she had some tooth pain due to her tooth chipping. Review of the progress note dated 06/27/26 at 2:10 P.M. revealed Resident #93 complained of broken tooth that was making the side of her mouth sore. Resident #93 issues were recorded on communication for referral for dentist. Resident #93 had poor meal intake due to mouth pain. Review of the progress note dated 06/28/26 at 10:54 A.M. revealed Resident #93 complained of broken tooth that was making the side of her mouth sore. Resident #93 issues were recorded on communication for referral for dentist. Resident #93 had poor meal intake due to mouth pain. Review of the progress note dated 06/29/26 at 10:40 A.M. revealed Resident #93 received a new order for antibiotics related to possible tooth infection. Resident #93 complained of pain, swelling and difficulty eating. Registered Dietician (RD) #624 was made aware and diet changed to pureed. Review of the pain assessment dated [DATE], 06/27/26, 06/28/26, and 06/29/26 that correlated with Resident #93's voiced concerns of pain related to her tooth, revealed she had pain that reached a level of 8 out of 10. Resident #93's pain levels indicated acute pain that required medical treatment. Review of the list of scheduled residents to be examined dated 07/24/26 revealed Resident #93 was not listed to be seen for dental services, and no designated procedures were listed. Review of the dental visit summary dated 07/24/26 revealed Resident #93 was listed as being seen regarding limited oral evaluation with a recommendation to continue daily oral care. Review of the dental summary revealed no future treatments listed. Review of the dental visit summary and list of scheduled residents to be examined, both dated 07/24/26, revealed contradicted information. Resident #93 was not listed on the scheduled visit list with a designated procedure; however, she was listed as being examined on the dental visit summary. Review of the handwritten note provided by the Administrator revealed the next dental visit would occur on 12/07/26. Review of the dental visit document dated 07/24/26 revealed Resident #93 had a visit with the dentist regarding a broken tooth being [NAME] and cutting mouth. Review of the document revealed her tooth was smoothed to prevent further damage. Review of the document directed readers to review previous exam history for previous exams and conditions, however, there were no previous visits due to Resident #93 signed consents starting in March 2026. Interview on 08/03/26 at 9:27 A.M. with Resident #93 revealed she had a broken tooth that caused her a lot of pain. Resident #93 revealed it has taken a long time for her to be seen by the dentist and she was still waiting. Resident #93 revealed the facility altered her diet and put her on pureed textures to accommodate her tooth and/or mouth pain. Resident #93 revealed she did not know when she would be seen by the dentist. Interview on 08/04/26 at 3:31 P.M. with RD #624 revealed Resident #93 diet textures were downgraded to pureed diet and thin liquids due to her tooth pain. RD #624 revealed Resident #93 complained of pain and swelling and was subsequently placed on antibiotics for a tooth infection. RD #624 revealed he was not aware of Resident #93 dental visits. However, he did not see any upcoming visits scheduled. RD #624 confirmed and verified the above findings at the time of the interview. Interview on 08/05/26 at 7:25 A.M. with the Administrator revealed she had received dental service notes related to residents in the facility; however, Resident #93 notes were not available. The Administrator revealed she did not know or understand why Resident #93's visits were not added. The Administrator revealed she was unable to provide documentation regarding previous, current and future dental appointments and services provided for Resident #93. Interview on 08/05/26 at 9:52 A.M. with Licensed Practical Nurse (LPN) #527 revealed she was first made aware of Resident #93's tooth pain approximately 4 weeks ago. LPN #527 revealed Resident #93 tooth pain had worsened and after notifying her physician, she received a new order for an antibiotic for pain and infection. LPN #527 revealed she was not sure if she's been seen by the dentist or if she was on the list to be seen on the upcoming visit. LPN #527 revealed Resident #93 was placed on a boost supplement due to difficulty eating. LPN #527 revealed Resident #93 had a care plan related to dental services with interventions to follow when necessary. LPN #527 confirmed and verified the above findings at the time of the interview. Interview on 08/05/26 at 1:06 P.M. with the Administrator revealed she was unable to provide any requested documents to verify Resident #93's access to dental services, previous dental visits and procedures, and any upcoming dental appointments and/or services. The Administrator revealed the last dental visit was on 07/24/26, which was approximately a month after Resident #93's initial complaint of pain. The Administrator revealed residents had access to emergency dental services. The Administrator confirmed and verified the above findings at the time of the interview. Interview on 08/05/26 at 2:57 P.M. with Resident #93's husband revealed she was seen by the dentist after multiple complaints of pain and request to be seen. Resident #93's husband revealed her tooth was stabbing her tongue and initially the dentist canceled but came back the following week. Resident #93's husband revealed her diet had to be changed due to the issue with her tooth. Review of the facility document titled Comprehensive Person-Centered Care Plans revised March 2022, revealed the facility had a policy in place that care plans would be implemented to meet the physical, psychological, psychosocial, and functional needs of each resident. Review of the document revealed the facility did not implement the policy. 2. Review of the medical record for Resident #15 revealed an admission date of 12/30/25 and diagnoses including Alzheimer's disease, adjustment disorder with anxiety, and dementia without behavioral disturbance. Review of consulting psychiatrist note dated 01/31/26 revealed Resident #15 was displaying verbal and physical agitation and increased confusion and paranoia. Review of consulting psychiatrist note dated 03/06/26 revealed Resident #15 continued to experience nighttime agitation. Review of physician's order dated 03/09/26 revealed Resident #15 was ordered 5 milligrams (mg) Melatonin for insomnia. Review of consulting psychiatrist note dated 04/02/26 revealed Resident #15 was experiencing delusions, psychosis, and was picking at face which was a suspected behavior. Review of physician's order dated 04/08/26 revealed Resident #15 was ordered 125 mg Depakote sprinkles for agitation. Review of informed consent for use of psychotropic medication management form dated 04/08/26 revealed Rexulti was prescribed to target symptoms of dementia with agitation and psychosis, walking with no direction and agitation at times. Non-pharmacological interventions included redirection, offering food and beverages, monitoring, and encouraging activity participation. Review of resident care card dated 05/08/26 revealed Resident #15 had behavior symptoms of wandering and agitation. Behavior interventions included redirection, food and beverage, encourage activity and monitor when agitated. Review of physician's order dated 07/03/26 revealed Resident #15 was ordered 1 mg Rexulti for psychosis. Review of Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #15 had brief interview for mental status (BIMS) score of three indicating severe cognitive impairment. Resident #15 had behaviors including rejection of care and wandering. Review of the plan of care for Resident #15 revealed there had not been a comprehensive care plan developed to address behavioral health and dementia care needs with use of medications to limit symptoms. Interview on 08/06/26 at 10:10 A.M. with Director of Nursing (DON) reviewed and confirmed there was not a care plan developed to address Resident #15's behavioral and dementia care needs. Review of facility policy Behavioral Assessment, Intervention and Monitoring dated March 2019 revealed care plan will include a minimum description of behavioral symptoms - frequency, intensity, duration, outcomes, location, environment, and precipitating factors/situations, targeted interventions for behavioral/psychosocial symptoms, rationale for interventions, specific measurable goals, how staff to monitor for effectiveness. 3. Review of the medical record for Resident #5 revealed he was admitted to the facility on [DATE] with re-entry on 08/18/24 with diagnoses that included dependence on renal dialysis, left sided hemiplegia (severe or complete loss of motor function on one side of the body) and hemiparesis (weakness on one side of the body), diabetes mellitus type two, heart disease, weakness, reduced mobility, and convulsions. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 was moderately cognitively impaired, did not reject care, was dependent on staff for most activities of daily living (ADL's), was always incontinent of bowel and bladder, and required dialysis. Review of the resident care card dated 05/07/26 revealed Resident #5 needed total assistance with bathing, toileting, dressing, and transferring. Resident #5 required extensive assistance for grooming and bed mobility. Review of the care plan for Resident #5 revealed the absence of interventions related to the assistance required for personal hygiene, bathing, bed mobility, toileting, oral hygiene, and dressing. An interview on 08/06/26 at 10:03 A.M. with the Director of Nursing (DON) verified the above findings. Review of the facility policy titled Care Plans, Comprehensive Person-Centered, dated 04/2022 revealed a comprehensive care plan would be developed and implemented for resident's physical, psychosocial, and functional needs. The care plan was to include services provided to attain or maintain the resident's highest practicable well being and the interdisciplinary team were to review and update the care plan as needed.

Based on observation, interview, and facility policy review the facility failed to ensure hand hygiene and infection control standards were maintained during incontinence care for Resident #65 and during medication administration for two residents (#45 and #117) of seven residents reviewed for infection control. The facility census was 87.Findings include: 1. An observation on 08/05/26 at 1:17 P.M. of incontinence care of Resident #65 with Certified Nursing Assistant (CNA) #592 revealed CNA #592 wheeled a covered supply cart to the doorway of Resident #65's room. She introduced herself and explained the procedure to Resident #65. CNA #592 washed her hands and applied gloves. She then took a disposable absorbent pad, a pack of disposable wipes, and an incontinence brief and placed the folded absorbent pad directly onto the bedside table. CNA #592 put the other supplies on top of the pad and raised the height of the bed. CNA #592 then removed her gloves and put on a new pair without completing hand hygiene. CNA #592 started to remove the incontinence brief, stopped in order to grab a different size brief from the supply cart, removed her gloves, and then applied new gloves without completing hand hygiene. CNA #592 then removed the old incontinence brief, placed the package of wipes directly onto Resident #65's bed linens, and completed perianal care. CNA #592 placed a new incontinence brief, then removed the package of wipes off the bed. CNA #592 then removed her gloves and put on a new pair without completing hand hygiene. CNA #592 lowered the resident's height of the bed bed, removed her gloves, removed and tied the resident trash bag, and washed her hands. CNA #592 then took the package of wipes and unused absorbent pad and placed them back into the supply cart in the doorway.An interview on 08/05/26 at 1:29 P.M. with CNA #592 verified the lack of hand hygiene between glove applications and improper placement of supplies during incontinence care. Review of the facility policy titled Handwashing/Hand Hygiene, dated 08/2019 revealed hand hygiene was the primary way to prevent the spread of infection and staff were to follow hand hygiene procedures. Hand hygiene was to be completed before and after resident contact, after contact with intact resident skin, after removing gloves, and after contact with items in the immediate area of the resident.2. An observation on 08/05/26 at 8:34 A.M. of medication administration for Resident #117 with Registered Nurse (RN) #576 revealed Resident #117 had signage on his door indicating he was in enhanced barrier precautions. RN #576 cleansed her hands and dispensed the medications for Resident #117. RN #576 applied personal protective equipment (PPE) and carried the medications and a portable manual blood pressure cuff into the room. RN #576 applied the blood pressure cuff, removed the stethoscope from around her neck, and took Resident #117's blood pressure before administering his morning medications. RN #576 placed her stethoscope back around her neck, removed the blood pressure cuff, and then administered the medications. After completing the medication administration, RN #576 removed her PPE, sanitized her hands, and exited Resident 117's room. RN #576 placed the blood pressure cuff onto the medication cart and then immediately started dispensing medications for Resident #45. While dispensing medications for Resident #45, one tablet of Pregabalin 50 milligrams (mg) landed directly onto the medication cart; RN #576 applied a glove, picked up the medication and placed it into the medication cup, and then administered the medication to Resident #45.An interview on 08/05/26 at 9:52 A.M. with RN #576 verified the above findings.Review of the facility policy titled Administering Medications, dated 04/2019 revealed staff were to follow infection control procedures for the administration of medications.This deficiency represents non-compliance investigated under Complaint Number 2973237.

Based on record review, review of a photograph, and interview, the facility failed to serve foods at an appropriate texture for Resident #39 and Resident #124. This affected two residents (Resident #39 and #124) of four reviewed for nutrition. The facility census was 87. Findings include: 1. Review of the medical record for Resident #39 revealed he was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, type 2 diabetes and chronic obstructive pulmonary disease. Review of the physician orders dated 07/21/26 revealed an order to assist with ADLs and transfers as necessary. Review of the physician orders dated 07/22/26 revealed an order for Consistent Carbohydrate (CCHO) diet, pureed texture with thin consistency. Review of the speech therapy evaluation and plan of treatment notes dated 07/22/26 revealed had a history of decreased appetite, abnormal weight loss, and consuming pureed textures. Resident #39 presented with pharyngoesophageal dysphagia and placed on pureed diet and swallow precautions. Resident #39 also required assistance with feeding due to hand weakness. Review of the care plan dated 07/22/26 revealed Resident #39 was at nutritional risk related to a therapeutic diet with a mechanically altered texture, dysphagia and required therapy services with interventions that included assist with meals as necessary, speech therapy and providing diet as ordered. Review of the Comprehensive Medical Nutrition Therapy Assessment (CMNTA) dated 07/27/26 revealed Resident #39 was on a CCHO diet, pureed with thin liquids. Review of the CMNTA revealed he was being followed by speech therapy, had a history of dysphagia with coughing with meals and difficulty swallowing at times. Review of the CMNTA revealed he required assistance with meals. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had a Brief Interview for Metal Status (BIMS) score of 11 that indicated he was alert with some cognition impairment. Review of the MDS assessment revealed he had disorganized thinking, had impairment on both sides of his upper and lower extremities and was dependent on staff for activities of daily living (ADLs). Review of the progress note dated 07/27/26 at 9:44 P.M. revealed Resident #39 recently had trouble using his hands, a hard time feeding himself and was having his food pureed. Review of the speech therapy encounter (STE) note dated 07/23/26 revealed Resident #39 required feeding assistance due to significant weakness in both hands. Review of the skilled progress note assessment dated [DATE] revealed Resident #39 required substantial and/or maximum assist with eating. Observation on 08/03/26 at 9:30 A.M. revealed Resident #39 lying in bed with his bedside table positioned over him with his breakfast tray on top. Observation revealed a plate with scrambled eggs and sausage. The eggs were yellow with a soft texture, and the sausage was in a ground state. Resident #39 plate was barely touched with one scoop of sausage missing. Resident #39 was alone in his room without staff present. Interview on 08/03/26 at 9:32 A.M. with Resident #39 revealed his meal was not in a pureed state, and he couldn't chew or swallow it. Resident #39 stated I can't get it down. Puree is easier to swallow. Resident #39 revealed prior to his admission to the facility he used a straw for his meals at the hospital. Resident #39 also revealed he required some help with his meals, but staff had not helped him. Interview and observation on 08/03/26 at 9:34 A.M. with Registered Nurse (RN) #515 revealed Resident #39 required a pureed diet and confirmed it in his medical record in Point Click Care (PCC). RN #515 revealed Resident #39 also required assistance with his meals. Observation in Resident #39 room of his breakfast tray revealed scrambled eggs and a grounded-up sausage. RN #515 confirmed and verified Resident #39 breakfast meal was not in the pureed state, his meal ticket identifying meals in puree state and there were no staff assisting with his meal. Interview on 08/04/26 at 11:51 A.M. with the Director of Rehab (DOR) #500 revealed Resident #39 was currently receiving speech therapy for dysphagia, but he was unsure of any updates. DOR #500 revealed he started services on 07/22/26 and was fairly new to the facility. DOR #500 confirmed and verified the above findings at the time of the interview. Interview on 08/04/26 at 1:08 P.M. with the Speech Therapist (ST) #541 revealed Resident #39 was currently on a pureed diet with thin liquids and upon admission was a complete feed. ST #541 revealed he still had an order in place for assistance from staff with meals. ST #541 revealed she currently had concerns with the texture of his meals and had notified the kitchen staff many times. ST #541 revealed on 08/03/26 she had to send his lunch tray back to the kitchen due to his hamburger not in the pureed state. ST #541 revealed she recently had an issue with his breakfast tray that consisted of scrambled eggs and ground sausage that was not in pureed state. ST #541 confirmed and verified the above findings at the time of the interview. Interview on 08/04/26 at 3:31 P.M. with the Registered Dietician (RD) #624 revealed Resident #39 was recently admitted and was on pureed diet with thin liquids and required help with his meals. RD #624 revealed Resident #39 had an issue with his breakfast eggs not being in the correct puree form. RD #624 confirmed and verified the above findings at the time of the interview. 2. Review of the closed medical record for Resident #124 revealed an admission date of 01/31/25 with diagnoses including adjustment disorder, altered mental status, and vascular dementia. Resident #124 expired on 08/16/25. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #124 had moderate cognitive impairment. Review of the physician's orders for Resident #124 identified an order for consistent carbohydrate diet with mechanical soft texture effective 02/03/25 and discontinued 03/18/25. Review of photographs from Former Certified Nursing Assistant (CNA) #700's personal cell phone revealed there was a photograph of a meal tray with a piece of paper dated February 15th (the year was not visible) that indicated Resident #124 was ordered a mechanical soft texture with ground meats. The tray of food consisted of creamed corn, rice, chicken with peppers and onions, and tortillas. On 08/04/26 at 1:15 P.M., an interview with Speech Language Pathologist (SLP) #541 confirmed the photo of Resident #124's tray did not represent a mechanical soft diet and verified the tray ticket visible in photo indicated Resident #124 was on mechanical soft texture with ground meats. SLP #541 said they should not have been served tortillas, the meat should have been more ground up, and further stated if she had seen a tray like that she would have taken it back to the kitchen. This deficiency represents non-compliance investigated under Complaint Number 2973237.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure Resident #43 was provided a palatable, warm meal following dialysis services. This finding affected one (Resident #43) of two residents reviewed for dialysis services. The facility census was 87. Findings include:Review of Resident #43's medical record revealed the resident was admitted on [DATE] with diagnoses including end stage renal disease with dependence on renal dialysis, chronic obstructive pulmonary disease and hypertension.Review of Resident #43's nutritional care plan revealed an intervention dated 05/06/26 to honor food preferences.Review of Resident #43's physician orders revealed an order dated 05/06/26 for a consistent carbohydrate ([NAME]), renal diet with a regular texture and thin consistency; and an order dated 06/29/26 for dialysis on Monday, Wednesday and Friday with a chair time of 9:15 A.M.Review of Resident #43's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Interview on 08/05/26 at 9:00 A.M with Resident #43 revealed his lunch meal tray was always sitting on his overbed table because staff delivered the tray while he was in dialysis on Mondays, Wednesdays, and Fridays and the food was always cold. Observation on 08/05/26 at 12:12 P.M. revealed Resident #43 was in dialysis. His meal tray was sitting on his overbed table and the resident's door was closed.Observation on 08/05/26 at 1:00 P.M. revealed Resident #43 was in dialysis and the resident's lunch meal was sitting on the resident's overbed table with the door closed.Observation on 08/05/26 at 1:06 P.M. revealed an unknown staff member come out of Resident #43's room. The unknown staff member did not come out of the resident's room with a meal tray.Observation on 08/05/26 at 1:14 P.M. revealed Resident #43 was still not in his room. The lunch meal tray was still sitting on the overbed table.Observation on 08/05/26 at 1:45 P.M. revealed Resident #43 was in dialysis and the resident's lunch tray was sitting on the overbed table.Observation on 08/05/26 at 1:50 P.M. with Transportation #627 revealed Resident #43 was returned to the resident's room following dialysis. The meal tray was vegetables and turkey tetrazzini, pound cake, and a grape and cranberry cocktail.Interview on 08/05/26 at 1:59 P.M. with Licensed Practical Nurse (LPN) #514 revealed the resident wanted his meal heated up. The nurse stated she did not know about the time frame and the resident stated he did not want to eat cold food.Review of the Therapeutic Diets policy revised 10/17 revealed therapeutic diets were prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.This deficiency represents non-compliance investigated under Master Complaint Number 3044343.

Based on record review, interview, and facility policy review, the facility failed to ensure medications were timely obtained and available for administration as ordered. This affected one resident (#93) of five residents reviewed for medication administration. The facility census was 87. Findings include: Review of the medical record for Resident #93 revealed she was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement, other specified disorders of synovium, left knee and chronic pain syndrome.Review of the care plan dated 06/20/25 revealed Resident #93 was prescribed an opioid for pain management with interventions that included to administer mediations as ordered.Review of the physician orders dated 12/08/25 revealed an order for Hydrocodone-Acetaminophen (Norco, an oral opioid pain medication) 7.5-325 milligram (mg) to give one tablet by mouth every six hours routinely for pain, scheduled for administration daily at 12:00 A.M., 6:00 A.M, 12:00 P.M., and 6:00 P.M.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 had a Brief Interview for Mental Status (BIMS) score of 12 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #93 had impairments to both upper extremities, one side of her lower extremities, and was dependent on staff for activities of daily living. Review of the progress note dated 05/06/26 at 9:11 P.M. revealed a call was placed to the pharmacy to reorder Resident #93's Norco (Hydrocodone-Acetaminophen) and was informed that a new script was needed. Review of the progress note revealed Resident #93 did not have enough medication to last until the morning, and her physician said she would call in a new script.Review of the progress note dated 06/06/26 at 5:06 A.M. revealed Resident #93 had no current script for Norco.Review of the progress note dated 06/06/26 at 12:50 P.M. revealed Resident #93 had no current script for Norco and the medication was still unavailable.Review of the progress note dated 06/06/26 at 12:58 P.M. revealed Resident #93 was still waiting on a script for Norco and the medication was not available.Review of the progress note dated 06/06/26 at 5:04 P.M. revealed Resident #93 was still waiting on script for Norco.Review of the progress note dated 06/07/26 at 8:08 A.M. revealed Resident #93 was still waiting on script for Norco.Review of the progress note dated 06/07/26 at 8:09 P.M. revealed Resident #93 was still waiting on script for Norco.Review of the progress note dated 06/07/26 at 12:02 P.M. revealed Resident #93 was still waiting on script for Norco to be faxed over.Review of the progress note dated 06/07/26 at 5:59 P.M. revealed Resident #93 was still waiting on script for Norco and the medication was unavailable.Review of the progress note dated 06/08/26 at 2:53 A.M. revealed Resident #93 was still waiting on script for Norco to be sent over by the physician.Review of the progress note dated 06/08/26 at 5:40 A.M. revealed Resident #93 was unable to receive medication [Norco] due to waiting for the physician to send over script.Review of the progress note dated 06/08/26 at 12:27 P.M. revealed Resident #93 was waiting for the script to be delivered.Review of Resident #93's pain monitoring, dated 06/06/26 to 06/08/26, revealed she had pain levels that ranged from four to seven on a one to ten scale (a pain rating scale with ten being the worst possible pain imaginable) on the days the facility did not have her pain medication available for administration.Review of the care conference note dated 06/25/26 at 9:13 A.M. revealed Resident #93's daughter requested the facility refill her pain medication prior to the weekend so that it doesn't run out.Review of the progress note dated 07/09/26 at 6:21 A.M. revealed Resident #93 Norco was on order.Review of the progress note dated 07/09/26 at 10:54 A.M. revealed Resident #93 was waiting for the pharmacy to send her Norco.Review of the progress note dated 07/09/26 at 2:42 P.M. revealed Resident #93 was waiting for the pharmacy to send her Norco.Review of the progress note dated 07/09/26 at 7:36 P.M. revealed Resident #93 was waiting for the pharmacy to send her Norco.Review of Resident #93's pain monitoring, dated 07/09/26, revealed she had a pain level of seven on a one to ten scale on the day the facility did not have her pain medication in place.Review of the progress note dated 07/25/26 at 1:38 A.M. revealed Resident #93's Norco was unavailable and not in the Cubex (a medication dispensing cabinet used to securely store and track medications).Review of Resident #93's pain monitoring, dated 07/25/26, revealed she had pain levels that ranged from a two to an eight on a one to ten scale on the day the facility did not have her pain medication in place.Interview on 08/03/26 at 9:27 A.M. with Resident #93 revealed she had constant pain and the facility did not administer her Norco every six hours as ordered and never ordered it in a timely manner.Interview on 08/05/26 at 9:52 A.M. with Licensed Practical Nurse (LPN) #527 revealed Resident #93 was on pain medication and sometimes the facility did not have it to administer due to the pharmacy not having it and the facility not having it on hand as backup. LPN #527 revealed sometimes the physician and the pharmacy had issues with refilling the script, but she did not know why. LPN #527 confirmed and verified the above findings at the time of the interview.Interview on 08/06/26 at 1:48 P.M. with the Director of Nursing (DON) revealed the facility relied on the pharmacy to refill scripts, and it was hard to keep up with Resident #93's dosage. The DON stated, when the script runs out, it's out of our control, we don't control what they do. The DON revealed the facility has run out of Resident #93's script and it was unavailable in the facility Cubex as well. The DON confirmed and verified the above information at the time of the interview.Review of the facility document titled Administering Medications revised April 2019, revealed the facility had a policy in place to administer medications as ordered, including within ordered timeframes.

Based on observations, resident record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure Resident #39 received adequate assistance with eating and failed to provide meals in the prescribed pureed texture to maintain the resident's nutritional status. This affected one resident (Resident #39) of one resident reviewed for nutrition. The facility census was 87. Review of the medical record for Resident #39 revealed he was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, type 2 diabetes and chronic obstructive pulmonary disease. Review of the physician orders dated 07/21/26 revealed an order to assist with ADLs and transfers as necessary. Review of the physician orders dated 07/22/26 revealed an order for Consistent Carbohydrate (CCHO) diet, pureed texture with thin consistency. Review of the speech therapy evaluation and plan of treatment notes dated 07/22/26 revealed had a history of decreased appetite, abnormal weight loss, and consuming pureed textures. Resident #39 presented with pharyngoesophageal dysphagia and placed on pureed diet and swallow precautions. Resident #39 also required assistance with feeding due to hand weakness. Review of the care plan dated 07/22/26 revealed Resident #39 was at nutritional risk related to a therapeutic diet with a mechanically altered texture, dysphagia and required therapy services with interventions that included assist with meals as necessary, speech therapy and providing diet as ordered. Review of the Comprehensive Medical Nutrition Therapy Assessment (CMNTA) dated 07/27/26 revealed Resident #39 was on a CCHO diet, pureed with thin liquids. Review of the CMNTA revealed he was being followed by speech therapy, had a history of dysphagia with coughing with meals and difficulty swallowing at times. Review of the CMNTA revealed he required assistance with meals. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had a Brief Interview for Metal Status (BIMS) score of 11 that indicated he was alert with some cognition impairment. Review of the MDS assessment revealed he had disorganized thinking, had impairment on both sides of his upper and lower extremities and was dependent on staff for activities of daily living (ADLs). Review of the progress note dated 07/27/26 at 9:44 P.M. revealed Resident #39 recently had trouble using his hands, a hard time feeding himself and was having his food pureed. Review of the speech therapy encounter (STE) note dated 07/23/26 revealed Resident #39 required feeding assistance due to significant weakness in both hands. Review of the skilled progress note assessment dated [DATE] revealed Resident #39 required substantial and/or maximum assist with eating. Observation on 08/03/26 at 9:30 A.M. revealed Resident #39 lying in bed with his bedside table positioned over him with his breakfast tray on top. Observation revealed a plate with scrambled eggs and sausage. The eggs were yellow with a soft texture, and the sausage was in a ground state. Resident #39 plate was barely touched with one scoop of sausage missing. Resident #39 was alone in his room without staff present. Interview on 08/03/26 at 9:32 A.M. with Resident #39 revealed his meal was not in a pureed state, and he couldn't chew or swallow it. Resident #39 stated I can't get it down. Puree is easier to swallow. Resident #39 revealed prior to his admission to the facility he used a straw for his meals at the hospital. Resident #39 also revealed he required some help with his meals, but staff had not helped him. Interview and observation on 08/03/26 at 9:34 A.M. with Registered Nurse (RN) #515 revealed Resident #39 required a pureed diet and confirmed it in his medical record in Point Click Care (PCC). RN #515 revealed Resident #39 also required assistance with his meals. Observation in Resident #39 room of his breakfast tray revealed scrambled eggs and a grounded-up sausage. RN #515 confirmed and verified Resident #39 breakfast meal was not in the pureed state, his meal ticket identifying meals in puree state and there were no staff assisting with his meal. Interview on 08/04/26 at 11:51 A.M. with the Director of Rehab (DOR) #500 revealed Resident #39 was currently receiving speech therapy for dysphagia, but he was unsure of any updates. DOR #500 revealed he started services on 07/22/26 and was fairly new to the facility. DOR #500 confirmed and verified the above findings at the time of the interview. Interview on 08/04/26 at 1:08 P.M. with the Speech Therapist (ST) #541 revealed Resident #39 was currently on a pureed diet with thin liquids and upon admission was a complete feed. ST #541 revealed he still had an order in place for assistance from staff with meals. ST #541 revealed she currently had concerns with the texture of his meals and had notified the kitchen staff many times. ST #541 revealed on 08/03/26 she had to send his lunch tray back to the kitchen due to his hamburger not in the pureed state. ST #541 revealed she recently had an issue with his breakfast tray that consisted of scrambled eggs and ground sausage that was not in pureed state. ST #541 confirmed and verified the above findings at the time of the interview. Interview on 08/04/26 at 3:31 P.M. with the Registered Dietician (RD) #624 revealed Resident #39 was recently admitted and was on pureed diet with thin liquids and required help with his meals. RD #624 revealed Resident #39 had an issue with his breakfast eggs not being in the correct puree form. RD #624 confirmed and verified the above findings at the time of the interview. This deficiency represents non-compliance investigated under Complaint Number 2973237.

Based on record review and interview, the facility failed to ensure Resident #114's baseline care plan was developed within 48-hours of the resident's admission to include the initial goals of the resident, a summary of the resident's medications and dietary instructions, as well as services and treatments to be administered by the facility, and personnel acting on behalf of the facility with a summary of the baseline care plan provided to the resident and their representative. This finding affected one (Resident #114) of one resident reviewed for care planning. The facility census was 87. Findings include:Review of Resident #114's medical record revealed the resident was admitted on [DATE] and discharged on 06/08/26 with diagnoses including diabetes, chronic diastolic congestive heart failure and end stage renal disease with dialysis services. Review of Resident #114's medical record revealed the resident's husband was the power-of-attorney (POA) for healthcare. The POA documentation was dated 01/24/26 and uploaded into the facility's records on 05/18/26.Review of Resident #114's admission Assessment/Baseline Care Plan dated 05/19/26 and locked on 05/21/26 revealed the resident was interviewed regarding medications, pain, dietary needs, urinary continence, bowel continence, special treatments, skin condition, discharge arrangements, and activities.Review of Resident #114's admission 5-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment.Review of Resident #114's signed baseline care plan conference meeting dated 05/26/26 revealed the resident, two family members, Activities Staff #510, Licensed Practical Nurse (LPN) MDS #512, Prior Social Service Designee (SSD) #642 and the Administrator attended the care conference.Interview on 08/04/26 at 8:28 A.M. with the Administrator revealed she was unaware of why Resident #114's baseline care plan conference meeting was held on 05/26/26 when the resident was admitted on [DATE] and the baseline care plan was to be completed within 48 hours (by 05/21/26).Telephone interview on 08/04/26 at 10:32 A.M. with Prior SSD #642 revealed she didn't conduct Resident #114's baseline care conference plan meeting for seven days because she didn't think the resident could make it to the care conference. Prior SSD #642 confirmed she did not conduct the necessary 48-hour care plan conference meeting as required.Interview on 08/06/26 at 1:21 P.M. with Registered Nurse (RN) Regional #646 revealed the resident was her own person and the husband was the POA. RN Regional #646 confirmed the resident had moderate cognitive impairment but was able to answer the questions on the baseline care plan and the full care plan included the husband's input seven days later during the care conference. RN Regional #646 stated she felt the facility had followed the regulatory guidelines when interviewing the resident for her baseline care planning needs during admission.Review of the Baseline Care Plan policy revised 03/2022 revealed a baseline plan of care to meet the resident's immediate health and safety needs was developed for each resident within 48 hours of admission. The resident and/or representative were provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but was not limited to the stated goals and objectives of the resident; a summary of the resident's medications and dietary instructions; any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and any updated information based on the details of the comprehensive care plan, as necessary. Provision of the summary to the resident and/or resident representative was documented in the medical record.Review of the State Operations Manual Appendix PP dated 07/23/25 revealed a resident representative means any of the following including an individual chosen by the resident to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications. A person authorized by State or Federal law to act on behalf of the resident in order to support the decision-making process; a legal representative or a court appointed guardian or conservator of a resident. This deficiency represents non-compliance investigated under Complaint Number 3044343.

THE FOLLOWING SURVEY FINDINGS PERTAINS TO AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of photographs, review of personnel file, and interview, the facility failed to prevent staff from taking photographs of residents and resident personal information on their personal cellular devices. This affected four residents (#75, #124, #125, and #126) of four reviewed for privacy. The facility census was 87. Findings include:1. Review of the medical record for Resident #75 revealed an admission date of [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, vascular dementia, major depressive disorder, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #75 had no cognitive impairment. Review of photographs from Former Certified Nursing Assistant (CNA) #700's personal cell phone revealed there was a photograph of Resident #75 sitting in bed with a meal tray in front of him that had a piece of paper with his name and room number visible. On [DATE] at 1:44 P.M., an interview with the Administrator verified photos of residents and resident personal information from Former CNA #700's personal cell phone. On [DATE] at 2:00 P.M., an interview with the Director of Nursing (DON) verified the content of the photos. DON said there was a domestic issue that was going on and she was not even sure Former CNA #700 willingly sent those photos via text message, however, DON did confirm the photos were still on the phone regardless of whether they were willingly shared or not. On [DATE] at 2:08 P.M., an interview with Human Resources (HR) Director #701 and Regional Director #640 stated CNAs were allowed to take pictures on their phones of residents with their consent to show that they were repositioned or to document concerns that were then forwarded to the DON. Regional Director #640 said the CNAs were supposed to delete the photos after they were communicated to their supervisor. HR Director #701 confirmed the write up for Former CNA #700's improper cell phone use was related to retaining those pictures of residents and resident personal information. Regional Director #640 said their legal team was involved and determined a violation of the Health Insurance Portability and Accountability Act (HIPAA) occurred. 2. Review of the closed medical record for Resident #124 revealed an admission date of [DATE] with diagnoses including adjustment disorder, altered mental status, and vascular dementia. Resident #124 expired on [DATE]. Review of the quarterly MDS assessment dated [DATE] indicated Resident #124 had moderate cognitive impairment. Review of photographs from Former CNA #700's personal cell phone revealed there was a photograph of a meal tray with a piece of paper visible that included Resident #124's name, room number, and therapeutic diet order. On [DATE] at 1:44 P.M., an interview with the Administrator verified photos of residents and resident personal information from Former CNA #700's personal cell phone. On [DATE] at 2:00 P.M., an interview with the DON verified the content of the photos. DON said there was a domestic issue that was going on and she was not even sure Former CNA #700 willingly sent those photos via text message, however, DON did confirm the photos were still on the phone regardless of whether they were willingly shared or not. On [DATE] at 2:08 P.M., an interview with HR Director #701 and Regional Director #640 stated CNAs were allowed to take pictures on their phones of residents with their consent to show that they were repositioned or to document concerns that were then forwarded to the DON. Regional Director #640 said the CNAs were supposed to delete the photos after they were communicated to their supervisor. HR Director #701 confirmed the write up for Former CNA #700's improper cell phone use was related to retaining those pictures of residents and resident personal information. Regional Director #640 said their legal team was involved and determined a violation of the Health Insurance Portability and Accountability Act (HIPAA) occurred. 3. Review of the closed medical record for Resident #125 revealed an admission date of [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, and vascular dementia. Resident #125 expired on [DATE]. Review of the quarterly MDS assessment date [DATE] indicated Resident #125 had severe cognitive impairment. Review of photographs from Former CNA #700's personal cell phone revealed there were three photographs of Resident #125 including one photograph that was a side by side with Resident #125 on the left and a fictional character with scaly skin and sharp pointy teeth on the right side. On [DATE] at 1:44 P.M., an interview with the Administrator verified photos of residents and resident personal information from Former CNA #700's personal cell phone. On [DATE] at 2:00 P.M., an interview with the DON verified the content of the photos. DON said there was a domestic issue that was going on and she was not even sure Former CNA #700 willingly sent those photos via text message, however, DON did confirm the photos were still on the phone regardless of whether they were willingly shared or not. On [DATE] at 2:08 P.M., an interview with HR Director #701 and Regional Director #640 stated CNAs were allowed to take pictures on their phones of residents with their consent to show that they were repositioned or to document concerns that were then forwarded to the DON. Regional Director #640 said the CNAs were supposed to delete the photos after they were communicated to their supervisor. HR Director #701 confirmed the write up for Former CNA #700's improper cell phone use was related to retaining those pictures of residents and resident personal information. Regional Director #640 said their legal team was involved and determined a violation of the Health Insurance Portability and Accountability Act (HIPAA) occurred. 4. Review of the closed medical record for Resident #126 revealed an admission date of [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, dependence on wheelchair, second degree burns, and end stage renal disease. Resident #126 discharged to home on [DATE]. Review of the discharge MDS assessment dated [DATE] indicated Resident #126 had no cognitive impairment. Review of photographs from Former CNA #700's personal cell phone revealed there was one photograph of Resident #126's electronic medical record that displayed his photograph, full name, date of birth , room number, gender, physician's name, medication allergy, and code status. On [DATE] at 1:44 P.M., an interview with the Administrator verified photos of residents and resident personal information from Former CNA #700's personal cell phone. On [DATE] at 2:00 P.M., an interview with the DON verified the content of the photos. DON said there was a domestic issue that was going on and she was not even sure Former CNA #700 willingly sent those photos via text message, however, DON did confirm the photos were still on the phone regardless of whether they were willingly shared or not. On [DATE] at 2:08 P.M., an interview with HR Director #701 and Regional Director #640 stated CNAs were allowed to take pictures on their phones of residents with their consent to show that they were repositioned or to document concerns that were then forwarded to the DON. Regional Director #640 said the CNAs were supposed to delete the photos after they were communicated to their supervisor. HR Director #701 confirmed the write up for Former CNA #700's improper cell phone use was related to retaining those pictures of residents and resident personal information. Regional Director #640 said their legal team was involved and determined a violation of the Health Insurance Portability and Accountability Act (HIPAA) occurred. On [DATE] at 1:51 P.M., an interview with the Administrator confirmed the four residents whose faces or personal information were in the photos on Former CNA #700's cell phone included Resident #126's electronic health record with personal information was visible. Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of [DATE]:-[DATE] CNA #700 was suspended pending investigation.-[DATE] Added concern with photographs to Quality Assurance (QA) for review.-[DATE] to [DATE] CNA #700 was interviewed regarding the photographs on her phone.-[DATE] CNA #700 received written disciplinary action for violating the facility's cell phone policy.-[DATE] The facility's legal team was notified of the allegation of a HIPAA violation.-[DATE] to [DATE] The facility's legal team conducted an investigation.-[DATE] Reviewed by QA committee.-[DATE] to [DATE] Audits conducted by the Director of Nursing or designee to ensure cell phone policy compliance.-[DATE] to [DATE] staff educated by the Director of Nursing or designee regarding cell phone policy.-[DATE] to [DATE] staff follow up and interviews regarding cell phone policy education and compliance. This deficiency represents non-compliance investigated under Complaint Number 2584911.

Based on record review, interview, and policy review the facility failed to ensure pain relieving medications were available to administer as ordered. This affected one (Resident #72) of three residents reviewed for medications. Findings include: Review of the medical record for Resident #72 revealed an admitted [DATE]. Resident #72 had a discharge date of [DATE]. Diagnoses included primary osteoarthritis, malignant neoplasm of the bladder, cervicalgia, anxiety disorder and pain, unspecified. Review of physician order dated 01/25/25 revealed Resident #72 was to receive belbuca buccal film 150 micrograms, one patch every 12 hours for chronic pain. The order had no stop date. Review of the admission medication list revealed Resident #72 was admitted with a seven-day supply of the belbuca film. Review of the plan of care dated 01/27/25 revealed Resident #72 could experience altered comfort. Interventions included to administer analgesic medications as ordered and encourage the resident to notify staff at the onset of pain. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/31/25, revealed Resident #72 had intact cognition, required moderate assistance with activities of daily living, and was on a pain management regimen program. Review of the facility Pain Assessment Tool dated 01/31/25 revealed Resident #72 was in constant pain. Review of the medication administration record (MAR) for February 2025 noted Resident #72 did not receive the belbuca buccal medication on 02/01/25 and 02/02/25. The MAR indicated Resident #72 received 1000 milligrams of acetaminophen on 02/01/25 for a pain level of 10 out of 10. Further review revealed documentation Resident #72's pain level went down to five out of ten after the administration of the acetaminophen. Review of the nurse progress note dated 02/01/25 timed 10:18 P.M. revealed the belbuca buccal film was not available. Review of the nurse progress note dated 02/02/25 timed 8:20 A.M. noted the facility was waiting on the pharmacy to deliver the belbuca buccal film. Interview on 05/02/25 at 9:32 A.M. with Resident #72 revealed he was receiving the belbuca buccal medication twice a day from 01/24/25 to 01/31/25. Resident #72 stated he went two days without the belbuca medication because the facility would not refill the order. Resident #72 stated he spoke to a day shift nurse on 02/01/25 regarding the belbuca medication and the nurse told him the belbuca was ordered and awaiting pharmacy delivery. Resident #72 said he told the nurses that he was in pain and spoke with three additional nurses from 02/01/25 through 02/02/25 who stated the belbuca medication was ordered and they were waiting for the delivery. Interview on 05/02/25 at 12:28 P.M. with Nurse Practitioner (NP) #205 revealed staff did not inform her of the need to refill the belbuca pain medication for Resident #72. NP #205 stated the facility was in contact with her and the primary physician frequently due to other medical concerns for Resident #72 so she was not sure why staff did not ask for a refill. Interview on 05/02/25 at 12:33 P.M. with the pharmacist that provided medication for the facility revealed the facility did not contact the pharmacy to refill the order for belbuca pain medication. Review of the facility policy Pain-Clinical Protocol, dated 2022 revealed the physician would order appropriate non-pharmacologic and medication interventions to address an individual's pain. This deficiency represents non-compliance investigated under Complaint Number OH00162692.

Based on record review, interview, review of a facility self-reported incident (SRI) and review of the facility policy, the facility failed to ensure staff treated Resident #49 in a respectful and dignified manner during incontinence care. This affected one resident (#49) of three residents reviewed for abuse. The facility census was 71. Findings include: Record review revealed Resident #49 had diagnoses including chronic respiratory failure with hypoxia, emphysema, chronic obstructive pulmonary disease, pleural effusion, obstructive sleep apnea and use of continuous positive airway pressure (CPAP) nasal device, polyosteoarthritis, high blood pressure, buttock open wound, contact dermatitis, fatigue, right shoulder pain, depression, anxiety, diabetes mellitus, chronic kidney disease, bilateral eye disease with blindness in one eye, spondylosis (degeneration of the vertebra due to the general wear and tear caused due to the process of aging) of lumbar region with intervertebral disc degeneration. Resident #49's plan of care initiated on 10/29/23 revealed the resident had impaired self-care for activities of daily living (ADL). Interventions on the plan of care indicated to allow the resident the time needed to complete tasks, assemble all equipment/materials necessary for resident to accomplish ADL task and provide assistance as needed. A plan of care also revealed the resident had bladder incontinence with interventions including to provide assistance with toileting promptly in advance of need to void as much as possible and provide incontinence care with good perineal care and apply moisture barrier cream after each incontinence episode. Resident #49's Minimum Data Set (MDS) Significant Change assessment dated [DATE] revealed the resident required (staff) assistance with toileting, bathing, dressing, mobility including transfer to the toilet, and used a walker for ambulation. The MDS assessment dated [DATE] indicated Resident #49 was always incontinent of bowel and bladder. During an interview with Resident #49 on 12/11/24 at 11:25 A.M. the resident shared a concern she had with a staff member. The resident revealed Certified Nursing Assistant (CNA) #73 had an attitude as soon as she answered her call light. Resident #49 stated she needed assistance with incontinence care. Resident #49 stated she left the bathroom light on for the staff to see and asked that they not turn on her overhead light because it hurt her eyes due to her eye disease. Resident #49 stated she asked CNA #73 to turn off the overhead light which she refused. Resident #49 asked CNA #73 to use a hot soapy washcloth to clean her perineal area after she was incontinent of urine. The resident stated CNA #73 grabbed the cold disposable wipes and started to clean her perineal area with the cold wipes. Resident #49 stated CNA #73 grabbed her headphones out of her hand after she roughly pulled the pillow out from under her head. Resident #49 stated she became angry because of the way CNA #73 was treating her and asked her to leave the room. CNA #73 refused to leave because she told her she was the staff member who was assigned to provide care for her. Resident #49 stated she then pushed her call light two or three times and CNA #73 promptly turned off the call light and informed Resident #49 she would assist her with her care needs. Resident #49 eventually started yelling for help, and CNA #73 finally left the room. An interview with CNA #73 on 12/17/24 at 4:50 P.M. revealed she had entered Resident #49's room to provide incontinence care on 10/20/24 in the evening. CNA #73 stated she encouraged Resident #49 to walk to the bathroom because she believed she was perfectly capable of using the toilet instead of the bedpan. Resident #49 refused, and CNA #73 stated she asked Resident #49 to turn on her side so she could clean her perineal area. CNA #73 tried to reposition Resident #49's pillow for comfort when Resident #49 accused her of being rough during the task and asked her to leave the room. The CNA reported Resident #49 then became verbally abusive calling her derogatory names. CNA #73 stated she noticed Resident #49's headphones were tangled up in her oxygen tubing and was attempting to untangle them while Resident #49 was grabbing her arm. CNA #73 stated during the task after Resident #49 asked her to leave the room, Resident #49 pushed her call light a couple times and CNA #73 stated she turned off the call light because she was the staff member who was supposed to provide care for Resident #49. CNA #73 stated she eventually left the room to allow Resident #49 to use the bedpan after she stated she needed to have a bowel movement. CNA #73 stated she notified the charge nurse of what happened with Resident #49. CNA #73 stated she completed a witness statement and after the charge nurse notified the Director of Nursing (DON) she was sent home pending the outcome of the investigation. CNA #73 stated approximately one week later she was terminated because a customer had made a complaint about her, and she was still in the 90 day probation period. A review of the facility's SRI dated 10/20/24, tracking number 253136, revealed the facility reported this incident involving Resident #49 as an allegation of abuse. The SRI included Resident #49 reported CNA #73 entered her room to assist her to the restroom. Upon entering, Resident #49 insisted that she was not able to get up to use the restroom. CNA #73 encouraged Resident #49 to get up to go to the restroom instead of utilizing the bed pan. Resident #49 became agitated by CNA #73 stating that she can't tell her what she can and can't do. During this time, Resident #49 began turning on her call light multiple times for someone else to assist her. CNA #73 turned off the call light, as she was there to assist the Resident #49. CNA #73 and Resident #49 then noted that the resident's headphones cord was tangled in the resident's continuous positive airway pressure (CPAP) cord. CNA #73 reported attempting to untangle the cords for the resident, but the resident was agitated with the staff member and grabbed CNA #73's arm. Resident #49 also reported grabbing the CNA #73's arm, and CNA #73 then grabbed Resident #49's arm. CNA #73 stated that she told the resident not to grab her, removed her hand and left the room. CNA #73 was issued education and disciplinary action for customer service. Based on facility review of staff statements, like-resident statements and the resident's medical record, the facility unsubstantiated the allegation of physical abuse. An interview with the Administrator on 12/17/24 at 1:38 P.M. revealed the facility had submitted an SRI to the State agency (as noted above) related to Resident #49 and an allegation of physical abuse. The Administrator stated the facility conducted an investigation and felt no abuse had occurred, but CNA #73 failed to meet the facility's expectations for customer service. The Administrator stated CNA #73 had only worked in the facility for a short time, had been trained extensively during her orientation to the facility, but lacked customer service skills. The Administrator stated CNA #73 was unwilling to meet the facility's expectations for customer service. The Administrator indicated CNA #73 had a preference for the way her workday should be organized to complete her job duties. In addition, the Administrator stated CNA #73 was trying to assist Resident #49 to the best of her ability but was not communicating well with Resident #49. During the interview the Administrator verified the above findings. The facility undated policy titled How to Provide Excellent Customer Service Staff and Resident Interactions included: Patients should not know how busy you are! This is very BAD customer service. Do not share with residents' facility business in terms of someone calling off or using terms like short staffed or I'm the only one working. Such phrases are unacceptable. THIS DOES NOT COMFORT A RESIDENT! If anything, it leaves them anxious and lacks confidence in our ability to provide them with quality care. Complaining to a resident adds stress and worry and could be seen as emotional abuse. How would you feel if you dropped your child off at daycare and they told you they were short staffed' today? Staff should always include the residents and interact while providing care and talk directly to the residents. Even if they cannot respond It is absolutely inappropriate behavior to discuss what you are doing tonight or did yesterday, etc. Talk about things that are important and of value to the residents. Talk to the residents and not shout from a distance. Never tell a resident you will help them when you get back from break, etc. Take care of the residents BEFORE your break. RESIDENTS COME FIRST. They are the ONLY reason we are here. The facility Customer Service Promise: We all play a big role in customer service within the facility. This is your opportunity to make a difference. What other reason would you have to be working in this industry? We do not make widgets here. We TAKE CARE OF REAL PEOPLE'S LIVES. Think of how you want your loved one to be cared for . because someone is depending on you to care for them. This deficiency represents non-compliance investigated under Master Complaint Number OH00160364.

Based on medical record review, observation, interview, and review of facility policy, the facility failed to ensure proper infection control practices were maintained for Resident #63 related to transmission-based precautions and tube feeding procedures. The facility also failed to ensure infection control procedures were maintained during medication administration. This affected Individual #33, one of five residents observed during medication administration. The facility census was 75. Findings include: 1. Review of the medical record for Resident #63 revealed an admitted [DATE]. Diagnoses included pneumonia, COVID-19 (added 11/17/23), neuromuscular dysfunction of the bladder, urinary tract infection, urogenital candidiasis, nontraumatic intracranial brain hemorrhage, gastrostomy status, and other bacterial infections of unspecified site. Review of Resident #63's orders revealed a physician order dated 09/20/23 to maintain contact precautions. Further review of physician orders revealed a tube feeding order dated 12/11/23 for Isosource 1.5 milligrams (mg), 360 milliliters (ml) bolus feed, five times a day, followed by a 210 ml water flush after each bolus through the gastrostomy tube (GT). Review of the admission Minimum Data Set (MDS) assessment, dated 11/17/23, revealed Resident #63 had moderately impaired cognition. Further review of the MDS revealed Resident #63 had an indwelling urinary catheter and received tube feeding. Observation on 12/12/23 at 2:50 P.M. of Resident #63's room revealed an unsealed 1000 ml bag of Isosource 1.5 sitting on the windowsill. The upper corner side of the bag was diagonally cut open. The window blind was pulled down over the top of the open bag. The sun was shining in the room. Further observation on 12/12/23 at 3:24 P.M. of Resident #63's room with Licensed Practical Nurse (LPN) #816 revealed the opened unsealed bag of Isosource was lying flat on the windowsill. Interview at this time with LPN #816 revealed she cut open the 1000 ml bag because there were no small cartons of Isosource 1.5 available for the 8:00 A.M. tube feeding. LPN #816 used the same bag for the 8:00 A.M. and 12:00 P.M. feeding and the bag was left unsealed between the two feedings. During this interview, LPN #816 leaned into the resident's room, grabbed the plastic graduated cylinder sitting at Resident #63's bedside with ungloved hands, and brought the graduated cylinder outside of the room, pushing it in the air toward the surveyors to show the lines she drew with marker indicating how much tube feed and flush she used for Resident #63's bolus feeds. At this time, LPN #816 confirmed she knew she should not have removed the unclean item from the resident's room or touched the container with ungloved hands, acknowledging Resident #63 was in contact isolation. Observation on 12/14/23 at 1:40 P.M. revealed State tested Nurse Aide (STNA) #915 pulled a pile of gloves out of her pocket and laid them on the bed of Resident #63 who was in contact isolation during a dressing change. Once the dressing change was completed, she picked the pile of gloves up from the bed, placed them in her pocket, and exited the room. Interview on 12/14/23 at 1:50 P.M. with STNA #915 confirmed she put some gloves on the Resident #63's bed, then placed them in her pocket. She further confirmed they were still in her pocket. Review of the policy titled Isolation - Categories of Transmission-Based Precautions dated 09/15/22, revealed staff were supposed to wear gloves when entering a room of a resident in contact precautions and when handling potentially infective equipment. Review of the manufacturer's instructions for Isosource 1.5 revealed SpikeRight bags were to shaken before use, and kept out of excessive heat. Staff were to ensure proper technique was followed, which included accessing the formula by inserting a SpikeRight Plus connector into the port and securing tightly. 37096 2. Observation of medication administration for Resident #33 on 12/12/23 at 8:12 A.M. revealed Registered Nurse (RN) #851 preparing the morning medications. RN #851 opened a bottle of ferrous sulfate, shook out one ferrous sulfate tablet onto the inside of the lid of the ferrous sulfate bottle then dropped the ferrous sulfate in a medication cup along with the other medications. RN #851 screwed the lid back on the ferrous sulfate bottle and when placing the bottle back in the cart the lid came loose and fell to the floor. RN #851 picked up the lid and screwed it back on the bottle and placed it back in the cart without cleaning the lid. Interview on 12/12/23 at 8:50 A.M. with RN #851 confirmed she placed the ferrous sulfate bottle back in the cart without sanitizing/cleaning the lid which had fallen to the floor. RN #851 stated she was unsure of what to do with the lid after it was dropped.

Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure oxygen tubing was up-to-date per physician orders and sterile water containers were changed and dated for use with oxygen concentrator. This affected two residents (#7 and #174) of two residents reviewed for oxygen. The facility census was 75. Findings include: 1. Review of the medical record for Resident #7 revealed an admitted [DATE] with diagnoses that included dementia, epilepsy, and acute respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15 that indicated he was alert and oriented to person, place, and time. Further review of the MDS assessment revealed Resident #7 required oxygen therapy. Review of the care plan dated 11/01/23 revealed Resident #7 was at risk for respiratory distress and had a history of chronic obstructive pulmonary disease (COPD). Interventions included administer oxygen as ordered, monitor, and report change in condition to physician. Review of the physician orders dated 10/31/23 revealed an order for oxygen via nasal cannula at two liters per minute continuously every shift. Review of the physician orders dated 11/05/23 revealed an order to change and date oxygen mask, tubing and humidifier bottle, every night shift every Sunday. Observation and interview on 12/12/23 at 8:57 A.M. with Resident #7 revealed a blue oxygen concentrator with a plastic bottle with a minimal amount of sterile water located adjacent to the foot of the bed. The bottle of sterile water was dated 11/25/23 in blue writing . There was no date located on the oxygen tubing or oxygen mask. Resident #7 revealed he utilized his oxygen every day, but staff did not change his tubing and mask regularly. Resident #7 revealed he used oxygen via nasal cannula. Observation and interview on 12/12/23 at 9:03 A.M. with State tested Nursing Assistant (STNA) #918 confirmed Resident #7's oxygen mask and tubing was not dated and the bottle of sterile water was dated 11/25/23. STNA #918 verified the current date of 12/12/23, approximately three weeks after the water bottle was dated. Interview on 12/12/23 at 3:47 P.M. with Licensed Practical Nurse (LPN) #852 revealed Resident #7 utilized oxygen on a continuous basis. LPN #852 revealed Resident #7 received two liters of oxygen per minute to keep oxygen saturation levels up. LPN #852 said she changed his oxygen tubing, mask, and sterile water as needed. Observation and interview on 12/13/23 at 1:56 P.M. with Registered Nurse (RN) #851 confirmed Resident #7's oxygen tubing and mask was undated and the sterile water container was dated 11/25/23. RN #851 revealed the sterile water usually became empty after a week of use and the oxygen tubing, mask, and sterile water would be changed at the same time. 2. Review of the medical record for Resident #174 revealed an admitted [DATE] with diagnoses that included pneumonia, muscle weakness, and chronic respiratory failure with hypoxia. Review of the care plan dated 12/06/23 revealed Resident #174 was at risk for respiratory distress and chronic obstructive pulmonary disease (COPD). Interventions included administering oxygen as ordered, monitoring, and reporting changes in condition to physician. Review of the physician orders dated 12/10/23 revealed an order to change and date oxygen mask, tubing and humidifier bottle, every night shift every Sunday. Review of the physician orders dated 12/11/23 revealed an order for oxygen via nasal cannula at one liter per minute continuously every shift to maintain oxygen saturation levels above 90 percent. Observation on 12/12/23 at 9:00 A.M. of Resident #174's room, revealed a blue oxygen concentrator with a plastic bottle with a minimal amount of sterile water located adjacent to the left side of the bed. The bottle of sterile water and oxygen tubing was undated. Observation and interview on 12/12/23 at 9:03 A.M. with State tested Nurse Aide (STNA) #918 confirmed Resident #174's oxygen tubing and sterile water was undated. Observation on 12/13/23 at 1:00 P.M. revealed Resident #174's bottle of sterile water was empty and undated. Observation and interview on 12/13/23 at 2:20 P.M. with Registered Nurse (RN) #851 confirmed Resident #174's oxygen tubing was undated and the sterile water was undated and empty. RN #851 revealed the sterile water usually became empty after a week of use and the oxygen tubing, mask, and sterile water would be changed at the same time. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed it was in progress. Review of the facility document titled Oxygen Administration revised October 2010, revealed guidance to verify physician orders, assemble equipment and supplies as needed and document the date and time of oxygen setup or adjustment.

Based on medical record review, observation, interview, and review of facility policy, the facility failed to ensure sufficient treatment and services were provided that appropriately addressed the urological needs of a resident. This affected one (Resident #19) of two residents reviewed for urinary catheters or urinary tract infection (UTI). The facility census was 75. Findings include: Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included acute kidney failure, depression, hydronephrosis, stage three chronic kidney disease, mild protein calorie malnutrition, congenital occlusion of ureteropelvic junction, hyperkalemia, infection or inflammatory reaction due to indwelling urethral catheter, sepsis, bladder neck obstruction, and bacteremia. Review of the admission Minimum Data Set (MDS) assessment, dated 11/19/23, revealed Resident #19 had intact cognition and had the ability to make himself understood and to understand others. The MDS assessment further revealed Resident #19 had an indwelling urinary catheter. Review of the admission assessment progress note dated 11/12/23 revealed Resident #19 was admitted to the facility with bilateral nephrostomy tubes (a tube that lets urine drain from the kidney through an opening in the skin on the back) to straight drain. Review of physician orders revealed Resident #19 had no orders in place that addressed his nephrostomy tubes. Random observation on 12/12/23 at 3:27 P.M. revealed Resident #19's catheter drainage bag laying on the floor next to the resident's bed. Interview on 12/12/23 at 3:27 P.M. with Licensed Practical Nurse (LPN) #816 confirmed the catheter bag was on the floor. After picking up the bag and tubing and hooking the drainage bag to the side of Resident #19's bed, she stated at least it had the right bag; he has a blue bag to maintain privacy. Observation on 12/13/23 at 2:40 P.M. revealed the drainage bag from the right nephrostomy full and bulging. A closer look at the drainage bag revealed it held up to 600 milliliters (ml) of urine and dark amber urine was filled over the line marking the 600 ml volume. Further observation revealed the left nephrostomy drainage bag contained approximately 350 to 400 ml yellow urine. Interview on 12/13/23 at 2:40 P.M. with Resident #19 confirmed the nephrostomy drainage tubes and bags had not been monitored and stated, nobody has been in here to look at this all day. Further interview revealed the state tested nurse aides (STNAs) would empty his nephrostomy bags in the evenings at change of shift, but no facility staff routinely checked or cleaned his tube insertion sites. He added that the nurses never did anything with his nephrostomies. Resident #19 further stated the nephrostomy tube sites only got cleaned when he rinsed them off in the shower. Observation on 12/13/23 at 2:55 P.M. revealed STNA #912 draining the urinary catheter bag and both nephrostomy drainage bags. No glove changes or cleaning of the exit ports of the tubing was performed during the process. STNA #912 stated out loud to Resident #19 at the time she was draining urine from his catheter bag that there were no alcohol swabs in his room for her to swab the end of the tubing from his drainage bag. At the time of the observation, STNA #912 confirmed 600 ml was emptied from the right nephrostomy, 300 ml was emptied from the left nephrostomy, and 600 ml was emptied from the indwelling urinary catheter. Interview on 12/13/23 at 3:01 P.M. with STNA #912 revealed she was taught she was supposed to clean the tubing after she drained the urine, before securing it back on the bag, but did not clean the tubing at any time during the process of draining Resident #19's urinary drainage bags. STNA #912 further stated Resident #19's room never had any alcohol swabs available for her to clean the way she was taught. An interview on 12/13/23 at 3:05 P.M. with Licensed Practical Nurse (LPN) #826 confirmed Resident #19's medical record contained no orders or written instructions on nephrostomy tube care. Interview on 12/13/23 at 4:00 P.M. with STNA #912 revealed Resident #19's urinary output was documented in the chart under the bladder task. STNA #912 confirmed that she combined all the urine output from the catheter and nephrostomy tubes and documented it, then confirmed the amount entered for that date was 600 ml. Interview on 12/14/23 at 9:59 A.M. with Registered Nurse (RN) #874 confirmed Resident #19 had bilateral nephrostomy tubes since admission and there were no orders or care plan interventions regarding the nephrostomy tubes prior to 12/13/23. During the interview, RN #874 confirmed nephrostomy tubes should be cleaned and a dry dressing should be applied daily by the assigned floor nurse. RN #874 further indicated it was her expectation the drainage bags be checked by nurses when they were passing medications and by the STNAs when they responded to call lights or at least approximately every two hours. RN #874 stated nephrostomy output should be recorded by the nurse after the STNA reported the total to the nurse and then the STNA should document the output from the urinary catheter. RN #874 confirmed there was no place for staff to document nephrostomy output separately from the indwelling urinary catheter urine output prior to 12/13/23 and verbalized uncertainty as to whether the total recorded urine outputs were accurate. Review of facility policy dated October 2010, titled Nephrostomy Tube, Care of, revealed physician orders should be verified for residents with nephrostomy tubes. The policy listed the following guidelines: assess the resident for indications of bleeding in the flank area every eight hours, verify tube placement and integrity during assessments, empty bag every shift and as needed, change drainage bag monthly or and as needed, measure output every eight hours, measure output from the right and left kidneys separately and record the output from the kidneys separately from the urine output, change the dressing every one to three days, and use sterile technique during dressing changes. Review of the policy titled Catheter Care, Urinary (last revised August 2022) revealed aseptic technique must be used when handling the drainage system and the catheter tubing and drainage bag were to be kept off the floor.

Based on medical record review, interview, and review of facility policy, the facility failed to revise resident care plans when interventions were changed. This affected two residents (#40 and #63) of 23 reviewed for care planning. The facility census was 75. Findings include: 1. Review of the medical record for Resident #40 revealed an admitted [DATE]. Diagnoses included generalized muscle weakness, malaise, polycythemia vera, fatigue, history of transient ischemic attack, chronic venous hypertension, diabetes mellitus, neuropathy, anxiety, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/17/23, revealed Resident #19 had intact cognition and required moderate assistance for toileting, bathing, bed to chair and shower transfers. Review of the care plan dated 11/22/23 revealed Resident #40 was to be transferred with a one person assist. Interview with Resident #40 on 12/11/23 at 10:20 A.M. revealed he needed a Hoyer (mechanical) lift for transfers out of bed. Interview on 12/14/23 at 11:43 A.M. with State tested Nurse Aide (STNA) #906 confirmed Resident #19 required a Hoyer lift and two staff for all transfers. Interview on 12/14/23 at 11:49 A.M. with Registered Nurse (RN) #874 confirmed the physician's order and comprehensive care plan indicated Resident #40 was to be transferred with one-assist. RN #874 further confirmed the written care card for STNAs indicated Resident #40 required a mechanical lift for transfers. RN #874 stated she wasn't sure where they got that information, since there was no order or care plan intervention for a mechanical lift. Interview on 12/14/23 at 12:27 P.M. with Therapy Director #940 and Corporate Nurse #944 confirmed Resident #40 required a Hoyer lift. Corporate Nurse #940 confirmed the care plan needed updated to indicate Resident #40's need for a Hoyer lift. 2. Review of the medical record for Resident #63 revealed an admitted [DATE]. Diagnoses included pneumonia, COVID-19 (added 11/17/23), neuromuscular dysfunction of the bladder, urinary tract infection, urogenital candidiasis, nontraumatic intracranial brain hemorrhage, gastrostomy status, and other bacterial infections of unspecified site. Review of Resident #63's orders revealed a physician order dated 09/20/23 to maintain contact precautions. The indication for contact precautions was not listed within the order. Review of the care plan dated 11/22/23 revealed Resident #63 required contact isolation precautions due to colonization of candida auris and droplet isolation precautions related to COVID-19. Interventions included contact isolation, droplet precautions and use of the appropriate personal protective equipment (PPE) as indicated by the isolation type listed in the care plan. An interview on 12/12/23 from 3:10 P.M. to 3:20 P.M. with Licensed Practical Nurse (LPN) #816 confirmed Resident #63 was to be under contact precautions and that the care plan stated both contact and droplet precautions. LPN #816 further confirmed she was unaware of the source of infection that triggered contact precautions but was certain Resident #63 was no longer in droplet isolation for COVID-19. Throughout this interview, LPN #816 searched Resident #63's electronic medical record and hard chart at the nurses station to find the reason Resident #63 was in contact isolation. After ten minutes of searching, LPN #816 confirmed she could not determine the source of infection and stated, it looks like they never downgraded him from droplet precautions to just contact precautions. Interview on 12/13/23 at 2:00 P.M. with Registered Nurse (RN) #945 confirmed Resident #63 was on contact precautions for colonization of Carbapenem-resistant Enterobacterale (CRE) in his sputum. RN #945 further confirmed Resident #63 was no longer in droplet isolation. Review of the policy titled Isolation - Categories of Transmission-Based Precautions dated 09/15/22 revealed the facility was to ensure the resident's care plan and specialist communication system indicated the appropriate type of isolation precautions implemented for each resident.

Based on medical record review, observation, interview, and review of facility policy, the facility failed to ensure a comprehensive care plan was in place that addressed the urological needs of Resident #19. This affected one (#19) of two residents reviewed for urinary catheters or urinary tract infection (UTI). The facility census was 75. Findings include: Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included acute kidney failure, depression, hydronephrosis, stage three chronic kidney disease, mild protein calorie malnutrition, congenital occlusion of ureteropelvic junction, hyperkalemia, infection or inflammatory reaction due to indwelling urethral catheter, sepsis, bladder neck obstruction, and bacteremia. Review of the admission Minimum Data Set (MDS) assessment, dated 11/19/23, revealed Resident #19 had intact cognition and had the ability to make himself understood and to understand others. The MDS assessment further revealed Resident #19 had an indwelling urinary catheter. Review of the admission assessment progress note dated 11/12/23 revealed Resident #19 was admitted to the facility with bilateral nephrostomy tubes (a tube that lets urine drain from the kidney through an opening in the skin on the back) to straight drain. Review of the comprehensive care plan dated 11/14/23 revealed Resident #19 had no interventions related to nephrostomy tube monitoring or care from 11/14/23 to 12/13/23. Observation on 12/13/23 at 2:40 P.M. revealed the drainage bag from the right nephrostomy was full and bulging. A closer look at the drainage bag revealed it held up to 600 milliliters (ml) of urine and dark amber urine was filled over the line marking the 600 ml volume. Further observation revealed the left nephrostomy drainage bag contained approximately 350 to 400 ml yellow urine. Interview on 12/13/23 at 2:40 P.M. with Resident #19 revealed the nephrostomy drainage tubes and bags had not been monitored and stated, nobody has been in here to look at this all day. Further interview revealed the state tested nurse aides (STNAs) would empty his nephrostomy bags in the evenings at change of shift and the nurses did not clean or provide care to the nephrostomy tube sites. Interview on 12/15/23 at 3:05 P.M. with Licensed Practical Nurse (LPN) #826 confirmed the medical record contained no written instructions on nephrostomy tube care but stated they kept them clean and provide resident education. LPN #826 was unable to elaborate on specific cleaning frequency or method. Interview on 12/14/23 at 9:59 A.M. with Registered Nurse (RN) #874 confirmed Resident #19 had bilateral nephrostomy tubes and there were no orders and no care plan interventions regarding the nephrostomy tubes prior to 12/13/23. She further confirmed there was no place for staff to document nephrostomy output separately from the indwelling urinary catheter urine output prior to 12/13/23 and verbalized uncertainty as to whether the total recorded urine outputs were accurate. Review of facility policy date October 2010, titled Nephrostomy Tube, Care of, revealed the resident's care plan should be reviewed to assess any specific nephrostomy care needs.

Based on interview and record review, the facility failed to ensure Resident #54 was able to attend a cardiology appointment. This affected one resident (#54) of one reviewed for appointments and transportation. The facility census was 75. Findings include: Review of the medical record for Resident #54 revealed an admitted [DATE] and diagnoses including old myocardial infarction, tachycardia, chest pain, hypertension, congestive heart failure, and atherosclerosis. Review of the Resident Appointments and Transportation form dated 09/12/23 revealed Resident #54 had an appointment with cardiology on 01/10/24 at 2:15 P.M. and Resident #54 was to be transported via cot. Transportation had not yet been set up. Review of the Progress Note dated 11/02/23 revealed Resident #54's cardiology appointment on 01/10/24 had been rescheduled for 12/08/23 per his request. Review of Physician's Orders dated 12/08/23 revealed Resident #54 had an order for an appointment with a cardiologist on 12/08/23 at 11:00 A.M. Further review of Resident #54's medical record revealed no evidence of an appointment scheduled for 01/10/24. Interview on 12/11/23 at 10:15 A.M. with Resident #54 revealed he was supposed to have an appointment on 12/08/23 however the facility messed up transportation. Resident #54 indicated he got ready for the appointment, but no transport arrived to take him to the appointment. Interview on 12/13/23 at 11:20 A.M. with Transport Scheduler #880 revealed she was unaware of an appointment on 12/08/23 for Resident #54. Transport Scheduler #880 had not received an appointment scheduling form for Resident #54's appointment on 12/08/23. Transport Scheduler #880 thought Resident #54 had an appointment with cardiology in January 2024. Transport Scheduler #880 indicated Resident #54 had to be transported via cot. Interview on 12/13/23 at 11:53 A.M. with Licensed Practical Nurse (LPN) #826 revealed he had re-scheduled Resident #54's cardiology appointment for 12/08/23. They had gotten Resident #54 ready on 12/08/23 for his appointment however there was no transport arranged. LPN #826 indicated Resident #54 had a cardiology appointment scheduled for 01/10/24. Interview on 12/13/23 at 4:47 P.M. with a representative from Resident #54's cardiology office confirmed Resident #54 was supposed to have an appointment on 12/08/23 however he did not come to the appointment. The representative indicated there was no appointment scheduled for 01/10/24 as it had been canceled. Interview on 12/14/23 at 9:25 A.M. with Transport Scheduler #880 confirmed she did not set up transportation for Resident #54's cardiology appointment on 12/08/23.

Based on observation, staff interview, and policy review, the facility failed to ensure call light devices were in reach. This affected two residents (#12 and #46) of two residents reviewed for call light devices. The facility census was 75. Findings include: 1. Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses that included quadriplegia, vascular dementia, and adjustment disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of five indication he had short and long-term memory impairment. Resident #12 required a two-person total dependent assist for activities of daily living (ADLs). Review of the care plan dated 10/30/23 revealed Resident #12 had a self-care deficit as evidenced by altered cardiac status, altered cognition, impaired mobility, impaired balance and dependence on staff for ADLs. Interventions included using blow type call light and ensure call light within reach. Observation on 12/11/23 at 10:47 A.M. revealed Resident #12 was in bed, a blow type call light was above his head and out of reach. Observation and interview on 12/12/23 at 3:40 P.M. with State tested Nurse Assistant (STNA) #871 revealed Resident #12 was laying in bed with the call light situated above his head and not in reach. STNA #871 revealed Resident #12 required his call light to be situated near his face and within reach of his mouth. Interview on 12/12/23 at 3:44 P.M. with Licensed Practical Nurse (LPN) #852 revealed Resident #12 utilized a blow type call light. LPN #852 revealed Resident #12 alerted staff by blowing into the call light device and it needed to be in reach at all times. 2. Review of the medical record for Resident #46 revealed an admitted [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left side, vascular dementia, and COVID-19. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of six indicating he had short and long-term memory impairment. Resident #46 required a two-person assist for activities of daily living (ADLs). Review of the care plan dated 10/30/23 revealed Resident #46 was at risk for falls. Interventions included using call light and keep in easy reach at all times. Observation on 12/11/23 at 3:00 P.M. revealed Resident #46 was in bed with the call light hanging to the floor and out of reach. Observation and interview on 12/11/23 at 3:05 P.M. with State tested Nurse Assistant (STNA) #898 confirmed Resident #46's call light was out of reach and he was unable to retrieve it if he needed assistance. STNA #898 revealed Resident #46 had a history of stroke and required staff assistance. Observation and interview on 12/12/23 at 3:36 P.M. revealed Resident #46 in his room sitting in his wheelchair yelling out for assistance to use the bathroom. Resident #46 revealed he needed to go the bathroom and needed help. Resident #46's call light was not in reach. Observation and interview on 12/12/23 at 3:38 P.M. with State tested Nurse Assistant (STNA) #872 confirmed Resident #46's call light was not in reach. Review of the facility document titled Answering the Call Light revised September 2022, revealed the policy provided guidance to ensure the call light was accessible to the resident.

Based on observation, record review, review of Centers for Medicare and Medicaid Services (CMS) guidance and interview, the facility failed to ensure it was administered in a manner which enabled it to use its resources effectively and efficiently when they did not terminate the use of a temporarily certified Health Care Isolation Center (HCIC) area per CMS waiver guidelines as required. This affected 11 residents (#13, #52, #54, #55, #56, #57, #58, #59, #60, #61 and #64) of 11 residents residing in HCIC rooms. The facility census was 64. Findings include: Review of a facility application and survey history, revealed on 02/01/21, the facility was approved to operate as a HCIC with an In-House Surge Facility. The location of the HCIC was the first floor, Rooms 111 through 134. The approval allowed a surge in capacity of 24 for the facility to operate 128 certified beds. Review of CMS MEMO, QSO-22-15-NH & NLTC & LSC, dated 04/07/22 and revised 08/29/22, revealed the following Emergency Declaration Blanket Waivers for Various Provider-Types Ending 60 Days from Publication of this Memorandum included: Physical Environment for SNF/NFs - CMS waived requirements to temporarily allow for rooms in a long-term care facility not normally used as a resident's room, to be used to accommodate beds and residents for resident care in emergencies and situations needed to help with surge capacity. Certain conditions of participation and certification requirements for opening a NF if the state determines there is a need to quickly stand up a temporary COVID-19 isolation and treatment location. Requirements to temporarily allow for rooms in long-term care facility not normally used as a resident's room, to be used to accommodate beds and residents for resident care in emergencies and situations needed to help with surge capacity. Review of an Enhanced Information Dissemination Collection (EIDC) electronic reporting system Memo, dated 05/09/22, revealed facilities with Health Care Isolation Centers (HCIC) were further informed of the reference to end COVID-19 Emergency Declaration Blanket Waivers and HCIC Program. CMS waived requirements to allow for a non-SNF building to be temporarily certified and available for use by a SNF in the event there were needs for isolation processes for COVID-19 positive residents. The memo included this may not have been feasible in the existing SNF structure to ensure care and services during treatment for COVID-19, provided that the state approved the location as one that sufficiently addresses the safety and comfort for patients and staff. The waiver also included the requirements to temporarily allow for rooms in a long-term care facility not normally used as a resident's room to be used to accommodate beds and residents for resident care in emergencies and situations needed to help with surge capacity. Per the CMS MEMO, QSO-22-15-NH & NLTC & LSC, dated 04/07/22, the above-mentioned waivers for HCIC and in-house surge facilities were ending 60 days from the date of the CMS memo. Therefore, effective Tuesday, 06/07/22, all SNF that were approved to be a HCIC and utilize certified space outside of the SNF (i.e. in a licensed residential care facility or in a building separate from the SNF), as well as any SNF that surged its certified capacity beyond its existing license and certified capacity, would need to terminate providing care within its HCIC or in-house surge facility effective 06/07/22. Effective 06/07/22, approved HCIC providers must cease billing for enhanced reimbursement for HCIC isolation and quarantine services and would resume billing using usual and customary Medicaid NF service codes. Any claims inappropriately billed for HCIC services after this service date would be denied or payments recouped. Review of the facility census dated 05/10/23 revealed 11 residents, Resident #13, Resident #52, Resident #54, Resident #55, Resident #56, Resident #57, Resident #58, Resident #59, Resident #60, Resident #61 and Resident #64 resided in Rooms 111 through 134. Observation on 05/10/23 at 7:57 A.M. revealed residents were residing on the first floor, including the above residents who were residing in Rooms 111 through 134. Interview on 05/10/23 at 10:25 A.M. with the Administrator confirmed the facility had a HCIC unit located with Rooms 111-134 with 11 residents currently residing in those rooms. The Administrator revealed it was his understanding the facility had until the end of the Public Health Emergency (05/11/23) to terminate the HCIC unit and move residents off out of those rooms. Interview on 05/10/23 at 11:16 A.M. with the Owner revealed the facility believed when the order came through to terminate the HCIC unit in June 2022, it stated no more isolation services, but the order did not indicate decertification of the unit or that the facility could not bill for services within the unit. The Owner indicated the facility was not currently using the HCIC unit as an isolation unit but verified there were 11 residents currently located in those beds. This finding represents non-compliance investigated under Complaint Number OH00142650.

Based on observation, staff and family interview, record review and review of the facility policy Pressure Ulcer Prevention and Assessment the facility failed to ensure Resident #330 was turned and repositioned at least every two hours to relieve pressure on his buttocks, failed to maintain an intact, ordered dressing in place to his sacrum and failed to ensure the setting on his low air loss (LAL) mattress was adjusted to the proper setting demonstrating a lack of care and services to prevent the development of a deep tissue pressure injury (persistent non-blanchable deep red, maroon or purple discoloration intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue). In addition, the facility failed to ensure Resident #335's pressure ulcers and injuries were accurately and thoroughly evaluated, measured, and documented in the medical record and Resident #52 was adequately repositioned to provide pressure relief to his wound areas. This affected three residents (Resident's #52, #330, #335) out of four residents reviewed for pressure ulcers. The facility census was 80. Actual Harm occurred to Resident #330 on 03/14/23 when Resident #330, who returned to the facility from a hospitalization on [DATE] with a documented excoriated buttocks and groin area with barrier cream in place, was assessed and observed by Wound Nurse Practitioner (WNP) #925 and found to be laying on a hard, LAL mattress not properly adjusted to the required settings, and Resident #330 had developed a deep pressure injury on his coccyx radiating to the right buttock. Findings include: 1.Review of Resident #330's medical record revealed an admitted [DATE] and a re-entry date of 03/07/23 after being in the hospital with the diagnoses of urinary tract infection and clostridium difficile (a bacteria that can cause diarrhea and inflammation of the bowel) . Resident #330's additional diagnoses included enterocolitis due to clostridium difficile (C Diff), acute kidney failure and dehydration. Review of Resident #330's Braden Scale for Predicting Pressure Sore Risk, dated 01/14/23, revealed Resident #330 was at low risk for developing a pressure ulcer, injury. Review of Resident #330's hospital Physician Orders and Transfer of Care Form, dated 02/28/23 through 03/07/23, included Resident #330 was incontinent of bladder and bowel. Resident #330 was alert, oriented and cooperative. Resident #330's skin was intact, he had excoriation (an abraded area of the skin) on his bottom and groin, and barrier cream was applied. Review of Resident #330's physician orders, dated 03/07/23, revealed protective barrier cream ointment topically to peri-area (perineal area) after each incontinent episode. This order was discontinued on 03/08/23 and a new order written dated 03/08/23 at 8:15 A.M. for a treatment to buttocks and perineal area, cleanse with wound cleanser, apply Triad (adheres to wet skin, keeping the wound covered and protected from incontinence) and cover buttocks with a large sacral dressing for protection, change three times a week and as needed. Review of Resident #330's Initial Wound Assessment Documentation dated, 03/07/23 at 7:44 P.M., included Resident #330's buttocks and groin were excoriated with no open areas. Review of Resident #330's Admission Minimum Data Set (MDS) 3.0 assessment, dated 03/07/23, revealed Resident #330 had moderate cognitive impairment. Resident #330 required extensive assistance of one staff member for bed mobility and toilet use and required extensive assistance of two staff members for transfers. Resident #330 was frequently incontinent of urine and occasionally incontinent of bowel. Resident #330 did not have a pressure ulcer. Review of Resident #330's physician orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR), State tested Nursing Assistant (STNA) charting, care plan, and progress notes dated 03/07/23 through 03/14/23, did not reveal documentation Resident #330 had physician orders to be turned and repositioned every two hours or evidence Resident #330 was turned and repositioned every two hours. Further review of the progress notes did not reveal documentation Resident #330 refused to be turned and repositioned. Review of Resident #330's TAR, dated 03/08/23, revealed he did not receive the treatment orders dated 03/08/23 at 8:15 A.M. for a treatment to buttocks and perineal area, cleanse with wound cleanser, apply Triad and cover buttocks with a large sacral dressing for protection, change three times a week and as needed. Review of Resident #330's care plan, dated 03/08/23, included Resident #330 had impaired skin integrity with risk of pain and infection related to fragile skin and incontinence MASD (moisture associated skin damage) to buttocks due to loose stools from clostridium difficile. Resident #330 would have pain managed as evidenced by no complaints of pain, Resident #330 would have wound resolved, Resident #330's wound would be without signs and symptoms of infection, Resident #330's wound would decrease in size as noted measurements. Care plan Interventions dated 03/08/23 included to apply barrier cream after each incontinence cleansing, check skin with showers/baths and report abnormalities to the physician as indicated; a low air loss mattress, notify physician and resident, resident representative of change in condition, positioning interventions, appliances, wound treatments per protocol and physician orders. Review of Resident #330's general progress notes and assessments, dated 03/10/23 through 03/13/23, revealed no documentation of characteristics of a wound or reddened area on Resident #330's coccyx, sacral area or buttocks including measurements, color, drainage. Review of Resident #330's skilled progress notes dated, 03/10/23 at 11:09 A.M., revealed Resident #330 had no change to skin or current impairments. Review of Resident #330's STNA charting for skin observation, dated 03/10/23 at 11:38 A.M., revealed Resident #330 had a new skin impairment, red area. The new skin impairment, red area was reported to the nurse. This charting did not indicate what area of the body the STNA noted the red area of skin impairment. Review of Resident #330's skilled progress notes dated, 03/11/23 at 5:47 P.M. revealed Resident #330 had no change to skin or current impairments, dressing on left buttock wound. Review of Resident #330's skilled progress notes dated, 03/12/23 at 5:59 P.M., revealed Resident #330 had no change to skin or current impairments, wound on sacrum, coccyx, dressing present. Review of Resident #330's skilled progress notes dated, 03/13/23 at 6:48 P.M., revealed no change to skin or current impairments. Review of Resident #330's Wound Evaluation, dated 03/14/23, and completed by WNP #925 included findings that Resident #330 had a pressure injury, Deep Tissue Injury, on his coccyx radiating to the right buttock. The measurements were a length of 15 centimeters (cm), width seven cm, and depth at least 0.1 cm. Resident #330 had a red, open area directly over the coccyx with a reddish-purple linear discoloration radiating from the right buttock to the right ischial area, area was all measured as one. Eighty percent of the measured area was intact but discolored. Treatments to consider included to turn and reposition every two hours, pressure reducing mattress, alternating, pressure redistribution cushion to all seated surfaces. Treatment for the pressure ulcer was to cleanse with wound cleanser, apply xeroform to the open area over the coccyx. Then apply a large sacral foam dressing. Change three times a week and as needed. Ensure static mode was turned off and weight was consistent with patient's weight. Further review of the wound evaluation included resident was admitted to the facility to undergo rehab and family was present during the exam. Wife #950 stated resident was having some discomfort and a pillow was placed underneath Resident #330's buttocks. It was explained to Wife #950 the pillow negated the offloading properties of the specialized mattress that Resident #330 was on, and the pillow could be used to help position him so he was offloaded on his buttocks but should not come in contact with the wound itself. Resident #330 had a dark, purplish red linear line along the right buttock consistent with possible pillow coming in contact with this area or folded bedding. There was a small superficial area directly over the coccyx, the entire area was measured as one given the discoloration throughout. The above treatment would be applied using the large sacral foam to incorporate the entire area. Resident #330 was currently treated for clostridium difficile (C Diff) and this placed him at a greater risk of further tissue breakdown and posed a barrier to resolution. The large sacral foam should help protect the area from exposure. The facility would ensure the low air loss mattress was not set on static position and coincided with his current weight which was 204 pounds. Recommend limiting time in chair to less than two-hour intervals and Resident #330 could rotate back and forth between the bed and chair frequently throughout the day. Review of the manufacturer instructions for Resident #330's LAL mattress included the pump and mattress system was indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. The instructions included to determine the patient's weight and set the control knob to that weight setting on the control unit. Further review included to press the static button to shift between alternating mode and static mode. In alternating mode, the air cells will alternate in ten-minute cycles. When in static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition. The static mode will help ensure the patient does not bottom out when in a sitting position. Observation on 03/13/23 at 8:22 A.M. revealed Resident #330's wife called surveyor to Resident #330's room. Wife #950 stated Resident #330's incontinence brief was not changed and now his rear end was raw. Wife #950 stated she registered a complaint with Resident #330's nurse and aide, but she did not know what their names were. Wife #950 stated this happened on 03/08/23 and 03/10/23, and Wife #950 stated she did not know who the nurse was those days. Wife #950 stated the aide and Licensed Social Worker (LSW) #881 reported it to the nurse. Wife #950 indicated Resident #330 was very restless and his incontinence brief was not changed timely during the night. Observation on 03/13/23 at 8:30 A.M. of Resident #330's buttock and sacral area with Registered Nurse (RN) #910 revealed Resident #330's incontinence brief was wet with urine. Resident #330 did not have a dressing on his sacral or buttock area. Observation of Resident #330 revealed he had an open area with a pink wound bed on his coccyx which was approximately the size of a nickel, and a dark red and purple line extending down his right buttock. Further observation revealed Resident #330's buttocks were excoriated, had open areas, and barrier cream was noted on buttocks. Observation on 03/13/23 at 9:48 am revealed Resident #330 lying on his back in bed. There was no observation of staff turning and repositioning Resident #330 or encouraging Resident #330 to turn and reposition. Interview on 03/13/23 at 9:48 A.M. with Wife #950 revealed on 03/09/23 or 03/10/23 the aides changed Resident #330's incontinence brief and reported the red and raw areas to the nurse. Wife #950 stated when she arrived on 03/10/23 Resident #330's buttocks was very red and sore, and it was reported to the nurse. Wife #950 stated the nurse did not come to the room to evaluate Resident #330's buttocks. Wife #950 indicated Resident #330's incontinence brief was changed, and his red buttocks addressed only after she arrived on 03/10/23. Wife #950 stated today (03/13/23) Resident #330's buttocks was still very red and very sore. Wife #950 indicated Resident #330 did not have a bed sore when he was admitted to the facility. Wife #950 stated cream was put on Resident #330's buttocks when he was changed. Wife #950 stated she was pretty pissed off about the way Resident #330's buttocks looked now. Observation on 03/13/23 at 11:00 A.M., 12:00 P.M., 2:00 P.M. revealed Resident #330 lying on his back in bed. There was no observation of staff turning and repositioning Resident #330 or encouraging Resident #330 to turn and reposition. Observation on 03/14/23 at 10:09 A.M. revealed Resident #330 lying on his back in bed. There was no observation of staff turning and repositioning Resident #330 or encouraging Resident #330 to turn and reposition. Observation on 03/14/23 at 10:09 A.M. of Resident #330 with Wound Nurse Practitioner (WNP) #925 revealed Resident #330's coccyx had an open area with a pink wound bed. Resident #330 had a dark purple line approximately one-half inch wide and one and one-half inch long along his right buttock and ischial area which did not blanche. WNP #925 stated the purple area was due to some kind of pressure injury. Wife #950 was at the bedside and stated the staff did not turn and reposition Resident #330 and he was always lying on his back. Wife #950 stated staff got Resident #330 up for a little bit on 03/13/23, but otherwise he was lying on his back all the time. Observation revealed Resident #330 was lying on his back with a pillow under his buttocks. WNP #925 stated the pillow was causing pressure to the area and should not be under the buttocks. WNP #925 noted the LAL mattress setting was at 350 which was the highest level, and the static button was on which prevented the LAL mattress from redistributing the pressure. WNP #925 stated the LAL mattress setting should be according to weight and should be set at 180 and not 350 and the static button should be off. WNP #925 felt the bed and stated the bed was very hard under Resident #330's buttock and sacral area. The surveyor confirmed the bed was very hard under Resident #30's buttock and sacral area. WNP #925 stated the staff needed to be educated on the proper settings for the LAL mattress. Interview on 03/15/23 at 3:55 P.M. with Registered Nurse (RN) #910 revealed Resident #330 was admitted at the end of her shift and his buttocks and groin were excoriated, a little red, but Resident #330 had no open areas on his bottom. RN #910 stated Resident #330 was admitted with C Diff and his wife was in the room when the admission skin assessment was completed. RN #910 stated Resident #330's wife arrived every day at 8:00 A.M. and stayed until about 6:00 P.M. Interview on 03/16/23 at 4:38 P.M. with Wife #950 revealed she did not know who put the pillow under Resident #330 when WNP #925 visited her husband. Wife #950 stated one of the aides placed the pillow under Resident #330's buttocks. Wife #950 stated she did not place the pillow under Resident #330 to relieve pain he was having on his bottom. Interview on 03/20/23 at 8:07 A.M. of State tested Nursing Assistant (STNA) #826 revealed she often was assigned to care for Resident #330. STNA #826 stated she was not working when Resident #330 was admitted but following a night shift she changed Resident #330's incontinence brief and his bottom was red and bleeding. STNA #826 stated she did not remember which day this occurred but it happened within the first week Resident #330 was readmitted to the facility on [DATE]. STNA #826 stated Resident #330's incontinence brief was soaked, the bed was soaked, his bottom was red and bleeding and it was horrible. STNA #826 indicated she reported the situation to the nurse and the Director of Nursing (DON), and the night shift aide was written up. STNA #826 stated she could not remember the aides name but did not think the aide still worked at the facility. STNA #826 stated she put pillows under Resident #330's side and buttocks to keep the pressure off. Interview on 03/20/23 at 8:21 A.M. with LSW #881 confirmed he spoke with Wife #950 and the nurse supervisor (Licensed Practical Nurse (LPN) #884) regarding Resident #330's diarrhea and his bottom being red and raw. LSW #881 confirmed Wife #950 was upset about Resident #330's red and raw bottom. Interview on 03/20/23 at 10:08 A.M. with Licensed Practical Nurse/Unit Manager (LPN/UM) #813 revealed STNA #826 reported Resident #330's incontinence brief and bed were soaked and Resident #330's bottom had an open area. LPN/UM #813 stated she could not remember which day this happened, but it was in the morning. LPN/UM #813 stated she entered Resident #330's room, looked at his bottom, and it was excoriated. LPN/UM #813 stated she looked at the initial wound assessment, and there was nothing else significant. LPN/UM #813 stated Triad cream was applied to Resident #330's buttocks. LPN/UM #813 indicated Resident #330's buttocks were red but not bleeding, and the purple line was not observed on Resident #330's bottom. Interview on 03/20/23 at 1:24 P.M. with LPN/UM #813 and the Director of Nursing (DON) revealed LPN/UM #813 stated she reported the lack of timely incontinence care for Resident #330 to the nurse on the floor but did not remember who she talked to. LPN/UM #813 indicated she told the nurse to pass it on in report to the next shift to make sure the STNAs were providing incontinence care and doing last rounds to check on the residents before going home. LPM/UM #813 stated the aides should be giving report to each other. LPN/UM #813 stated she did not talk to the night shift aide about Resident #330's incontinence care but told the DON about it. The DON stated she did not talk to the aide about Resident #330's incontinence care or write the aide up for customer service because she could not prove Resident #330 was not wet at the beginning of the shift because he was not checked by STNA #826 until 8:30 A.M. 2. Review of Resident #335's medical record revealed an admitted [DATE] and diagnoses including ventricular tachycardia, acute respiratory failure with hypoxia and type two diabetes mellitus. Review of Resident #335's Admission Assessment and Baseline Care Plan, dated 03/08/23, revealed Resident #335 arrived via a cot and was alert to self, person, place, and time. Resident #335 required partial or moderate assistance for bed mobility. Resident #335 required assistance of two staff and used a mechanical lift for transfers. Resident #335 was occasionally incontinent of bowel and bladder. Resident #335 had an unstageable pressure ulcer to the sacrum and measurements were length four centimeters (cm) and width of three cm, with slough (necrotic, dead tissue) and MASD (moisture associated skin damage) surrounding. Review of Resident #335's hospital discharge instructions titled Gold Form: Provider Orders, dated 03/08/23, included Resident #335 had an evolving deep tissue pressure injury on his sacrum, buttocks and the wound measured a length of 12 cm, and a width of 10 cm. The form further stated Resident #335 had a wound site of peri wound skin on bilateral ischium and both had intact deep tissue pressure injuries. The right ischium measured length of four centimeters (cm), width of two cm and the left ischium measured a length of two cm and a width of two cm. Review of Resident #335's care plan, dated 03/08/23, included Resident #335 had impaired skin integrity with risk of pain and infection. Resident #335 was admitted to the facility with a pressure ulcer on his sacrum. Resident #335's wound would be without signs and symptoms of infection. Resident #335's wound would decrease in size as noted by measurements. Interventions included apply barrier after each incontinence cleansing and wound treatments per protocol and physician orders. Review of Resident #335's physician orders on 03/09/23 revealed treatment, sacrum, cleanse with wound cleanser, apply Triad and then cover with xeroform, cover with sacral dressing, and change three times a week and as needed. Review of Resident #335's physician orders dated 03/08/23 through 03/13/23 did not reveal orders to turn and reposition Resident #335 every two hours or orders for a LAL mattress. Orders on 03/09/23 revealed orders for a pressure redistributing mattress. Observation on 03/13/23 at 3:09 P.M. of Resident #335 with Registered Nurse (RN) #837 revealed Resident #335 was lying on his back in bed and the head of the bed was elevated approximately 45 degrees. Resident #335 stated he had diarrhea and needed cleaned up. RN #837 stated she would make sure that happened. Observation on 03/13/23 at 3:35 P.M. of Resident #335 revealed he was lying in bed on his back and the head of the bed was elevated 45 degrees. Resident #335 stated his incontinence brief had not been changed. Observation on 03/13/23 at 4:13 P.M. of State tested Nursing Assistant (STNA) #922 revealed STNA #922 exited another resident room at the end of the nursing unit Resident #335 resided on. After surveyor intervention, STNA #922 entered Resident #335's room to provide incontinence care. STNA #922 stated he arrived for work at 3:00 P.M., had been answering resident call lights and had not provided incontinence care for Resident #335. RN #837 walked in Resident #335's room and stated she did not tell STNA #922 that Resident #335 needed his incontinence brief changed. RN #837 stated she told STNA #820 who left at 3:00 P.M. Resident #335 needed his incontinence brief changed. RN #837 assisted STNA #922 to provide incontinence care for Resident #335. Observation revealed Resident #335's incontinence brief was soaked with urine and a very large diarrhea bowel movement and no dressing was observed when the incontinence brief was removed. Further observation revealed Resident #335's buttocks and sacral area were dark red and purple areas were noted along with a large black area on the left buttock. The large black area measured approximately three inches by one inch. The dark red and purple areas extended across both buttocks and did not blanche in the middle. Large open areas with red wound beds and reddish drainage approximately three inches in diameter were noted across bilateral buttocks, the coccyx area was a dark purple black in color and did not blanche. Further observation revealed a small dark area on right buttock sacral area, the left leg upper thigh had a small open red area with a dark center. These observations were confirmed by RN #837. RN #837 used wound cleanser, applied Triad cream, xeroform, and a foam border dressing to the sacral area. After surveyor intervention RN #837 and STNA #922 cleaned additional diarrhea from the crease of Resident #335's buttocks which was missed when incontinence care was completed. Additional observations revealed Resident #335's upper thigh was red in area of scrotum, scrotum was red and irritated looking, right upper thigh wound revealed a dark wound bed and was approximately a quarter size, red around edges. Resident #335 did not have a LAL mattress on his bed. Additional observations were confirmed by RN #837. Interview on 03/13/23 at 5:13 P.M. with the DON revealed she did Resident #335's initial wound assessment. The DON indicated there was one spot that looked like it had MASD surrounding it, and was not macerated, open and bleeding. The DON stated there was some redness and the wound had a lot of slough, slough was pretty yellow, and a little darkened. The DON stated the wound possibly had a small amount of necrotic (dead) tissue. The DON stated she noted Resident #335 had excoriation on the inside of his thighs and scrotum. The DON indicated Resident #335 was admitted from the hospital on 03/08/23. The DON stated she did not measure the wounds and she should have. The DON confirmed Resident #335 was on a pressure reducing mattress and not a LAL mattress. Interview on 03/14/23 at 6:54 A.M. with State tested Nursing Assistant (STNA) #900 revealed she saw Resident #335's bottom when he was admitted . STNA #900 stated Resident #335 had a sacral dressing and she could not see under the dressing, but the wounds around the dressing were present on admission. Observation on 03/14/23 at 10:50 A.M. of Resident #335 with Wound Nurse Practitioner (WNP) #925 and the Director of Nursing (DON) revealed this was her first visit for Resident #335. Observation revealed Resident #335 was lying on his back in bed and his incontinence brief was soaked with urine and a very large liquid bowel movement which was brownish green in color. Resident #335's urine and bowel movement leaked out of the incontinence brief and was noted on the sheets and blanket. Resident #335 did not have a dressing on his sacral area. Resident #335 had a left ischium wound which was measured at a length of 1.5 cm, width of 1.8 cm and depth was unable to be determined. A sacrum wound measured a length of 11.5 cm and a width of 11.5 cm and depth was unable to be determined due to it was unstageable. The DON stated she did the initial assessment when Resident #335 was admitted to the facility, but Resident #335 had a dressing on and she did not pull the dressing all the way down to do a full assessment. The DON stated she did not know if all the wounds were present when Resident #335 was admitted to the facility. The DON stated she changed Resident #335's dressing this morning and he had a dressing on at that time. Further observation revealed Resident #335 had an unstageable pressure ulcer to the right ischium and measured a length of 3.5 cm, width of 2.5 cm and depth was unable to be determined. The DON stated Resident #335's wound changed since she saw it when he was admitted , and she thinks the top part deteriorated. The DON stated when he was admitted she just pushed the dressing down a little bit but did not see the entire wound. The DON stated another nurse started the assessment and she finished it. The DON indicated she did not measure Resident #335's wounds upon admission, used the hospital paperwork as a guide when she filled out the initial assessment. Interview on 03/14/23 at 2:33 P.M. with Licensed Practical Nurse (LPN) #884 revealed he admitted Resident #335. LPN #884 could not remember details about Resident #335's wounds but remembered the wounds were dark in spots, had some redness, purple areas and the wounds were not bleeding. LPN #884 stated he started, and the DON finished up the admission assessment. LPN #884 stated Resident #335 was weak and sore and needed a lot of help with bed mobility and could not do it on his own. Interview on 03/15/23 at 8:42 A.M. and 11:00 A.M. and 4:48 P.M. revealed Resident #335 was lying on his back in bed. There was no observation of staff turning and repositioning or encouraging Resident #335 to turn and reposition. Observations on 03/16/23 at 9:13 AM and 10:50 A.M. revealed Resident #335 was lying on back. No observations of staff turning and repositioning Resident #335. Interview on 03/16/23 at 10:59 A.M. with STNA #960 revealed she had not provided incontinence care for Resident #335 or turned and repositioned him. STNA #960 stated she started at the back of her nursing unit and worked her way forward and was going in Resident #335's room in the next few minutes. STNA #960 stated another aide told her Resident #335 was changed around 8:00 A.M. 34297 3. Review of Resident #52's medical record revealed he was admitted on [DATE] with diagnoses including hemiplegia, acute respiratory failure and cerebral infarction. Review of Resident #52's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited a memory problem. Review of Resident #52's Wound Evaluation form dated 03/14/23 indicated he had a sacrum stage three (full thickness skin loss, involving damage or death of subcutaneous tissue that may extend down to, but not through, underlying tissues and muscles) pressure wound measuring 4.5 cm length by 4.0 cm depth by at least 0.5 cm depth with 60% (percent) granulation tissue, 20% necrotic tissue (slough). The treatments included to cleanse the wound with wound cleaner, apply anasept gel (antibiotic) then apply dermablue (antimicrobial) or hydrofera blue (antimicrobial), cover with a large sacral foam dressing and change three times a week and as needed. Position side to side only. Observation on 03/16/23 at 7:00 A.M. revealed Resident #52 was lying on his back with his arms positioned at his sides and he was lying on an air mattress. He was not alert and oriented, had a tracheostomy tube and a feeding tube with feeding solution infusing at 75 ml (milliliters) per hour at the time of the observation. Interview on 03/16/23 at 7:30 A.M. with Licensed Practical Nurse (LPN) #858 confirmed Resident #52 was positioned on his back when he should be positioned side to side only to prevent further deterioration of his pressure ulcer wound. Interview on 03/16/23 at 7:34 A.M. with LPN Minimum Data Set (MDS) Coordinator #907 revealed Resident #52's care plans did not include the intervention to only position the resident from side to side and not on his back. Interview on 03/16/23 at 9:10 A.M. with the Director of Nursing (DON) confirmed Resident #52's wound documentation indicating he should be positioned side to side only and she was unsure why it was not care planned as a wound/skin intervention in his medical record. Review of the facility policy titled Pressure Ulcer Prevention and assessment dated , 12/17/13, included it was the policy of the facility to prevent the development of pressure ulcers to the greatest extent possible and as allowed by the resident's compliance, cognition and or physical function. For a person in bed change position at least every two hours or more frequently as needed, determine if the resident needed a special mattress, raise the head of the bed as little and for as short a time as possible and only as necessary for meals, treatments and medical necessity. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of skin irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor and physician. Place resident on a minimum of every two hour check and change. Impaired mobility, decreased functional ability, cognitive impairment, exposure of skin to urinary and fecal incontinence are additional clinical condition that indicate a resident was at risk for pressure ulcers. This deficiency represents noncompliance investigated under Complaint Number OH00140816 and Complaint Number OH00140473.