Every finding on record at Flint Ridge NRSG & Rehab CTR

Based on interview, medical record review, and facility policy review, the facility failed to ensure appropriate treatment and services to maintain or improve the resident's ability to carry out activities of daily living. This affected one (Resident #93) of three residents reviewed for falls. The facility census was 75.Findings include:Review of Resident #93's medical record revealed an admission date of 04/13/23. Diagnoses include sarcoid myocarditis, sarcoidosis of other sites, difficulty in walking, muscle weakness, other vascular myelopathies, neuromuscular dysfunction of bladder, seizures, anxiety, major depressive disorder, retention of urine, insomnia, GERD, iron deficiency anemia, obesity, hypothyroidism, hypopituitarism, nonrheumatic aortic stenosis, essential (primary) hypertension, and diabetes mellitus due to underlying condition with diabetic neuropathy.Review of Resident #93's medical record revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact.Review of Resident #93's Fall Risk assessment dated [DATE] revealed a score of 4.0 indicated as a low risk.Review of Resident #93's medical record revealed progress note dated 10/30/25 states Certified Nursing Assistant (CNA) was assisting Resident #93 from recliner to wheelchair then Resident #93's knees buckled and CNA assisted Resident #93 to floor on to knees then to buttocks then called for help. Resident #93 was assisted to wheelchair with two- person stand and pivot to chair. New order for x-rays to both knees.Review of Resident #93's 10/30/25 fall investigation revealed a root cause of fall as Resident #93's legs were weak, and knees buckled during transfer. New interventions post fall included two-person assist with transfers to care plan and therapy referral made and picked up 10/31/25. No adverse effects or further injury status post incident.Review of Resident #93's Fall Risk assessment dated [DATE] completed after the fall revealed a score of 9.0 indicated as a moderate risk.Review of Resident #93's care plan for falls updated on 10/31/25 states actual fall 10/30/25 transferring and knees gave out Resident #93 to be two person assist with transfers. Usage of gait belt not noted in care plan.Review of Resident #93's Kardex information for staff revealed safety interventions include actual fall 10/30/25 transferring and knees gave out, to be a two person assist with transfers. Also noted under transferring, actual fall: 10/30/25 to be a two person assist with transfer, stating extensive assistance x2. Toileting noted extensive assist x1.Review of Resident #93's physical therapy (PT) discharge note dated 10/13/25 confirms the Physical Therapist recommends stand by assist with front- wheeled walker and cuing for catheter management; resident typically with good brake management but continues to require infrequent cuing for this as well. Discharge reason noted as highest practical level achieved.Interview on 11/19/25 at 1:35 P.M. with Resident #93 revealed staff do not use a gait belt or a walker when transferring. Resident #93 stated the physical therapist recommended staff use a walker when transferring.Interview on 11/19/25 at 2:00 P.M. with Physical Therapist #300 revealed Resident #93 is currently doing physical therapy to build strength to use walker and staff should be using a walker to transfer Resident #93. Resident #93 was discharged from PT on 05/11/23 with recommendations for stand transfer with front wheeled walker. Resident #93 was discharged from PT on10/13/25 with recommendations for stand pivot transfer to various surfaces with front wheeled walker with stand by assist. Resident #93 was referred to PT after fall on 10/30/25 and we have been working on sit to stand from wheelchair to walker as Resident #93 has not been steady on her feet. with physical therapist #300 verifies all staff should be using a gait belt when transferring residents.Interview on 11/19/25 at 9:29 A.M. with CNA #150 revealed Resident #93 is a one-person assist who can bear weight and turns well stating I do not use a gait belt or walker when transferring Resident #93 since I am usually taking her to the bathroom.Interview on 11/19/25 at 1:30 P.M. with CNA #88 revealed Resident #93 is a one-person assist and can bear weight but if she is feeling weak, we will use a two-person assist and stating I do not use a gait belt or walker when I transfer Resident #93.Interview on 11/19/25 at 2:22 P.M. with the Director of Nursing (DON) verified that using a gait belt to transfer residents is a standard of care. The DON was not aware of a PT recommendation for Resident #93 to use a walker when transferring. The DON states staff are educated on PT recommendations by a communication binder stating we also complete education with staff. The DON also updates the Kardex system which allows staff (CNAs and Nurses) to read updated interventions similar to what was placed in the care plan. The DON continues Kardex would not state to use a gait when transferring residents because a gait belt should be used on all Residents, there is a gait belt in every room.Review of the facility's Falls- clinical protocol revised 09/2012 verified the staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. For an individual who has fallen, the staff and physician will continue to collect and evaluate information until either the cause of the falling is identified. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. If underlying causes cannot be identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason identified for its continuation. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.This deficiency represents non-compliance investigated under Complaint Number 2656988.

Based on observations, interviews and facility policy review, the facility failed to perform hand hygiene during medication administration. This affected nine residents (#19, #30, #36, #46, #49, #59, #65, #76, and #83) of 15 residents receiving medications during afternoon medication administration and had the potential to affect all 28 residents residing on the Main Unit hallway. The facility census was 80.Findings Include: An observation on 08/28/25 from 11:45 A.M. to 12:25 P.M. revealed Registered Nurse (RN) #234 completed noon medication administration on the Main Unit hallway. RN #234 prepared and administered medication for Resident #52, returned to the medication cart to begin preparation of medications for Resident #83 without sanitizing or washing hands. RN #234 administered Resident #83 ' s medications and returned to the medication cart to prepare Resident #30 ' s medications without sanitizing or washing hands. RN #234 administered Resident #30 ' s medications and returned to the medication cart to prepare Resident #36 ' s medications without sanitizing or washing hands. RN #234 administered Resident #36 ' s medications and returned to the medication to prepare Resident #59 ' s medications without sanitizing or washing hands. RN #234 administered Resident #59 ' s medications and returned to the medication cart to prepare Resident #19 ' s medication without sanitizing or washing hands. RN #234 administered Resident #19 ' s medications and returned to the medication cart to prepare medications for Resident #49 ' s without sanitizing or washing hands. An observation on 08/28/25 from 1:30 P.M. to 2:05 P.M. revealed RN #234 completed afternoon medication administration on the Main Unit hallway. RN #234 began preparing Resident #83 ' s medications without sanitizing or washing hands. RN #234 administered Resident #83 ' s medications and returned to the medication cart to prepare Resident #59 ' s medications without sanitizing or washing hands. RN #234 administered #59 ' s medications and returned to the medication cart to prepare Resident #46 ' s medications and sanitized hands. RN #234 administered Resident #46 ' s medication and returned to the medication cart to prepare Resident #76 ' s medications without sanitizing or washing hands. RN #234 administered Resident #76 ' s medications and returned to the medication cart to prepare Resident #65 ' s medications without sanitizing or washing hands. RN #234 administered Resident #65 ' s medications and returned to the medication cart without sanitizing or washing hands.An interview on 08/28/25 at 2:10 P.M. with RN #234 confirmed during the noon medication administration and again during the afternoon medication administration, RN #234 did not sanitize or wash hands between residents. RN #234 stated hand sanitizing and/or washing is to be performed before preparing medications and after administration of medications.Review of the facility ' s policy titled, Administering Medications, undated revealed, Staff follows established facility infection control procedures; handwashing, antiseptic technique, gloves, isolation precautions, for the administration of medications, as applicable.Review of the facility ' s policy titled, Handwashing/Hand Hygiene, dated 10/23 revealed This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.This deficiency is an incidental finding discovered during the complaint investigation.

Based on observation, staff interview, resident interview, and policy review, the facility failed to ensure meals were kept at appropriate temperatures while serving food. This affected two residents (Resident #35 and #61) and had the potential to affect 69 out of 76 residents, with five residents who received nothing by mouth (NPO) diets. The facility census was 76. Findings include: Interview with Resident #61 on 04/28/25 at 12:09 PM revealed that he often does not receive his preferred beverages during meals. Observation of his meal ticket showed orders for milk and apple juice, neither of which were present on his tray at the time of observation. Interview with Licensed Practical Nurse (LPN) #450 at the same time confirmed that milk and apple juice were not provided with the resident's meal. Additionally, Resident #35's nephew reported that food often arrives cold to the room. Observation of the meal service on 04/29/25 at 12:34 P.M. revealed the following food temperatures were taken at the end of the resident dining hall: Baked chicken: 126.1 degrees ( ) Fahrenheit (F) Mixed vegetables: 118 F These temperatures were confirmed by Dietary Manager #456, who was present during the temperature check. According to the Food Code and accepted food safety standards, hot food should be maintained at or above 135 F to prevent bacterial growth and ensure safe and palatable meals. The vegetables and chicken were below this threshold at the time of service. During the resident council meeting on 05/05/25 at 1:20 P.M. residents expressed ongoing dissatisfaction with the temperature of meals served, stating that food often arrives cold due to delays in delivery. Although the facility acknowledged the issue and informed residents that new hotboxes had been ordered to help maintain proper food temperature, the equipment had not yet arrived at the time of the meeting. Residents also reported limited variety in alternate menu options and expressed a desire for more choices when they are dissatisfied with the main meal offerings. Review of the policy titled, Food Preparation and Service dated October 2017, revealed potentially hazardous foods (PHF) must be maintained above 135 F or below 41 F to prevent the rapid growth of pathogenic microorganisms, with the danger zone (41 F to 135 F) allowing only 4 hours if prepared from room temperature or 6 hours if cooked and cooled. Specific cooking temperatures, such as 165 F for poultry and 155 F for ground meat, must be achieved, and rapid cooling from 135 F to 70 F within 2 hours, followed by 41 F within 4 more hours, is mandatory. Additionally, foods not reheated to 165 F for at least 15 seconds must be discarded.

Based on observation, staff interview, and policy review, the facility failed to prepare, store, and serve food in a manner that to prevent contamination. This had the potential to affect 71 out of 76 residents with five residents being on nothing by mouth (NPO) diets. The facility census was 76. Findings include: Observation of the kitchen on [DATE] at 8:59 A.M. revealed multiple items including: undated and unlabeled shredded cheese in a platic container, a bag of shredded cheese which expired in [DATE], cinnamon rolls in the freezer that were opened with no label or expiration date, peas that were both loose in a box and in a bag in the freezer with no label or expiration date, cinnamon streusel coffee cake mix with an arrive date of [DATE] with no expiration date, four bags of opened cereal with no label or expiration date. Observation on [DATE] at 9:15 P.M. revealed the ice machine had black grime on the inside above the ice with water dripping from this area onto the ice. Interview on [DATE] at 9:18 A.M. with Dietary manager #456 confirmed all of the above mentioned items. Observation on [DATE] at 10:47 AM, during a food temperature and preparation check with [NAME] #533, food thermometer use was observed to be inconsistent with safe food handling practices. She checked the temperature of each food item but for the pureed chicken and mashed potatoes she pushed the thermometer passed the cleaned area and the digital screen that was uncleaned went into the food. Interview on [DATE] at 11:04 with [NAME] #533 confirmed she pushed the uncleaned part of the thermometer into the food. Observation on [DATE] at 11:09 AM, a fan covered in dust was observed pointing directly at clean dishware. This was immediately confirmed with Dietary Manager # 456 who immediately decommissioned the fan until staff properly cleaned it. Observation on [DATE] at 11:20 AM, [NAME] #533 was observed washing hands and donning gloves appropriately, but then using gloved hands to touch the outside of a bun bag, then touching the bun and returning to using utensils without changing gloves or washing hands. She was also observed to cut a hotdog with the same gloved hands without changing gloves or performing hand hygiene after handling packaging materials. Interview on [DATE] at 11:49 A.M. with [NAME] #533 and dietary manager #456 confirmed the above findings. Review of facility policy titled Food Receiving and Storage policy dated [DATE], all food items must be properly labeled, dated, stored in clean and sanitary conditions, and handled in a manner that prevents contamination. Review of the facility policy titled, Handwashing/Hand Hygiene policy dated [DATE], staff are required to follow proper hand hygiene practices, including performing hand hygiene before and after resident contact, after glove removal, and when handling potentially contaminated items or surfaces, in order to prevent the spread of healthcare-associated infections.

Based on record review and interview the facility failed to complete a baseline care plan timely for one resident (#73) of five sampled for unnecessary medications and failed to complete a baseline care plan for one resident (#29) of one sampled for bowel and bladder incontinence. The facility census was 76. Findings include: 1. Review of Resident #73's medical record revealed an admitted [DATE] and diagnoses including schizoaffective disorder, bipolar, hypothyroidism, chronic embolism and thrombosis of deep veins of lower extremity, and anxiety. Review of Resident #73's baseline or initial care plan revealed that it was not signed as complete until 09/05/24. Review of Resident #73's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four indicating the resident had severe cognitive impairment. Further review of the admission MDS revealed the resident required substantial/maximum assist for eating, was dependent for all other activities of daily living, and was always incontinent of bowel and bladder. The resident had a stage four pressure ulcer (an open wound over a bony prominence with muscle and bone showing caused by unrelieved pressure) and three unstageable pressure ulcers (areas caused by unrelieved pressure where the stage is not clear because the base of the wound is not visible). In an interview on 05/01/25 at 3:47 P.M. Registered Nurse (RN) #445 stated Resident #73 was admitted on [DATE] and her baseline care plan was not signed as completed until 09/05/24. RN #445 verified the baseline care plan was not completed within 48 hours. 2. Review of Resident #29's medical record revealed an admitted [DATE], discharge return not anticipated date of 01/28/25, a re-entry date of 02/07/25 and diagnoses including acute kidney failure, constipation, unspecified dementia, chronic obstructive pulmonary disease, atrial fibrillation, hypertension, and hyperlipidemia. Review of Resident #29's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. Further review of the MDS revealed Resident #29 required setup assistance with eating and with oral hygiene, and partial/moderate assistance with dressing, moving from a seated position to a standing position, transferring from a bed to a chair or from a chair to a bed, transferring to a toilet and with toileting hygiene. Resident #29's MDS revealed she was frequently incontinent of bladder, had no skin impairments at the time of the assessment and was working with therapy at the time of the assessment. Review of Resident #29's medical record revealed no baseline or initial care plan present in the record at the time of the review. In an interview on 05/05/25 at 2:08 P.M. the Director of Nursing (DON) confirmed the baseline care plan for the 02/07/25 admission had not been completed.

Based on record review and interview the facility failed to ensure care plan conferences were held for two residents (#18 and #53) of two residents sampled for care planning. The facility census was 76. Findings include: 1. Review of Resident #18's medical record revealed an admitted [DATE], a re-entry date of 12/15/24 and diagnoses including insomnia, vitamin B 12 anemia, asthma, end stage renal disease, dependence on dialysis, anxiety, other seizures, diabetes, atrial fibrillation, major depressive disorder, and hypothyroidism. Review of Resident #18's physician's orders revealed an order dated 03/28/25 for dialysis on Tuesday, Thursday, and Saturday with a chair time at 7:45 A.M. Review of Resident #18's annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident has a mild cognition impairment. Resident #18 was on dialysis. In an interview on 04/28/25 at 3:12 P.M. Resident #18 stated she did not remember ever having a meeting to talk about her care or her treatment goals. In an interview on 05/05/25 at 2:58 P.M. Social Services Director (SSD) #410 stated the care conference on 04/09/24 was the most recent care conference held for Resident #18. SSD #410 stated that she and the nursing staff speak with Resident #18's family all the time but they have not had a formal care conference. 2. Review of Resident #53's medical record revealed an admitted [DATE], a re-entry date of 11/26/22, and diagnoses including chronic obstructive pulmonary disease, major depressive disorder, diabetes, anxiety, hypertension and heart failure. Review of Resident #53's significant change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #53's cognition was intact. Further review of Resident #53's MDS revealed she was receiving hospice services. In an interview on 04/28/25 at 10:58 A.M. Resident #53 stated that she has not been to a care conference. In an interview on 05/05/25 at 11:05 A.M. Social Services Director (SSD) #410 stated there were no recent care conferences for Resident #53. SSD #410 stated the most recent care conference held for Resident #53 was 12/01/22. SSD #410 stated that she and the nursing staff speak with Resident #53's family all the time but they have not had a formal care conference.

Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure timely activities of daily living (ADL) assistance for Resident #14. Additionally, the facility failed to ensure Resident #38 had adequate ADL assistance with his fingernails. This affected two (Resident #14 and #38) of four residents reviewed for ADL's. The facility census was 76. Findings include: 1. Review of the medical record for Resident #38 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, moderate protein-calorie malnutrition, weakness, traumatic ischemia of muscle, muscle weakness (generalized), dysphagia (oropharyngeal phase), unsteadiness on feet, difficulty in walking, cognitive communication deficit, syncope and collapse, adult failure to thrive, tachycardia, essential hypertension, epilepsy, and acute kidney failure. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #38, dated 02/09/25, revealed a Brief interview for mental status (BIMS) score of 14, indicating intact cognitive skills for daily decision-making. Additionally, Resident #38 required supervision for eating and oral hygiene, maximum assistance with toileting, showering, upper and lower body dressing, and was dependent for putting on/off footwear. Resident #38 required supervision or moderate assistance for various transfers and bed mobility. Review of physician orders for Resident #38 revealed no specific orders related to fingernail care or interventions regarding shower refusals. Review of the plan of care for Resident #38 revealed no individualized problem, goal, or intervention related to fingernail maintenance or shower refusals. There was no goal identified to address hygiene or prevention of discomfort from long fingernails in the contractured hand. Interventions to ensure resident hygiene compliance through documented shower refusal protocols were not in place. Review of nursing progress notes from February through April 2025 revealed no documentation of staff attempting to offer a shower three times per bathing day as required by facility practice. For example, the resident was documented as having refused showers on 02/01/25, 02/05/25, 02/09/25, 02/19/25, 02/22/25, 02/26/25, 04/05/25, 04/09/25, 04/12/25, and 04/30/25. However, there was no corresponding documentation in the progress notes to confirm that three attempts had been made on any of these dates. Review of shower and bath logs revealed inconsistencies in fingernail care documentation. On multiple dates including 03/01/25, 03/08/25, 03/12/25, 03/26/25, 03/29/25, and 04/26/25, logs indicated fingernails had been trimmed and cleaned. However, this was contradicted by a direct observation on 04/29/25 at 04:23 PM, which revealed the resident had long, yellow-colored fingernails on his contractured left hand measuring approximately one inch in length. The resident reported that the nails dug into his palm, causing discomfort and pain at times. Interview on 04/30/25 at 03:18 P.M. with the Director of Nursing (DON) confirmed the resident's nails were visibly long. The DON acknowledged the issue and offered to trim the nails, which the resident accepted. Observation on 04/30/25 at 03:38 P.M. confirmed some redness in the palm but no active injury. The DON stated that staff are expected to offer showers three times per assigned shower day and document each refusal in the progress notes. She acknowledged that this documentation had not occurred as required. Review of facility policy titled Care of Fingernails/Toenails, Level II, dated October 2010: The policy details nail cleaning and trimming to prevent infections, stressing daily cleaning and avoiding trimming for residents with diabetes or circulatory issues unless permitted. Nails are trimmed in an oval shape (fingernails) or straight across (toenails) using equipment like clippers, emery boards, towels, rinse basins, warm soapy water, orange sticks, linen protectors, lotion, paper towels, and protective gear. The procedure includes washing, soaking, cleaning, trimming, and documenting skin or nail issues. Staff must report signs of poor circulation, swelling, bleeding, or hard nails to the supervisor, ensuring resident safety. 2. Review of the medical record for Resident #14 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, chronic kidney disease stage 3, depression, vascular dementia, type 2 diabetes mellitus with diabetic neuropathy, and muscle weakness, among others. Review of the admission Minimum Data Set (MDS) assessment for Resident #14, dated 4/22/25, revealed a BIMS score of 14, indicating intact cognitive skills for daily decision-making. The assessment indicated that the resident required maximum assistance for various ADL's, including transfers to a wheelchair (manual W/C), use of a walker, setup for eating and oral hygiene, maximum assistance for toileting, showering, and dressing, as well as being dependent for personal hygiene and rolling in bed. Review of the care plan for Resident #14 revealed an intervention to provide assistance with transfers, including from bed to wheelchair, and noted that maximum assistance was required for various ADLs. Observation on 4/28/25 at 10:22 A.M. revealed that the resident requested assistance to get out of bed at 5:30 A.M. but was not assisted until a surveyor arrived at 10:22 AM, approximately 4 hours later. During this time, the staff were unable to locate the resident's wheelchair. The wheelchair was located approximately five to ten minutes after the surveyor arrived, and the resident was assisted out of bed. Interview on 4/28/25 at 4:27 PM with certified Nursing assistant (CNA) #411 revealed that there was a communication issue regarding the resident's wheelchair. She stated that the wheelchair had been relocated to the hallway but did not have the resident's name on it, so she did not know to retrieve it for the transfer. CNA #411 confirmed that the resident had been waiting for more than an hour and was visibly upset, even making a comment about throwing himself out the window. CNA #411 reported this comment to her charge nurse, and facility management took over from there. Review of the policy titled, Accommodation of Needs dated March 2021 revealed that individual needs and preferences be met to the extent possible, including providing assistive devices like wheelchairs, unless it endangers health or safety. Adaptations such as prioritizing private room placement, installing grab bars, and ensuring easy access to assistive devices are required. Staff attitudes and behaviors should assist residents in maintaining independence and dignity, including interacting in ways that accommodate physical or sensory limitations and arranging furniture to support mobility, such as enabling residents to rise independently. The Equipment - General Use for All Residents policy further mandates that wheelchairs, walkers, crutches, and canes be maintained for general use by all residents, without permanent assignment, and that requests for special equipment be referred to the Social Services Department.

Based on record review, family interview, staff interview, and policy review, the facility failed to ensure a comprehensive wound management program to promote healing of Resident #35's pressure ulcer. This affected one (Resident #35) out of three residents reviewed for pressure ulcers. The facility census was 76. Findings include: Review of the medical record for the Resident #35 revealed an admitted [DATE] and a re-entry on 8/16/17. Diagnoses included unspecified dementia without behavioral, psychotic, mood, or anxiety disturbances; stage 4 pressure ulcer (the most severe type of pressure injury, characterized by full-thickness skin and tissue loss with exposed muscle, bone, or tendon) of other site; type 2 diabetes mellitus without complications; unspecified intellectual disabilities; unspecified glaucoma; major depressive disorder (recurrent and unspecified); presence of a cerebrospinal fluid drainage device; paroxysmal atrial fibrillation and hydrocephalus. Review of the Quarterly Minimum Data Set (MDS) 3.0 Assessment, dated 03/17/25, revealed the resident had severely impaired cognition with a brief interview for mental status (BIMS) score of 03. The resident required extensive assistance of two staff for bed mobility, transfers, and ambulation. The assessment indicated the resident had a Stage 4 pressure ulcer. Review of the pressure ulcer risk assessment dated [DATE] for Resident #35 revealed the resident was at high risk for the development of pressure ulcers. Review of the plan of care dated 2/16/25 revealed the resident had a Stage 4 pressure ulcer to the right posterior thigh due to immobility, incontinence, and comorbid conditions including diabetes and dementia. Interventions included: pressure-relieving mattress, repositioning every two hours, use of barrier cream, nutritional supplements, daily skin assessments, and implementation of physician-ordered wound treatments. Review of the wound notes from Healing Partners from June 2024 to April 2025 for Resident #35 revealed the wound progressed from moisture associated skin damage (MASD) (06/07/2024) to unstageable (10/08/2024) and Stage 4 (12/10/2024), peaking at 6.0 centimeters (cm) x 3.5 cm x 1.5 cm with 6.5 cm tunneling (01/14/2025). By 04/29/2025, it improved to 1.0 cm x 0.4 cm x 0.3 cm with 60% epithelial tissue. Orders included Triad cream, medihoney, Santyl, Dakin's solution, silver antimicrobial gel, doxycycline, Amnio Core, NeoStim TL, and calcium alginate dressings, supported by a DPM air mattress, liquid protein, and Stress B/Zinc. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from September 2024 to May 2025 revealed multiple missed treatments for the right posterior thigh wound, with no explanations documented for any of the missed administrations. These included missed treatments on 09/24/24, 10/21/24, 11/02/24, 11/06/24, 11/22/24, 01/23/25, 03/06/25, 04/10/25, 04/17/25, and 04/21/25, involving cleansing, packing with various dressings (such as hydrofiber, Dakin's solution, silver antimicrobial gel, calcium alginate), and applying super absorbent dressings. The treatments were scheduled for daily or shift-based administration between 09/16/24 and 04/22/25, but no documentation provided reasons for the missed treatments. Interview on 05/1/25 at 9:25 A.M. with Registered Nurse (RN) #465 revealed detailed information about the wound, which was approximately 6 cm in circumference with fresh blood when she first started in December. RN #465 mentioned that a wound vac was suggested and treatment started in January. The resident preferred to be repositioned every two hours and had a urinary catheter to help maintain dryness, which contributed to the healing of the wound. Interview on 05/1/25 at 12:14 P.M. with ADON #426 revealed that the wound was initially a reddened area on 06/07/24 and became unstageable by 10/08/24. The ADON explained that the treatment was changed on 10/16/24 after a trial period and noted that missed treatments should be documented in the nurses' notes. Interview on 05/01/25 at 1:12 P.M. with Nurse Practitioner (NP) #621 regional clinical lead for the wound care provider stated they initially picked up the wound on 06/07/24 with MASD. When the wound changed on 10/08/24 NP #621 confirmed the treatment was in place as trial for the two week period and this is why the orders did not change for the treatment until 10/16/24. The NP stated that normally, if there were concerns for declining wounds or possible infections then they will order labs but typically that is only done on an as needed basis. Interview on 05/01/25 at 3:09 P.M. with the Director of Nursing (DON) verified there was no documentation to support the wound treatments were provided as ordered on the dates indicated. Review of the facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol dated March 2014, revealed that the facility is required to follow physician-ordered wound treatments, including wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration. The policy mandates that the physician will authorize pertinent orders related to wound management, which implicitly includes multiple dressing changes as part of routine care.

Based on observation, record review, resident interview, and staff interview, the facility failed to ensure there was follow-up care and monitoring for Resident #38's contracted wrist. This affected one (Resident #38) out of one residents reviewed for positioning and mobility. The facility census was 76. Findings include: Review of the medical record for Resident #38 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, weakness, traumatic ischemia of muscle, muscle weakness (generalized), unsteadiness on feet, difficulty in walking, cognitive communication deficit, adult failure to thrive and epilepsy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #38, dated 02/09/25, revealed a Brief interview for mental status (BIMS) score of 14, indicating intact cognitive skills for daily decision-making. Additionally, Resident #38 required supervision for eating and oral hygiene, maximum assistance with toileting, showering, upper and lower body dressing, and was dependent for putting on/off footwear. Resident #38 required supervision or moderate assistance for various transfers and bed mobility. Observation on 04/29/25 at 04:23 PM revealed the resident had a visibly contractured left wrist. Review of physician orders for Resident #38 revealed no active orders addressing the resident's left wrist contracture. Review of the care plan for Resident #38 revealed no documented problems, goals, or interventions addressing the resident's left wrist contracture. No positioning interventions or splinting goals were identified related to the contracture or to preventing injury from fingernails pressing into the palm. Review of therapy documentation revealed that on 02/09/25, the resident declined the use of a wrist splint for the left wrist. There was no documentation of follow-up by therapy after the refusal until 05/01/25, when occupational therapy re-engaged the resident about splinting following an unrelated fall and the discussion from the survey team regarding his wrist. Interview on 04/30/25 at 03:18 P.M. with the Director of Nursing (DON) revealed the resident was initially sent to therapy on admission. The DON confirmed the resident had a contractured left wrist since admission and that no splint had been implemented. She stated the facility referred to therapy for splint needs and that there is no policy in place requiring therapy follow-up after an initial refusal. Interview on 05/01/25 at 08:57 A.M. with the Director of Clinical Services (DCS) #615 revealed the only physician documentation available related to the contracture incorrectly identified the affected arm as the right. It was confirmed that the actual contracture was on the left and that no other documentation existed to address the condition accurately. Interview on 05/01/25 at 2:53 P.M. with the DON and the Director of Clinical Services #615 confirmed that the facility did not have a process in place to prompt reassessment by therapy for splints after a resident's initial refusal. Interview on 05/01/25 at 3:07 P.M. with Occupational Therapist #620 confirmed the resident was at a 60-degree flexion and improved to 30 degrees, and stated the resident could benefit from a splint and was open to being measured for one. She reproached the resident about splinting based on conversation with survey staff and found he was receptive. She confirmed he could benefit from a splint and would proceed with measuring.

Based on observation, interview, record review and manufacturer;s instruction review the facility failed to ensure the resident environment was free of potential accident hazards. This affected one resident (#46) of three sampled for accidents. The facility census was 76. Findings include: Review of Resident #46's medical record revealed an admitted [DATE] and diagnoses including Alzheimer's disease, unspecified dementia, schizoaffective disorder, insomnia, major depressive disorder, repeated falls, hypothyroidism, hyperlipidemia, and hypertension. Review of Resident #46's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) as she was rarely/never understood when speaking. Further review of the MDS revealed Resident #46 substantial/maximum assist to roll from lying on her back to her left or right side, and to then return to lying on her back on the bed. Resident #46's MDS indicated she was dependent for transfers from bed to chair and chair to bed. Review of Resident #46's physician's orders revealed a mechanical lift, a device used to move the resident from surface to surface, was to be utilized for all transfers in and out of bed. Review of Resident #46's care plan, initiated on 09/16/2019 with a target date of 08/12/2025, revealed interventions including the resident was to have a non-skid materiel to the seat of her wheelchair to help prevent the resident from sliding out of the chair, was to have an anti-roll back device to her wheelchair to prevent the wheelchair from rolling backwards away from her when she was being seated in the wheel chair, and the resident was to be encouraged to wear non-skid footwear when she was out of bed. No interventions were identified to be in place, during the review, to help prevent the resident from rolling out of bed. An observation on 04/28/25 at 11:50 A.M. revealed Resident #46 in bed lying on her right side facing the wall. Resident #46's bed was against the wall with the foot off the bed and the right side of the bed against the wall. A two-to-three-inch gap was noted between the wall and the bed. A solid triangular shaped cushion about three feet in length and eight inches in height had been placed between the mattress and the frame of the bed lifting the mattress and tilting it to the right and toward the wall at a 15 to 20-degree angle. An observation on 04/30/25 at 8:05 A.M. revealed Resident #46 lying in bed on her back. Resident #46 was moving her arms and legs about in bed at the time of the observation. Resident #46's bed was against the wall with the foot off the bed and the right side of the bed against the wall. A two-to-three-inch gap was noted between the wall and the bed. A solid triangular shaped cushion about three feet in length and eight inches in height had been placed between the mattress and the frame of the bed lifting the mattress and tilting it to the right and toward the wall at a 15 to 20-degree angle. The angle of the mattress and movement of the resident making it possible for the resident to slide into the gap between the bed and the wall and not be able to free herself. In an interview on 04/30/25 at 8:05 A.M. Licensed Practical Nurse (LPN) #431 stated she did not know the purpose of the solid triangular shaped cushion under the mattress. In an interview on 04/30/25 at 8:05 A.M. Certified Nursing Assistant (CNA) #455 stated they use the solid triangular shaped cushion between the mattress and the bed frame to elevate the edge of the mattress to keep the resident from rolling out of bed on to the floor. CNA #455 stated Resident #46 will sometimes become restless in bed and will put her feet over the side of the bed and staff did not want her to roll out on to the floor. In an interview on 04/30/25 at 8:30 A.M. the Director of Nursing (DON) stated that she was not aware the staff was placing a solid triangular shaped cushion between the mattress and the frame of the bed to lift the mattress and tilt it to the right and toward the wall. The DON further stated the staff should not be placing the cushion between the mattress and the bed frame. Review of the Primecare P503 Long Term Care Bed Owner's Manual revealed the bed had mattress retainers installed to keep the mattress in place on the sleep surface and the mattress should be snug against all the mattress retainers. Further review of the Primecare P503 Long Term Care Bed Owner's Manual revealed that entrapment issues can arise when components and accessories are not properly installed.

Based on record review, interview and policy review, the facility failed to obtain physician ordered laboratory studies to ensure therapeutic medication levels were achieved. This affected one resident (#17) of five reviewed for unnecessary medications. The facility census was 76. Findings include: Review of Resident #17's medical record revealed an admitted [DATE] with a hospital stay starting on 01/16/25 and ending with the resident's return on 01/19/25. Further review of Resident #17's medical record revealed diagnoses including a displaced intertrochanteric fracture of the left femur, chronic kidney disease stage four, dementia, obsessive-compulsive disorder, osteoporosis, hypothyroidism, major depressive disorder, anxiety, osteoarthritis, unspecified psychosis, epilepsy, hypertension, and chronic pain syndrome. Review of Resident #17's significant change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident has a mild cognition impairment and is receiving anticonvulsant medications, antidepressant medication, and diuretic medication. Review of Resident #17's physicians' orders revealed orders for levetiracetam (an anticonvulsant medication), a potassium supplement, fluvoxamine (an antidepressant medication), and aldactone and lasix (both diuretic medications). Further review of Resident #17's physicians' orders revealed orders for laboratory testing for a complete metabolic panel and levetiracetam level to be done every six months to determine efficacy and therapeutic medication levels. Review of Resident #17's medical record revealed laboratory testing for a complete metabolic panel and levetiracetam level dated 09/16/24. No laboratory testing for a complete metabolic panel and levetiracetam level were found after the 09/16/24 results. In an interview on 05/01/25 at 12:32 P.M. the Director of Nursing (DON) confirmed the most recent complete metabolic panel and levetiracetam level laboratory testing for Resident #17 was completed on 09/16/24. The DON verified the complete metabolic panel and levetiracetam level were ordered to be completed every six months and should have been completed in March. The DON stated the laboratory testing was being completed that day 05/01/25. Review of the policy titled Lab and Diagnostic Test Results - Clinical Protocol revised September 2012 reveled the facility staff were to process test requisitions and arrange for tests to be completed.

Based on record review, staff interview, and policy review, the facility failed to ensure antibiotic use was appropriate. This affected one (Resident #40) of three residents reviewed for urinary tract infections (UTI). The facility census was 76. Findings include: Review of the medical record for the Resident #40 revealed an original admitted [DATE] with a re-entry on 09/20/24. Diagnoses included unspecified systolic (congestive) heart failure, muscle weakness, difficulty walking, dysphagia in the oropharyngeal phase, cognitive communication deficit, Enterococcus as the cause of disease classified elsewhere, obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, bilateral hearing loss, presence of a cardiac pacemaker, gastrointestinal hemorrhage, urinary retention, cardiac murmur, hypertension, and nonrheumatic aortic valve stenosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/17/25, revealed the resident had impaired cognition with a brief interview for mental status (BIMS) score of 4, an indwelling catheter, always incontinent for bowels, and no bowel toileting program. Review of the plan of care dated 09/21/24 and revised 12/18/24 revealed the resident had an indwelling catheter related to urinary retention and obstructive and reflux uropathy. Interventions included monthly catheter changes and as needed (PRN) changes for blockage or dislodgement, monitoring for signs and symptoms of UTI, and notifying the physician for clinical changes. Review of physician orders for the months of October 2024 through March 2025 identified the following antibiotic orders for UTIs: Ciprofloxacin 500 milligrams (mg) by mouth twice daily - ordered and discontinued on 10/04/2024. Amoxicillin-Clavulanate 875-125 mg twice daily for six days - 10/04/2024 to 10/10/2024. Ciprofloxacin 500 mg twice daily for six days - 10/04/2024 to 10/10/2024. Ciprofloxacin 500 mg twice daily for 10 days - 11/12/2024 to 11/22/2024. Nitrofurantoin (Macrobid) 100 mg twice daily for 10 days - 11/02/2024 to 11/12/2024. Ciprofloxacin 500 mg twice daily for 10 days - 12/05/2024 to 12/06/2024 (discontinued after one day). Cefepime two grams intravenous (IV) daily for UTI - 12/09/2024 to 12/12/2024 (discontinued after three days). Ertapenem (Invanz) one gram (g) intravenous (IV) daily for UTI - 12/12/2024 to 12/26/2024. Sulfamethoxazole-Trimethoprim (Bactrim DS) 800-160 mg twice daily - 02/24/2025 to 03/06/2025. Doxycycline 100 mg twice daily - 02/28/2025 to 03/07/2025. Review of the results for the urine cultures there was no evidence that a culture and sensitivity was completed for the Ciprofloxacin and Amoxicillin-pot clavulanate oral tablets after Resident #40 went to the Emergency Department on 10/04/24 and the medications were still administered by the facility from 10/04/24 to 10/10/24. Additionally the culture and sensitivity completed on 02/19/25 did not include results for Doxycycline stating whether it is sensitive or resistant but was still administered from 02/28/25 to 03/07/25. Interview on 05/01/25 at 1:41 P.M. with the Director of Nursing (DON) and the Director of Clinical Services (DCS #615) revealed that when a resident returns from the hospital with an order for antibiotics, the facility does not obtain a urinalysis or urine culture and sensitivity, even if the hospital did not complete those tests. They confirmed that Resident #40 received the above-mentioned antibiotics without a culture and sensitivity being completed prior to administration. Review of the facility policy titled, Antibiotic stewardship dated December 2016 revealed when a resident is admitted from an emergency department, acute care facility, or other care facility the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders. Additionally, when a culture and sensitivity is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

Based on closed medical record review, policy review and interview, the facility failed to prevent a severe weight loss for Resident #2, a resident who received all nutrition via enteral feedings. This affected one resident (#2) of three residents reviewed for nutrition. The census was 72. Actual Harm occurred on 08/03/24 when Resident #2 was assessed to sustain a 10.55% weight loss (with the weight loss occurring between 07/30/24 and 08/03/24). The dietician was not notified and no new nutritional interventions were implemented. The resident continued to lose weight resulting in a 13.8% severe weight loss within 30 days of admission. Findings include: Closed medical record review revealed Resident #2 was admitted on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, atrial fibrillation, total colectomy, gastrostomy, acute kidney failure, hemodialysis and protein-calorie malnutrition. Review of the care plan titled At Nutritional Risk secondary to nothing by mouth (NPO)-tube feeding, hemodialysis treatment, body mass index (BMI) reflects underweight status and use of antibiotics, severe esophageal stricture and ascites (revised 07/19/24) revealed goals including the resident would maintain weight near dry weight and maintain fluid balance and skin integrity through next review on 11/06/24. Interventions included monitor/record/report to physician as needed (PRN) signs/symptoms of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Monitor intake, weight, skin, labs, medication, diet tolerance and hydration status. Weigh at same time of day and record: pre/post hemodialysis weights. Review of the record revealed no evidence the care plan was revised to reflect changes in dialysis and weight loss. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was cognitively intact for daily decision-making, received nutrition 51% or more from a feeding tube, weighed 123 pounds and was 71 inches tall. Review of Resident #2's electronic Physician Orders, Medication Administration Records, Progress Notes and Weights revealed the following: Between 07/17/24 and 07/24/24, the resident received the enteral feeding product, Nepro (therapeutic nutrition designed to help meet the specific nutrition needs of people on dialysis) 55 milliliters per hour (mL/hr) continuous via enteral feeding and his weights ranged between 115.8 pounds (lbs) and 119.9 (lbs). Between 07/24/24 and 07/30/24, the resident received Nepro 60 mL/hr for 18 hours a day via enteral feeding to provide a rest during dialysis treatments and his weights ranged between 119.9 (lbs) and 126.1 (lbs) on 07/30/24. Prostat (nutritional supplement) 30 mL three times a day was started on 07/29/24. Physician #922 ordered Resident #2's dialysis to be held between 07/30/24 through 08/02/24. On 08/03/24, the resident weight was 112.8 (lbs) and he continued to receive Nepro 60 mL/hr for 18 hours a day via enteral feeding with no new interventions implemented. This was noted to be a 13.3 pound/10.55% weight loss between 07/29/24 and 08/03/24. There was no evidence a re-weight was obtained for accuracy or that the physician or dietician were notified at this time. On 08/05/24, Physician #922 ordered Resident #2's dialysis to be discontinued due to improved kidney function. Review of the care plan: Requires Tube Feeding related to Dysphagia (dated 08/09/24) revealed the resident was dependent with tube feeding and water flushes. The registered dietitian was to evaluate quarterly and PRN. Monitor caloric intake, estimate needs, and make recommendations for changes to tube feeding as needed. The next documented weight was obtained on 08/13/24 and Resident #2 weighed 102.4 (lbs). This reflected an additional 10.4 pound weight loss for the resident from 08/03/24. The resident continued to receive Nepro 60 mL/hr for 18 hours a day via enteral feeding. Review of Assistant Director of Nursing (ADON) #350's progress note dated 08/13/24 revealed fluctuations in weight and weight loss noted when initiated weighing with different scale. The note indicated to check weights daily for three consecutive days. No new nutritional interventions were implemented at this time. On 08/14/24, the resident's weight was 99.8 (lbs). A significant weight loss of 13 (lbs) /11.5% in 11 days which constituted a severe weight loss of 13.8% over 30 days/admission weight was identified. Registered Dietitian #924 recommended to increase Nepro 60 mL/hr to 20 hours for a total volume of 1200 mL to infuse and provide 2160 kcal, 97.2 grams of protein and 872 mL of water. Recommendation was also made to increase flush to 100 mL every six hours and monitor weights daily. On 08/15/24, the resident's weight was 101.6 (lbs) and on 08/16/24 his weight was 100.0 (lbs). Resident #2 continued to receive Nepro 60 mL/hr for 18 hours a day via enteral feeding until the morning of 08/16/24. There was no evidence Registered Dietitian #924's recommendations were implemented between 08/14/24 until the morning of 08/16/24. Review of the discharge MDS 3.0 assessment dated [DATE] revealed the resident weighed 100 pounds and received nutrition 51% or more from a feeding tube. Review of a progress note dated 08/16/24 at 5:58 P.M. revealed NP #912 ordered Resident #2 to be sent to the emergency room for evaluation due to lab results and weight loss. The resident was admitted to the hospital and remained in the hospital at the time of the current survey. On 09/05/24 between 2:04 P.M. and 2:45 P.M., interview with the Director of Nursing (DON) verified Resident #2 had a severe weight loss while residing in the facility and receiving nutrition via enteral tube feedings. The DON verified the facility had not implemented interventions to address the weight loss identified on 08/03/24 until 08/16/24 as the dietitian's recommendation to increase the enteral feeding an additional two hours a day was not implemented as recommended on 08/14/24. The DON stated the dietitian was in the facility twice a week and reviewed all weights at that time; therefore, staff does not call or provide written notification to the dietitian with weight loss. On 09/10/24, the DON provided, via electronic interview, a statement from Nurse Practitioner #912 dated 08/14/24 stating Resident #2 has experienced a significant weight loss of greater than 20 (lbs) in the last two to three weeks, despite being on an enteral feedings and his daily caloric intake being followed by RD (registered dietitian). Patient with documented severe esophageal stricture. Patient then underwent colectomy and diverting ileostomy on 05/14/24 and was started on enteral feedings. Prior to those procedures, the patient had a documented weight loss of greater than 100 (lbs). Due to apparent malabsorption issues, chronic adult failure to thrive/protein-calorie malnutrition, and other co-morbidities, including end stage renal disease on hemodialysis, and chronic leukocytosis the nurse practitioner indicated weight loss may be unavoidable. On 09/11/24 between 3:05 P.M. and 3:15 P.M., interview with Registered Dietitian (RD) #924 revealed she reviews all high risk residents including dialysis residents. RD #924 revealed Diet Tech #928 was actually in the facility twice a week and notifies her of weight changes, but she still expected the facility to notify her and not wait until Diet Tech #928 was in the building. RD #924 stated she worked remotely and it was her expectation that weights and documentation was put in the electronic medical record timely so she had the most-up-to date information when completing her assessments to make appropriate recommendations. RD #924 stated the facility did not notify her of any weight loss involving Resident #2 until 08/14/24 due to weights not being entered (electronically). RD #924 also revealed no one had informed her Resident #2's dialysis had been discontinued on 08/05/24 stating she had called the resident's son on 08/14/24 to inform him of possible weight fluctuations with dialysis and he (the son) informed her Resident #2 was no longer receiving dialysis. RD #924 verified Resident #2 had GI malabsorption nutrition problems and having the tube feeding continuous at the lower rate could have resulted in a better tolerance, as his weights were stable during the first part of his stay but the facility failed to notify her of this and if the facility would have notified her of his weight changes, even when they thought it was possibly equipment error, she could have implemented additional interventions. RD #924 stated it was her expectation that staff implement her orders timely especially as she notifies three managers in writing when recommendations were made. RD #924 verified the facility failed to timely implement her recommendations and notify her of significant changes in treatment and weights. Review of the policy: Weight Assessment and Intervention (revised 10/06/22) revealed resident weights were monitored for undesirable or unintended weight loss or gain. Any weight change of 5% or more since the last weight assessment was retaken the next day for confirmation. If the weight was verified, nursing would immediately notify the dietitian in writing. Unless notified of significant weight change, the dietitian would review the unit weight record monthly to follow individual weight trends over time. This deficiency represents non-compliance investigated under Complaint Number OH00156965.

Based on observation, medical record review, policy review and interview, the facility failed to ensure Resident #37 was comprehensively assessed for pain and failed to develop an individualized pain management program to timely identify and prevent pain associated with the resident's pressure ulcers. This affected one resident (#37) of one resident reviewed for pain management. The census was 72. Actual Harm occurred on 09/05/24 when Resident #37 was observed yelling and moaning during pressure ulcer (wound) care. There was no evidence the facility identified the yelling/moaning was related to pain associated with the pressure ulcers and/or wound care and no evidence the facility provided any type of pain medication prior to the dressing change which included treatment of a Stage IV (defined as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcer. Findings include: Medical record review revealed Resident #37 was admitted on [DATE] with diagnoses including moderate intellectual disability, schizoaffective disorder, multiple pressure ulcers and anxiety. Review of the Nursing Admission/Re-admission Assessment - V 4 dated 08/31/24 revealed Resident #37 was not able to verbalize pain and was assessed for pain or possible pain by assessing negative vocalization, facial expressions, body language and consolability. Record review revealed from 08/31/24 through 09/04/24 there were no additional pain assessments or documentation addressing pain for Resident #37. There was no baseline plan of care developed for Resident #37 related to pain including pain associated with pressure ulcers. On 09/05/24 at 9:45 A.M., a resident could be heard yelling and moaning. As the surveyor approached Resident #37's room, the moaning and yelling was louder. There was a treatment cart observed outside of the resident's room and State tested Nursing Assistant (STNA) #621 stated the nurse and nurse practitioner (NP) were in the resident's room doing a wound treatment. Resident #37 could be heard yelling and moaning as Assistant Director of Nursing (ADON) #350 was observed exiting the room. ADON #350 stated NP #908 was completing an initial assessment and treatment of the resident's Stage IV sacrum pressure ulcer and heels. ADON #350 was asked if Resident #37 had been pre-medicated (prior to the pressure ulcer wound assessment and treatment) and stated she would have to check because that would have been given by a different nurse. NP #908 exited the room at that time and ADON #350 asked if the resident had been pre-medicated. NP #908 stated I don't know, that was the facility responsibility and returned to the resident's bedside and finished the treatment. ADON #350 reviewed the electronic medication administration record and verified there was no pain assessment prior to the treatment, no pain medication was administered prior to the treatment, and when the resident was screaming and moaning ADON #350 and NP #908 did not intervene to address the resident's pain and finished the treatment. An attempt to interview the resident following the observation was unsuccessful as the resident was not interviewable. Review of the electronic record revealed Resident #37 was ordered as needed (PRN) Tylenol 650 milligrams every four hours for mild pain. There was no evidence the resident had received any PRN Tylenol or non-pharmacological pain interventions on 09/05/24. There was no other scheduled or PRN pain medication ordered for Resident #37. Review of ADON #350's progress note dated 09/05/24 at 2:30 P.M. revealed Resident #37 was assessed due to being a new admission with wounds (pressure ulcers) including a sacrum Stage IV, left and right heels deep tissue injury (DTI) and left lateral foot DTI. The note included, Resident #37 was without complaints or signs of pain when initiated assessment. Resident began yelling with wound care, states I want to go to bed, resident reassured she was in bed, no complaints or signs of pain, continues to yell and strikes out at NP. Resident #37 with frequent yelling out and at times striking out with care. On 09/05/24 at 10:45 A.M., interview with the Director of Nursing (DON) revealed it was not the usual practice of the facility not to medicate prior to doing a pressure ulcer dressing change. The DON stated it was her expectation if a resident complained or exhibited signs of pain, the resident should be assessed and then treated for pain. Review of the physician order dated 09/05/24 revealed a new order for Resident #37 to receive Klonopin one milligram twice a day for anxiety on this date. Review of Resident #37's electronic Medication Administration Record (MAR) dated 09/11/24 revealed Klonopin (anxiolytic) 1 milligrams (mg) was administered at 8:00 A.M. and Tylenol 325 (mg) two tablets was administered at 9:25 A.M. PRN for pain. On 09/11/24 between 10:09 A.M. and 10:31 A.M., following the administration of the pain medication, observation of Resident #37's pressure ulcer dressing changes revealed no signs or symptoms of pain and no yelling and moaning was heard throughout the treatments to the resident's four pressure ulcers. Review of the policy: Pain- Clinical Protocol (dated June 2013) revealed staff and the physician would identify the nature of (characteristics such as location, intensity, frequency, pat tern, etc.) and severity of pain. Staff would assess pain using a consistent approach and a standardized pain assessment instrument ap propriate to the resident's cognitive level. The staff would observe the resident (during rest and movement) for evidence of pain; for example, grimacing while being repositioned or having a wound dressing changed. The nursing staff would identify any situations or interventions where an increase in the resident's pain may be anticipated; for example, wound care, ambulation, or repositioning. With input from the resident and/or advocate, the physician and staff would establish goals of pain treatment and order appropriate non-pharmacologic and medication interventions to address the individual's pain. This deficiency represents incidental findings of non-compliance investigated under Master Complaint Number OH00156965.

Based on observation and interview, the facility failed to ensure the facility map accounted for all resident rooms and resident rooms provided a safe environment for residents. This affected five residents (#67, #68, #73, #97 and #99) of 25 residents residing on the Serenity Hall. The facility census was 72. Findings include: On 09/03/24 between 2:26 P.M. and 2:50 P.M., observation with Maintenance Director (MD) #326 revealed the following: a. Observation of the posted floor plans revealed Resident #97 and #99's room was labeled as a storage room. There was no evidence of room [ROOM NUMBER] on the floor plan. Interview with MD #326 at the time of the observation verified the facility had been approved in January 2024 for the storage room to be designated as a resident room; however the name plate outside room [ROOM NUMBER] stated Storage Room with masking tape listing the resident names and there was no room [ROOM NUMBER] labeled on the facility maps. b. Observation of Resident #67 and Resident #68's room and revealed two black speckled areas along the lower aspect of the drywall near the floor where the baseboard had been removed. The black speckled areas were in a circular shape measuring approximately 5.5 inches. MD #326 verified the residents room remained in the room during renovations stated the areas had not been tested for black mold MD #326 stated the baseboard and baseboard heating system had been removed on 08/30/24 and the room had been in this condition since that time. c. Observation of Resident #73 in room [ROOM NUMBER] revealed electrical wires extending out four inches from a hole in the wall and room [ROOM NUMBER] (Resident #67 and #68) revealed electrical wires 12 inches from a hole in the drywall near the floor. Interview with MD #326 stated the electrical wires were pulled out from behind the drywall when the baseboard heating unit was removed. MD #326 stated the baseboard and baseboard heating system had been removed on 08/30/24 and the room had been in this condition since that time. MD #326 verified both room [ROOM NUMBER] and room [ROOM NUMBER] were occupied resident rooms. d. Observation of room [ROOM NUMBER] revealed the electric outlet faceplate covers were loose, the bathroom tile was cracked/broken around the door frame, no shower curtain in the large walk-in shower and no toilet paper holder was observed. A roll of toilet paper was observed sitting on the bathroom counter that was not within Resident #97 or #99's reach without leaning to their right side. MD #326 verified the observation and stated this room was scheduled for renovation the following week. MD #326 stated there was not a toilet paper holder within reach due to it used to be a storage room but residents had been in the room since around March 2024. The facility stated there was not a policy regarding maintaining a safe environment available for review at the time of the survey. This deficiency represents incidental non-compliance investigated under Master Complaint Number OH00156965.

Based on observation, dietary meal card review, and interview, the facility failed to provide ordered serving size and ensure whole milk was available for the breakfast meal. This affected seven residents (#19, #28, #41, #54, #71, #73 and #83) who were to receive whole milk and had the potential to affect any resident receiving meals from the kitchen except for seven residents (#17, #23, #67, #74, #78, #84 and #86) who did not receive anything by mouth. The census was 72. Findings include: Review of the Menu Extension dated 09/04/24 revealed breakfast meal included hot or cold cereal, juice, eight ounce glass of whole or 2% milk, six ounces of juice, four ounces of breakfast casserole (scrambled eggs with peppers) and a slice of toast. Review of the breakfast Dietary Meal Cards for Resident #19, #28, #41, #54, #71, #73 and #83 revealed daily items included whole milk. On 09/04/24 at 7:20 A.M., observation of the milk cooler revealed no whole milk was available for the breakfast meal. On 09/04/24 at 7:34 A.M., observation of the breakfast meal trayline service revealed [NAME] #309 was serving breakfast casserole with a spoodle. At the time of the above observation, [NAME] #309 verified she was using a three ounce spoodle to serve the breakfast casserole and stated whole milk was not available for the breakfast meal. Dietary Aide #320 was observed placing a single serving carton of 2% milk on resident breakfast trays. At the time of the above observation, Dietary Aide #320 stated there was currently no whole milk in the facility because they had ran out the previous day due to the observed holiday. Dietary Aide #320 stated the milk was to be delivered to the facility this afternoon and everyone who was ordered whole milk was being provided 2% milk for breakfast. This deficiency represents non-compliance investigated under Complaint Number OH00156069.

Based on observation, policy review and interview, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect all residents except seven residents (#17, #23, #67, #74, #78, #84 and #86) who did not receive anything by mouth. The census was 72. Findings include: 1. On 09/04/24 between 7:06 A.M. and 7:20 A.M., observation of the kitchen with [NAME] #309 verified the following: a. The stove hood above the steamer and six burner stove and flat top had large loose, flaking paint with exposed rust extending the length of metal and in the corner/creases of the hood. b. Dust tendrils were observed blowing from the diamond shaped grating on both sides of the stove hood over the steamer and flat top. Heavy dust and grease build up was observed on top of the stove hood, along the electrical outlet boxes and wire guards adjacent to the stove and behind the dishwasher storage racks containing clean dishes ready for meal service. c. Dust and grease build up was observed on the exhaust fans above the trayline service area. 2. On 09/04/24 at 1:13 P.M., observation of the kitchen with Dietary Manager #415 verified the following: a. The face plate covering the gasline was loose and hanging down. b. The lower front panel of the six burner stove was bent creating a one-half gab to the underlying electrical and service wires. c. The knobs on the griddle were installed backwards, the gas flame was unsymmetrical and the left front half of the griddle would not light. A warning sticker was observed on the lower front panel of the six burner stove stating improper installation, adjustment, alteration service or maintenance can cause property damage, injury or death. On 09/04/24 between 3:05 P.M. and 3:14 P.M., interview with Regional Maintenance Assistant #920 verified the kitchen should be clean, the stove hood was in poor condition and requested an estimate for a new hood. On 09/05/24 at 3:54 P.M., interview with Dietary Manager #415 verified the facility did not have a policy regarding cleanliness of the kitchen. This deficiency represents non-compliance investigated under Complaint Number OH00156069.

Based on observation, medical record review, policy review and interview, the facility failed to provide a dignified meal experience. This affected one resident (#24) of four residents observed during meal service in the dining room. The census was 72. Findings include: Medical record review revealed Resident #24 was admitted on [DATE] with diagnoses including cerebral infarction, hypertension, dysphagia and cognitive communication disorder. On 09/03/24 at 11:55 A.M., observation of the dining room revealed Resident ##24, #25, #27 and #81 were seated at a table in the dining room. Resident #25, #27 and #81 were served their lunch meals and observed being verbally cued and/or physically assisted with their meal by State tested Nurse Aide (STNA) #374. Resident #24 was observed sitting at the table watching Resident #25, #27 and #81 eat their food, and would randomly look at the other residents' eating their meals and then looking around the dining room. On 09/03/24 at 12:05 P.M., STNA #330 was observed bringing Resident #24's meal tray into the dining room. The lunch meal was placed it in front of Resident #24 and the resident stated good, I am hungry. On 09/03/24 at 12:13 P.M., interview with STNA #621 verified Resident #24 was not served her meal at the same time as the other residents at her table in the dining room stating Resident #24 normally eats in her room and her meal had not been delivered as it comes out on the hall trays to be served to bring her meal to her. On 09/05/24 at 4:05 P.M., interview with the Director of Nursing verified all residents at a table should be served meals at the same time and residents were to be treated with respect and dignity. Review of the undated policy: Your Rights and Protections as a Nursing Home Resident revealed residents have the right to be treated with respect and dignity. Review of the policy: Dignity (revised February 2021) revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with like and feelings of self-worth and self-esteem. Residents were to be treated with dignity and respect at all times. When assisting with care, residents are supported in exercising their right including a dignified dining experience. This deficiency represents non-compliance during the investigation of Complaint Number OH00156069.

Based on medical record review, policy review and interview, the facility failed to provide written notice before a resident's room was changed. This affected one resident (#99) of three residents reviewed for room changes. The facility census was 72. Findings include: Medical record review revealed Resident #99 was admitted on [DATE] with diagnoses including charcot's joint left ankle and foot and diabetes mellitus. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #99 was cognitively intact for daily decision-making. Review of Resident #99's Census revealed the following room moves: a. On 02/06/24, admitted to room [ROOM NUMBER]-A. b. On 02/07/24, moved to room [ROOM NUMBER]-A. c. On 02/23/24, moved to room [ROOM NUMBER]-B. d. On 09/05/24, moved to room [ROOM NUMBER]-B. Review of the medical record revealed no documented evidence that Resident #99 was provided written notification including the reason for the change on 02/07/24 or 02/23/24. On 09/11/24 at 11:01 A.M., interview with the Director of Nursing verified there was no evidence of a written notice for Resident #99's room changes. On 09/11/24 at 4:15 P.M., interview with Resident #99 stated she had only received written notice of her room changes on 09/05/24 but not the previous room moves. Review of the policy: Room Change/Roommate Assignment (dated 03/28/23) revealed residents were to receive written or verbal notice at least 24 hours advance notice of the change. Documentation of a room change was to be recorded in the resident's medical record. This deficiency represents non-compliance investigated under Complaint Number OH00156069.

Based on medical record review, observation and interview, the facility failed to provide assistance with meals as needed. This affected one resident (#37) of four residents sampled. The census was 72. Findings include: Medical record review revealed Resident #37 was admitted on [DATE] with diagnoses including moderate intellectual disability, acute respiratory failure, pressure ulcers and schizoaffective disorder. Review of the Nursing Admission/Re-admission Assessment - V 4 dated 08/31/24 revealed Resident #37 required limited assistance with eating. Review of the Skin and Wound Note dated 09/05/24 revealed Nurse Practitioner (NP) #908 assessed Resident #37 to have a Stage IV pressure ulcer to the coccyx, deep tissue injury to the left heel, right heel and left lateral foot. NP #908 indicated the resident had multiple factors that may impair wound healing including the risk of dehydration and malnutrition. Review of the dietitian Progress Notes dated 09/05/24 revealed Resident #37 was ordered a regular, puree texture, nectar thick liquids diet with 25-50% acceptance with refusals noted, and she was dependent for meals and received assistance with meals as needed. On 09/05/24 at 9:53 A.M., observation of Resident #37 revealed she was in bed with the head of the bed up. The resident's breakfast tray was pushed away from the bed out of reach and the food items of the tray were all sealed, covered and unopened. The eggs and bread were pureed and observed on the plate in a measuring scoop form. The juice and milk were unopened. On 09/05/24 at 9:55 A.M., observation with the Director of Nursing (DON) verified the above observation and that the food and drink items had not been set up for the breakfast meal. The drinks were room temperature, the food was not steaming and not within reach. On 09/05/24 at 9:58 A.M., observation revealed State tested Nurse Aide (STNA) #621 entered and exited the room with Resident #37's breakfast tray with the thin consistency juice and milk opened. STNA #621 stated she opened the items and gave the resident a sip of the juice but the resident pushed her away, and refused her breakfast meal at this time. Observation of the juice on the tray at the time of the interview revealed the juice was in the original container and was a thin consistency. On 09/05/24 at 10:26 A.M., interview with STNA #621 revealed Resident #37 needs assistance with meals including set-up but was able to eat independently after set-up. On 09/09/24 at 12:21 P.M., electronic interview with the DON revealed meal delivery times for the main hall was 8:15 A.M. to 8:30 A.M This deficiency represents incidental non-compliance investigated under Master Complaint Number OH00156965.

Based on closed record review, staff interview and review of the Shower/Bath Tub policy and procedure, the facility failed to ensure adequate interventions were in place to prevent the development of a pressure ulcer for Resident #61 and failed to identify or implement treatment until the ulcer was a Stage III (full thickness tissue loss into the fatty tissue layer). This affected one resident (#61) of six residents reviewed for pressure ulcers. Actual Harm occurred on 02/26/20 when Resident #61, who was severely cognitively impaired and required staff assistance for activities of daily living including bed mobility, transfers, toileting and personal care was assessed to have a Stage III pressure ulcer to the left buttocks. A red open area to the coccyx had been previously identified on 02/24/20 with no evidence a treatment was initiated at that time. An investigation noted these areas were in the same location. Findings include: Review of Resident #61's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A plan of care, dated 01/27/20 revealed Resident #61 was at risk for the potential for impairment to skin integrity. Interventions included to use draw sheet or lifting device for transfers, keep skin clean and dry, use lotion on dry skin as tolerated and encourage good nutrition and hydration to promote healthier skin. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition, required assistance from one staff member for bed mobility and transfers and extensive assistance from two plus staff members for toileting and personal care. Review of the weekly skin assessments, dated 02/15/20 and 02/22/20 revealed no documentation of any pressure ulcers. Pressure ulcer risk assessments completed at that time revealed the resident was at high risk for skin breakdown. Review of a Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review Sheet revealed on 02/24/20 a red open area was noted to the coccyx. Continued record review, review of the nursing progress notes and physician orders revealed no evidence the open area was comprehensively assessed or staged at this time. There was no evidence the physician was notified or any type of treatment was initiated. In addition, there was no evidence of pressure reducing interventions being implemented at this time. Review of a wound assessment and care plan, dated 02/26/20 revealed Resident #61 had a wound to the left buttock identified as Stage III pressure injury measuring 0.6 cm (centimeters) in length by 0.9 cm in width with 0.1 cm in depth. A treatment order was obtained at that time to cleanse the wound with normal saline or sterile water, apply collagen and cover with a dry sterile dressing. The documentation revealed the resident had muscle weakness and very limited mobility as well as combined incontinence. Start collagen due to health of wound bed. The note also indicated air mattress pending. On 11/09/20 at 12:30 P.M. interview with the Director of Nursing (DON) verified the area identified on 02/24/20 was in the same location as the area identified to be a Stage III on 02/26/20. The DON revealed the Stage III pressure ulcer to the left buttock should have been found before it had deteriorated to be a Stage III pressure ulcer due to the resident's dependence on staff for care. Review of the facility policy and procedure titled Shower/Tub Bath, dated 2001 and revised 10/2010 revealed the purpose of this procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin: Observe the resident's skin for any redness, rashes, broken skin, tender places, irritation, reddish or blue-gray area of skin over a pressure point, blisters, or skin breakdown. Documentation: The following information should be recorded on the resident's Activity of Daily Living (ADL) record and/or in the resident's medical record: All assessment data (e.g. any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. This deficiency substantiates Complaint Number OH 804.

Based on closed record review, staff interview and review of the facility policy and procedure for Managing Falls and Fall Risk the facility failed to ensure Resident #201, who was dependent on two staff for bed mobility, was provided adequate assistance during care to prevent the resident from falling out of bed. Actual Harm occurred on [DATE] when State tested Nursing Assistant (STNA) #10 was providing care to the resident without the assistance of a second staff person. After assisting the resident to roll to her side in bed, the resident fell from the bed and sustained a fractured neck requiring medical intervention and hospitalization . The resident did not return to the facility following the incident and subsequently passed away during the hospitalization . This affected one resident (#201) of three residents reviewed for falls. Findings include: Review of the closed medical record for Resident #201 revealed an admission date of [DATE] and discharge date of [DATE]. The resident was hospitalized on [DATE] and expired on [DATE] while in the hospital. Resident #201 had [DIAGNOSES REDACTED]. A plan of care, dated [DATE] and revised on [DATE] revealed Resident #201 was at risk for falls characterized by history of falls/injury and multiple risk factors related to impaired balance. The goal developed was for the resident to have no injury from falls. Interventions included call light in reach, Dycem (non-skid mat) to chair at all times, reinforce need to call for assistance, transfer and change positions slowly. An activities of daily living care plan, initiated on [DATE] revealed the resident had a self-care deficit related to previous stroke with [MEDICAL CONDITION] and [MEDICAL CONDITION], multiple contractures and [MEDICAL CONDITION]. Interventions under the area of bed mobility revealed the resident required extensive assistance to total dependence of two staff. The care plan had a revision date of [DATE] noted on it. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident exhibited severe cognitive impairment. The assessment also revealed the resident required extensive assistance from two staff for bed mobility. A fall risk assessment completed on [DATE] revealed the resident was at high risk for falls. A fall risk assessment, dated [DATE] revealed the resident was at moderate risk for falls. Review of the facility incident/accident log revealed Resident #201 sustained a fall on [DATE] at 7:35 A.M. with injury/fracture. The log revealed the resident was sent to the hospital. A nursing progress note, dated [DATE] at 7:57 A.M. and authored by Registered Nurse (RN) #11 revealed staff called this nurse to the resident's room. The resident was noted laying on the floor beside her bed partially on her back/left side. Bleeding was noted from a laceration to the mid/right forehead and the resident was noted to be incontinent of bowel and bladder at that time. The nursing note revealed the nursing assistant (identified to be STNA #10) stated that while providing care, assisting the resident to turn onto her right side, the resident kept rolling and rolled out of bed onto her stomach/left side. Pressure was applied to the laceration on the resident's forehead until bleeding slowed and then a pressure dressing was applied. The resident was assessed for further injuries with none noted. The resident denied any other pain other than to her forehead and range of motion to the right side was within normal limits. The resident's left side was impaired from a [MEDICAL CONDITION] could not be assessed for changes. The resident was left in place (on the floor) and 911 was called for transport to emergency department. The nurse practitioner for primary care physician was updated at 7:45 A.M. and a message was left for the resident's guardian. The Assistant Director of Nursing (ADON) was notified. 911 arrived at 7:47 A.M. and the resident was assisted off the floor to the stretcher and transported to the emergency department at 7:52 A.M. Report was called to the nurse at the emergency department at 7:56 A.M. On [DATE] at 10:45 A.M. the resident's guardian called the facility after speaking with hospital staff and stated the resident was transported to another hospital from there. Review of the local emergency room (ER) report, dated [DATE] revealed the resident was brought by Emergency Medical Services (EMS) from an extended care facility following a fall from her bed. The resident was assessed to have a hematoma and laceration above the right eyebrow with bleeding controlled at this time. The ER report included Chief Complaint: presents for evaluation of head injury, mechanism of injury, fall. Symptoms localized, most severe in the frontal region, [MEDICAL CONDITION] to the neck. The ER documentation revealed the resident arrived on [DATE] at 8:12 A.M. on stretcher via emergency medical services. The resident was assessed to be confused and in distress due to pain. She was cooperative and alert with her skin warm, dry, normal in color. The resident was assessed to have a laceration over the right eye, four centimeters in length with bleeding controlled. During triage the resident began vomiting and was turned onto her left side and vomit cleared from airway. ER testing showed a [MEDICAL CONDITION]'s neck. The resident was placed in a C-collar (due to the fracture) and arrangements were made to transfer the resident to a trauma center hospital with her condition described as serious. On [DATE] at 3:35 P.M. interview with RN #11 revealed she was present at the time of Resident #201's fall on [DATE] and was assigned to care for the resident. The RN verified the resident sustained [REDACTED].#10 was providing care. The resident rolled out of bed. On [DATE] at 1:39 P.M. interview with STNA #10 revealed she was the STNA caring for Resident #201 at the time of the fall on [DATE]. The STNA revealed she was fairly new to being an STNA and new to the facility. When asked about the fall the resident sustained [REDACTED]. She stated the resident had a care plan in the computer but she was not trained on how to use the care plan and there was a new nurse working that day. The STNA stated she had turned the resident in bed to provide care and the resident kept rolling and fell off the other side of the bed. On [DATE] at 3:32 P.M. interview with the Director of Nursing (DON) verified Resident #201 sustained a fall from bed on [DATE] that resulted in a neck fracture. The DON verified the resident required extensive to total dependence from two staff for bed mobility at the time of the incident. Resident #201 was subsequently hospitalized and passed away in the hospital. At the time of onsite survey, a death certificate for Resident #201 was not available. Review of the Managing Falls and Fall Risk, dated 2001 and revised ,[DATE] revealed staff, with the input of the attending physician, would identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. This deficiency substantiates Complaint Number OH 691.

Based on observation, record review, interview, and policy review the facility failed to ensure fall interventions were in place and new fall interventions were initiated after falls. This affected two residents (Resident #43 and #46) of three residents reviewed for accidents. Actual Harm occurred when Resident #46 sustained a left [MEDICAL CONDITION] following an avoidable fall without evidence fall interventions were in place as care planned. Findings include: 1. Review of Resident #46's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident was assessed to be at risk for falls. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 11/18/17 revealed the resident exhibited cognitive impairment. The assessment revealed the resident required extensive assistance from one staff member for bed mobility, transferring and ambulation. Review of Resident #46's fall care plan initiated on 09/28/17 revealed fall prevention interventions included bed in lowest position, instruct on safety measures, call light in reach, non-skid footwear, pad alarm to bed and chair, assist with transfers, and therapy as indicated. On 11/18/17 a new intervention included laboratory testing and offer toileting upon rising, before and after meals, at bedtime, and as needed. On 12/10/17 a new intervention for a mat to the right side of bed was initiated. Review of a [MEDICAL CONDITION] care plan, initiated on 09/28/17 revealed the resident had a history of [REDACTED]. Review of Resident #46's falls revealed: On 11/18/17 nurse's notes indicated the nurse was alerted by another resident that Resident #46 was on the floor. Upon entering the room, the nurse found the resident lying on the floor on her back with her legs extended out next to the roommate's bed. There were no acute injuries noted. The resident's alarm was found turned off with the cord wrapped around the alarm box. Resident #46 had stated I know I shouldn't have got up on my own. New orders were received for a urinalysis (UA) and laboratory testing including a complete blood count and a basic metabolic panel. Review of the fall interdisciplinary team (IDT) note, dated 11/20/17 revealed the resident was found lying on the floor on her back with her legs extended out in front of her. The resident stated, I know I shouldn't have got up on my own and stated that she was on her way to the bathroom. The resident was noted to have cognitive deficits and did not always remember to use the call light or wait for assistance. The note indicated the fall alarm was not sounding. No injuries were noted. The physician, daughter, and nurse manager were notified. Interventions included labs and UA. As a result of the incident, the state tested nursing assistant (STNA) assigned to care for the resident was reprimanded for not ensuring the alarming device was in place and functioning at the time of the fall. On 12/10/17 the nurse heard Resident #46 yelling out for help. Upon entering the room, the resident was observed lying on the floor on her left side at the end of the roommate's bed. A skin tear was noted to the right hand measuring 5.0 centimeters (cm) by 3.0 cm. New orders were received for a low bed; however, the low bed intervention had already been in place since 09/28/17. Review of the nursing progress note revealed no evidence the resident's alarm was sounding at the time of the incident. On 12/11/17 therapy reported to the nurse the resident had complaints of left leg soreness and favored her leg while doing therapy. New orders were received for a left hip and left femur X-ray. The X-ray showed a left [MEDICAL CONDITION] and the resident was sent to the emergency room for an evaluation and was admitted to the hospital with [REDACTED]. Review of a fall IDT note, dated 12/11/17 revealed Resident #46 was found lying on the floor on 12/10/17 at the end of her roommate's bed. The Resident #46 was unable to recall what she was trying to do and denied pain at that time with range of motion (ROM) within normal limits. A skin tear was noted to the back of the right hand. Resident #46 was assisted back to bed. A new intervention listed was for the bed to be placed in lowest position for safety and for a mat to be placed to the floor beside the bed. In the morning on 12/11/17, Resident #46 complained of some soreness to her leg during therapy. An X-ray was ordered with the results received on 12/12/17 and indicated a left [MEDICAL CONDITION]. The resident was sent to emergency room for evaluation. On 02/11/18 at 3:43 P.M., Resident #46 was observed lying in bed with no footwear on, no mats were observed to the floor, and the bed was in high position. Continued observations on 02/11/18, 02/12/13, and 02/13/18 at various times revealed the resident's bed remained in high position and no floor mats were in place. Attempts to interview Resident #46 during the observations were unsuccessful as Resident #46 exhibited cognitive impairment and did not recall sustaining any falls in the facility. On 02/13/18 at 10:52 A.M., observation and interview with Licensed Practical Nurse (LPN) #136 confirmed the resident was resting in bed at that time and her bed was not in lowest position and there was no mat on the right side of the bed as indicated in the care plan. LPN #136, who was the unit manager, thought she had removed the mat because it would be a more of a tripping hazard; however she did not remove the use of the mat from the care plan. On 02/13/18 at 2:03 P.M., interview with the Director of Nursing (DON) revealed the fall on 11/18/17 occurred when the resident was trying to get to the bathroom. She confirmed, following the incident, the STNA assigned to care for the resident was reprimanded for not putting the alarm in place. The DON confirmed at the time of the fall on 12/11/17 that resulted in the left [MEDICAL CONDITION] there was no evidence the alarm was in place or sounding per the fall investigation, nurse's notes, or IDT note. The DON confirmed the resident did have mats next to her bed at one time but if the unit manager thought it was not an appropriate intervention she should have put another fall intervention in place. Review of the facility fall policy revealed the fall risk care plan in the electronic medical record system to prevent accidents based on resident needs was to ensure discussion of the goals and interventions with the resident and family. The policy also indicated to provide training to staff regarding the use of prevention devices as needed. The policy included to implement an immediate intervention based on the assessment data to prevent further accidents from occurring, document the fall in the progress notes in the electronic medical record including resident activity at the time of the fall, physical assessment finding, injuries, family and physician notification and interventions placed. 2. A review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] revealed Resident #43 was at moderate risk for falls. Risk factors included having had one or two falls that occurred in the past six months, cognitive impairment, an inability to come to a standing position independently and requiring hands on assistance to move from place to place. A review of the MDS 3.0 assessment, dated 01/10/18 revealed Resident #43's cognition was severely impaired. She required an extensive assist of two for transfers and was an extensive assist of one for walking in her room and toilet use. A review of Resident #43's active care plans noted a care plan in place for the resident's risk for falls and there was a care plan for having had actual falls multiple times with the most recent fall occurring on 02/05/18. The interventions included the use of Dycem (a tacky pad that came in a roll and could be cut to fit to prevent slipping off of a seated surface) to the wheelchair seat. The intervention for the use of Dycem had been in place since 01/03/17. On 02/12/18 at 2:30 P.M., an observation of Resident #43 revealed she was sitting in the hall outside her room near the nurses' station. The resident was sitting on a cushion in her wheelchair but the Dycem was not visible. The staff approached the resident to ask her if she wanted to lie down and the resident agreed. The resident was assisted to bed. Her wheelchair was left in the corner of her room. There was no evidence of any Dycem being present on top of her cushion or underneath it. Findings were verified by LPN #10. On 02/12/18 at 2:37 P.M., an interview with LPN #10 and STNA #112 revealed they were the ones who laid Resident #43 down in bed. They verified Resident #43 did not have a Dycem in her wheelchair when they transferred her from the wheelchair into bed. LPN #10 reported the Dycem should have been on top of the resident's cushion if it was there. She verified she did not see it on top of the cushion and it was not under the cushion either. STNA #112 reported she had not seen the Dycem used since they changed her from a pad alarm to a tab alarm when up in her chair after her fall on 02/06/18. They obtained a piece of Dycem from the unit manager and placed it in her wheelchair for the future.

Based on record review and staff interview the facility failed to ensure weight loss was identified timely and nutritional interventions were implemented to prevent weight loss for Resident #18. This affected one resident (Resident #18) of three residents reviewed for nutrition. Actual Harm occurred when Resident #18, who was admitted to the facility on [DATE] sustained a 7.05 percent (%) significant weight loss 10.2 pounds between 12/08/17 and 01/04/18 and a 5.95% significant weight loss of eight pounds from 01/04/18 to 02/02/18, for a total of 18.2 pounds. There was no evidence the weight loss was identified timely or that comprehensive interventions were implemented to prevent and address the weight loss. Findings include: Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders, dated 12/01/17 revealed weekly weights times four weeks were ordered. A second order, dated 12/11/17 was also noted for weekly weights times four weeks. On 01/12/18, an order for [REDACTED]. Record review revealed a nutritional plan of care, dated 12/05/17 to weigh Resident #18 every month and as needed and on 12/07/17 a nutritional supplement was to be offered as ordered. However, there was no evidence the supplement was initiated until 01/12/18 when the order was obtained. The current care plan revealed the resident was at nutrition/hydration risk related to dementia and depression with a goal to be free from weight loss of 5% in one month, 7.5% in 3 months or 10% in 6 months by next review. Interventions included allowing family/friends to bring favorite food/fluids within diet. Assist with feeding as needs indicate. Monitor weights every month and as needed. Offer meat into a sandwich or cut into strips, soup to be offered in a mug, vegetables and fruit to be drained and in a bowl, casseroles in a mug. Offer substitutes for items she dislikes. Offer supplement as ordered, provide diet per physician order [REDACTED]. Review of a nutritional note assessment, dated 12/07/17 completed by Registered Dietary Technician (RDT) #86 revealed a 2.0 supplement, 120 cubic centimeters (cc's), two times a day, was recommended due to nutritional and hydration risk related to [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 12/08/17 revealed the resident was independent with eating with supervision required. The MDS assessment revealed the resident had no problems with swallowing/chewing. Review of Resident #18's weights and vitals summary revealed Resident #18 sustained a significant weight loss of 7.05% between 12/08/17 and 01/04/18 and a 5.95% weight loss from 01/04/18 to 02/02/18. The resident weighed 144.6 pounds on 12/01/17, 141.2 pounds on 12/03/17 and 144.6 pounds on 12/08/17. On 01/04/18 the resident weighed 134.4 pounds, on 01/16/18 the resident weighed 130.8 pounds, on 01/25/18 the resident weighed 134.6 pounds and on 02/02/18 the resident weighed 126.4 pounds. This reflected a 10.2 pound weight loss from 12/08/17 to 01/04/18 and an additional eight pound weight loss from 01/04/18 to 02/02/18. Resident #18 lost 18.2 pounds between 12/01/17 and 02/02/18. There was no documented evidence in the progress notes from 12/01/17 to 01/04/18 or from 01/04/18 to 02/02/18 that the dietician, physician or family had been notified of the significant weight loss the resident sustained [REDACTED].>Review of the Medication Administration Record [REDACTED]. There was no evidence Resident #18 had been administered the 2.0 supplement between those dates. Review of the MAR indicated [REDACTED]. Review of progress notes on 01/16/18 revealed RDT#86 recommended the use of [MEDICATION NAME] instead of [MEDICATION NAME] for depression as a possible means to increase appetite of Resident #18. The MAR from January, (YEAR) and February, (YEAR) revealed no evidence this recommendation was implemented. Further review noted no progress note had been completed related to the resident's weight loss at that time Interview with RDT #86 on 02/13/18 at 8:55 A.M. verified she was not notified of the significant change in Resident #18's weight. She stated she would get weekly weights on residents from the nurses and then make any recommendations needed. RDT #86 stated the nurses were responsible for notification to the physician and family if any change in condition occurred. RDT #86 verified the physician and family of Resident #18 were not notified of the weight loss. Interview with RDT #86 on 02/13/18 at 11:33 A.M. verified Resident #18's weekly weights had not been completed according to her recommendations, the 12/05/17 recommendation for a 2.0 supplement was not implemented timely and Resident #18 had sustained a significant weight loss. The RDT #86 verified there was no evidence individualized and comprehensive interventions were implemented timely to identify and prevent weight loss for the resident. RDT #86 confirmed there was no evidence her recommendation on 01/16/18 to change the [MEDICATION NAME] to [MEDICATION NAME] was addressed. Review of the facility's height and weight policy revealed that each resident's height and weight would be determined by appropriate methods and recorded within 24 hours of admission. Admissions would be weighed every week for four weeks, then monthly thereafter, unless the resident's condition required more frequent monitoring.