Every finding on record at Foundation Park Care Center

Based on staff interview, pharmacist interview, review of the Narcotic Shift Count sheet and review of facility policy, the facility failed to ensure the security of controlled medications by maintaining an uninterrupted chain of custody of the medication cart keys. This had the potential to affect six (#33, #30, #62, #10, #28 and #63) residents who had physician ordered controlled medications stored in the Hall-A medication cart. The facility census was 91. Findings include:Interview on 07/29/26 at 2:26 P.M. with Registered Nurse Supervisor (RNS) #200 revealed on the morning of 07/03/26, she received the Hall-A medication cart keys from Licensed Practical Nurse (LPN) #210. RNS #200 stated the controlled medication count was completed by two other licensed nurses. RNS #200 verified a controlled medication count was not completed when she accepted the Hall-A medication cart keys from LPN #210. Interview on 07/30/26 at 9:00 A.M. with LPN #210 revealed on the morning of 07/03/26, she had to leave early. LPN #210 stated she completed the Hall-A medication cart controlled medication count with a second nurse from another hall. LPN #210 stated she was unable to remember if the count was completed with LPN #250 or LPN #370. LPN #210 stated the Hall-A medication cart keys were then given to RNS #200. LPN #210 verified a controlled medication count was not completed with RNS #200, who accepted responsibility for the Hall-A medication cart controlled medications, prior to the keys being handed off to her. Interview on 07/30/26 at 10:00 A.M. with the Director of Nursing (DON) revealed she was aware of the Hall-A medication cart key hand off on the morning of 07/03/26. The DON confirmed LPN #210 and LPN #250 completed the controlled medication count. The DON also verified the Hall-A medication cart keys were then passed from LPN #210 to RNS #200 without the two licensed nurses completing a controlled medication count together. The DON verified the standard of care related to controlled medications was for the off-going nurse and the on-coming nurse to complete the controlled medication count together before handing off the medication cart keys to maintain chain of custody. Interview on 07/30/26 at 11:16 A.M. with Pharmacist #380 verified the best practice to maintain chain of custody of controlled medications was for the off-going nurse and the on-coming nurse to count the controlled medications together, prior to passing off the medication cart keys. Review of the Narcotic Shift Count for 07/03/26 verified LPN #210 completed the controlled substance count with LPN #250 for the Hall-A medication cart. The medication cart keys, along with the controlled medication storage key, were then handed off to a third nurse, RNS #200, who was not involved in the controlled medication count. RNS #200 did not complete a controlled medication count prior to taking the keys for the Hall-A medication cart. Review of the facility policy titled, Controlled Substance Storage, dated April 2018, revealed at each shift change, or when keys were transferred, a physical inventory of all controlled substances, including refrigerated items, was conducted by two licensed nurses and was documented. This deficiency was an incidental finding discovered during the complaint investigation.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure documentation of meal intakes were completed in the medical record. This affected three (#28, #35, #86) of three residents reviewed for meal intake documentation. The facility census was 83.Findings include:1. Review of the medical record for Resident #28 revealed an admission date of 07/30/20. Diagnoses included vascular dementia, hemiplegia/hemiparesis following cerebral infarction, dysphagia, and hypertension.Review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for eating meals.Review of the nutrition care plan last revised 02/18/26 revealed to provide food, fluids, and supplements as ordered. Monitor intake and record every meal. Review of the physician order dated 11/07/23 revealed the resident was on a regular diet with pureed texture and nectar consistency liquids. Review of the meal intake documentation dated 03/18/26 to 04/15/26 revealed no documentation of meal intakes for one meal on 03/18/26, two meals on 03/22/26, one meal on 03/26/26, two meals on 03/27/26, two meals on 03/28/26, one meal on 03/31/26, no meals on 04/01/26, one meal on 04/02/26, one meal on 04/06/26, two meals on 04/09/26, two meals on 04/10/26, one meal on 04/12/26, one meal on 04/13/26, one meal on 04/14/26, one meal on 04/15/26. Review of the nursing notes dated 03/18/26 to 04/15/26 revealed no documentation the resident had refused any meals.2. Review of the medical record for Resident #35 revealed an admission date of 08/02/23. Diagnoses included dementia, hypertension, and type two diabetes mellitus. Review of the quarterly MDS assessment dated [DATE] revealed the resident had sever cognitive impairment and was dependent of staff for eating meals.Review of the nutrition care plan last revised 11/23/25 revealed provide food, fluids, and supplements as ordered. Monitor intake and record every meal. Review of a physician order dated 08/02/23 revealed the resident was on a regular diet with mechanical soft texture with thin liquids.Review of the meal intake documentation dated 03/18/26 to 04/15/26 revealed no documentation of meal intakes for one meal on 03/18/26, two meals on 03/22/26, one meal on 03/26/26, two meals on 03/27/26, two meals on 03/28/26, one meal on 03/31/26, no meals on 04/01/26, one meal on 04/02/26, one meal on 04/06/26, two meals on 04/09/26, two meals on 04/10/26, one meal on 04/12/26, one meal on 04/13/26, one meal on 04/14/26, one meal on 04/15/26. Review of the nursing notes dated 03/18/26 to 04/15/26 revealed no documentation the resident had refused any meals.3. Review of the medical record for Resident #86 revealed an admission date of 03/19/26 and a discharge date of 03/30/26. Review of the admission MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for eating meals. Review of the nutrition care plan initiated 03/20/26 revealed to provide food, fluids, and supplements as ordered, monitor intake and record every meal. Review of a physician order dated 03/27/26 revealed the resident was on a regular diet with pureed texture with thin liquids. Review of the documented meal intakes dated 03/19/26 through 03/29/26 for FSR #86 revealed the resident had variable meal intakes of zero to 75 percent with seven documented meal refusals. There was no documentation of the resident's meal intake for nine meals.Interview on 04/16/26 at 3:22 P.M., Certified Nursing Assistant (CNA) #200 revealed staff should document the percentage of meal intakes for each resident at each meal. CNA #200 also revealed the nurse should be notified if a resident refused a meal. Interview on 04/16/26 at 4:56 P.M., the Director of Nursing (DON) verified staff were not documenting meals intakes for each meal for Residents #28, #35 and #86. The DON also verified the staff should be documenting meal intakes for each meal for Residents #28, #35 and #86 as ordered.Review of the facility policy Feeding Residents, last reviewed 2024, revealed to record meal intakes on the resident meal intake log. Also to report all concerns to the charge nurse. This was an incidental finding discovered during the course of the complaint investigation.

Based on observations, record review, staff interviews, consultant interviews, and policy review, the facility failed to ensure the dishwashing machine was functional, failed to ensure appropriate hand hygiene was practiced during meal service, and failed to ensure emergency water was stored in a sanitary environment. This had the potential to affect all residents in the facility. Additionally, the facility failed to ensure residents received food without foreign substances. This affected one (#73) of four residents reviewed for food and nutrition. The facility census was 87. Findings include: 1. Observation and interview on 03/10/26 at approximately 10:35 A.M. with Dietary Manager (DM) #418 revealed a high-temperature dishwasher was used by the facility. Observation revealed no plastic or glass covers were over the washing temperature gauge or the rinsing temperature gauge. Further observation during a dishwashing cycle of the machine revealed the temperature gauges did not fluctuate through two washing and rinsing cycles. DM #418 confirmed the gauge needles did not fluctuate while the machine was in use. DM #418 further stated the dishwasher was serviced by an outside company and DM #418 was told by a company representative covers could not be placed over the gauges because it caused fogging.Review of the dishwasher's servicing company's service report, dated 01/27/26, revealed appropriate washing and rinsing temperatures.Observation on 03/11/26 at 11:34 A.M. revealed new gauges with covers were in place on the dishwasher. Interview with Company Representative (CR) #521 confirmed he replaced both temperature gauges on the dishwasher. CR #521 stated he serviced the dishwasher in the past and had not noticed whether the gauges moved. CR #521 stated he replaced the gauges on 03/11/26 because the probes going into the gauges were rusted. CR #521 stated he had not checked the probes in the past. Further observation revealed the gauges functioned appropriately and reflected adequate washing and rinsing temperatures upon initiating a cycle of the dishwasher. 2. Observation during meal service on 03/10/26, beginning at 11:21 A.M., revealed [NAME] #485 serving the noon meal. [NAME] #485 was wearing disposable gloves while touching service utensils, plates, and drawer handles. Continued observation, at approximately 11:29 A.M. revealed [NAME] #485 wore the same gloves to pick up a plastic bag of buns and manipulated the bun out of the bag and onto a plate without touching the bun. [NAME] #485 then used the same gloves to open the bun to place meat into the bun. Interview on 03/10/26 at 11:31 A.M. with [NAME] #485 confirmed she touched several multi-use items before touching the ready-to-eat bun. [NAME] #485 confirmed clean gloves should be used when touching ready-to-eat foods.Continued observations during the noon meal service revealed [NAME] #485 continued to touch multi-use items and then used the same pair of gloves to hold open a bun and place meat inside. Concurrent interview with [NAME] #485 confirmed the gloves had touched other surfaces in the kitchen before touching ready-to-eat buns.3. Observation on 03/09/2026 at 2:37 P.M. of the A-Hall communal bathroom and shower revealed the facility's emergency water storage of one and a half pallets of 16-ounce water bottles in 24-count packs wrapped in plastic on the top and bottom was in a shower stall. A shower curtain was the barrier between the shower stall and the remainder of the bathroom. Interview at this time between Director of Maintenance (DOM) #409 and the Safety and Health Consultant (SHC) confirmed the emergency water was stored in the communal shower because the facility had no other storage for the pallets.Interview on 03/11/26 at 7:31 A.M. with Certified Nursing Assistant (CNA) #493 confirmed residents use the toilet and shower in the A-hall communal bathroom. Concurrent observation revealed staff taking Resident #24 into the shower room. Observation while the bathroom door was open revealed soiled clothing on the floor. 4. Observation during breakfast meal service on 03/09/26 at 8:05 A.M. revealed Resident #73 sitting at a table in the large dining room. Resident #73 had a plate of eggs, toast, and sliced banana in front of her. Resident #73 was eating slices of banana with her fingers. Further observation revealed a foreign substance was on Resident #73's eggs.Interview on 03/09/26 at 8:17 A.M. with the Director of Nursing (DON) and concurrent observation of Resident #73's plate confirmed a foreign substance was on Resident #73's eggs. The DON used Resident #73's fork to remove the item, stating the item may have been part of the jelly packet foil covering. The DON proceeded to attempt to feed Resident #73 who stated she did not want any more food. The DON spoke with CNA #457 who stated Resident #73 ate better with some assistance and CNA #457 asked the DON to cover the plate and CNA #457 would reheat it and provide assistance to Resident #73. The DON then covered Resident #73's plate, including the eggs from which the foreign substance was removed, for Resident #73 to consume later. Continued observation revealed CNA #457 took the plate to the kitchen to be microwaved and was advised the kitchen would provide a new plate with fresh, warm food.

Based on observation, staff interview, medical record review, policy review and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure a risk assessment was developed with facility specific measures to prevent the growth of Legionella. Additionally, the facility failed to ensure monitoring of Legionella control measures. This had the potential to affect all residents. Furthermore, the facility failed to wear proper personal protective equipment (PPE) while providing care to residents with physician orders for enhanced barrier precautions (EBP). This affected two (#11 and #22) of four residents reviewed for EBP. The facility identified nine residents (#5, #6, #60, #13, #24, #12, #47, #11, and #22) requiring EBP. Finally, the facility failed to ensure three staff (#433, #472, and #492) completed annual Mantoux (Tuberculosis) risk assessments. This had the potential to affect all residents in the facility. The facility census was 87. Findings include: 1. Review of the facility Legionella Risk assessment dated [DATE] revealed the description of the water system had not identified the facility water source and site-specific water flow systems throughout the building including if dead-end plumbing was present. Control and monitoring measures included weekly temperature controls/checks of hot and cold water with monthly water heater inspections, weekly flushing of low use outlets, regular use of showers and sinks with quarterly shower head cleaning, routine monthly cleaning of ice machines, and aerators as well as routine inspection of heating ventilation and air conditioning (HVAC) components that may produce moisture. Additionally, the Legionella Risk Assessment revealed water temperature logs, flushing logs, equipment cleaning records, risk assessment updates and incident reports (if applicable) would be documented. Review of the facility documentation revealed the facility was monitoring and documenting water temperatures. There was no documentation for flushing or equipment cleaning. Interview on 03/11/26 at 12:10 P.M. with Maintenance Supervisor (MS) #409 revealed the facility was performing flushing of unused outlets, but was not aware documentation of the monitoring was needed. MS #409 also revealed no further monitoring was in place for the Legionella control measures. Additionally, MS #409 verified the control measures listed in the facility Legionella Risk Assessment were not being performed. Control measures listed included, weekly outlet flushing logs, quarterly shower head cleaning and monthly water heater inspection. Interview on 03/12/26 at 8:14 A.M. with the Administrator and MS #409 verified the current Legionella Risk Assessment had not identified the flow of water throughout the building and specific potential sources of Legionella growth within the facility. Control measures listed in the facility risk assessment were reviewed with the Administrator. The Administrator verified the control measures listed in the facility Legionella Risk Assessment were not being implemented. Control measures listed included: weekly outlet flushing logs, quarterly shower head cleaning and monthly water heater inspection. Review of the facility policy titled Legionnaire's Disease Policy, revealed the Administrator would be responsible for the establishment and maintenance of an effective practice and policy to limit the potential hazards posed by Legionella disease. The Environmental Services Director was responsible for the control of Legionella processes and would maintain all records of completed testing, maintenance, and controlling/monitoring measures. Further review of the policy revealed key personnel would have general knowledge of the principles, design, and function of the domestic hot and cold-water service. 2.Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included dementia, severe protein calorie malnutrition, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of the Minimum Data Set (MDS) assessment completed on 02/22/26, revealed the Resident #11 had severe cognitive deficits and was dependent for activities of daily living. Review of the care plan for Resident #11 dated 02/03/26 revealed the resident had an indwelling urinary catheter. Interventions included for PPE to be located in or near the resident's room to be put on by staff before providing care for dressing, bathing/showering, transferring in the room, providing hygiene, changing lines, changing briefs or assisting with toileting, device care, and wound care with dressing changes. Review of the physician orders dated 02/10/26 for Resident #11 revealed an order for PPE, including a gown and gloves, located in or near the resident's room to be put on by staff before providing care for dressing, bathing / showering, transferring in the room, providing hygiene, changing lines, changing briefs or assisting with toileting, device care (central lines, urinary catheters, feeding tubes, tracheostomy care), and wound care with dressing changes. Observation and interviews on 03/10/26 at 10:43 A.M. revealed Certified Nursing Assistant (CNA) #506 assisted Licensed Practical Nurse (LPN) #464 with catheter care for Resident #11. LPN #464 wore a gown and gloves. CNA #506 was only wearing gloves. During an interview CNA #506 stated a gown was only needed when providing direct care for Resident #11's catheter. Once LPN #506 was complete with catheter care, CNA #506 closed and fastened the resident's incontinence brief. CNA #506 then proceeded to place the catheter drainage bag through the leg of a pair of grey sweatpants. CNA #506 assisted Resident #11 with rolling from side to side to pull the sweatpants up. CNA #414 then entered the room to assist CNA #506 in getting Resident #11 up from the bed into the wheelchair. CNA #506 and CNA #414 both had gloves on and neither were dressed in protective gowns. After Resident #11 was placed in his wheelchair, CNA #506 and CNA #414 verified they were not wearing protective gowns during the transfer. CNA #506 revealed a protective gown was not needed unless Resident #11 was being bathed or catheter care was being provided. CNA #506 stated if she was supposed to be wearing PPE at other times then she was not aware. Interview on 03/11/26 at 1:37 P.M., Infection Preventionist Registered Nurse (IPRN) #500 revealed the EBP signage outside of residents' rooms consisted of a laminated set of yellow hands placed next to the resident name. IPRN #500 stated direct care staff were educated on hire and annually on EBP practices and CNAs should also receive this information in report. IPRN #500 stated there is also signage at each nurses' station listing what to wear in EBP rooms. IPRN #500 verified CNAs should wear PPE when applying a brief and handling a urinary catheter drainage bag. Review of the facility policy titled Enhanced Barrier Precautions, dated 05/2024, revealed staff entering the identified resident's room would wear a protective gown and gloves prior to performing high-contact resident activities including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care. Review of Frequently Asked Questions about Enhanced Barrier Precautions released from the CDC on 06/28/24 provided by the facility revealed EBP was primarily intended to apply to care that occurs within a resident's room where high contact resident care activities, including transfers, were bundled together with other high contact activity, such as part of morning or evening care. This extended contact with the resident and their environment increased the risk of multidrug resistant organism (MDRO) spreading to staff hands and their clothes. 3. Review of the medical record for Resident #22 revealed an admission date of 07/31/19. Diagnosis included dementia, hemiplegia , gastrostomy status, dysphagia, and epilepsy. Review of the Minimum Data Set (MDS) assessment, dated 12/17/25, revealed Resident #22 was rarely/never understood, had impairment to both sides and was dependent on staff for transfers and all mobility and activities of daily life. Review of Resident #22's care plan, revised 02/20/26, revealed Resident #22 had a skin alteration to the left elbow. Interventions included: Personal protective equipment gown and gloves will be located in or near the resident's room to be put on by staff before providing care for dressing, bathing /showering, transferring in the room, providing hygiene, changing lines, changing briefs or assisting with toileting, device care (central lines, urinary catheters, feeding tubes, tracheostomy care), and wound care with dressing changes. Further review of Resident #22's care plan revealed Resident #22 required a tube feeding. Interventions included: Personal protective equipment gown and gloves will be located in or near the resident's room to be put on by staff before providing care for dressing, bathing / showering, transferring in the room, providing hygiene, changing lines, changing briefs or assisting with toileting, device care (central lines, urinary catheters, feeding tubes, tracheostomy care), and wound care with dressing changes. Review of Resident #22's physician order dated 04/25/25 revealed personal protective equipment, gown and gloves, will be located in or near the resident's room to be put on by staff before providing care for dressing, bathing / showering, transferring in the room, providing hygiene, changing linens, changing briefs or assisting with toileting, device care (central lines, urinary catheters, feeding tubes, tracheostomy care), and wound care with dressing changes, every shift related to feeding tube. Observation on 03/12/26 at 12:45 P.M. revealed the Director of Nursing (DON), Registered Nurse (RN) Supervisor #471, IPRN #500, and CNA #449 were present in Resident #22's room to provide assistance during an observation of Resident #22's skin integrity. No staff were wearing gowns and the DON was not wearing a gown or gloves. Resident #22 was sitting in his wheelchair when RN Supervisor #471 and CNA #449 used a mechanical lift to transfer Resident #22 from the wheelchair to his bed. The DON adjusted the mechanical lift pad under Resident #22, completed hand hygiene, and left the room. RN Supervisor #471 and CNA #449 positioned Resident #22 to provide clear visibility of Resident #22's skin, then proceeded to reposition and cover Resident #22. Interview on 03/12/26 at 12:53 P.M., in Resident #22's room, with IPRN #500 and concurrent review of Resident #22's electronic medical record confirmed staff should wear a gown and gloves when transferring and providing care to Resident #22. Continued interview and observation revealed disposable gowns were inside a cart inside Resident #22's closet. IPRN #500 confirmed no staff in the room wore a disposable gown. Interview on 03/12/26 at approximately 12:55 P.M., in Resident #22's room, with CNA #449 revealed she was not aware of the physician's order for staff to wear personal protective equipment, including gowns and gloves, when providing care to Resident #22. The facility identified nine residents (#5, #6, #60, #13, #24, #12, #47, #11, and #22) requiring EBP. Interview on 03/12/26 at approximately 12:56 P.M., outside Resident #22's room, with RN Supervisor #471 confirmed an Enhanced Barrier sign should be posted outside Resident #22's room, and was not posted. 4. Review of Certified Nursing Assistant (CNA) #433's personnel file revealed a hire date of 12/20/23. Review of the required Mantoux testing revealed the CNA failed to complete the yearly risk assessment in the previous 12 months. Review of CNA #472's personnel file revealed a hire date of 06/15/25. Review of the required Mantoux testing revealed the CNA failed to complete the yearly risk assessment in the previous 12 months. Review of CNA #493's personnel file revealed a hire date of 02/10/24. Review of the Mantoux testing revealed the CNA failed to complete the yearly risk assessment in the previous 12 months. Interview with the Human Resource Manager on 03/12/26 at 2:20 P.M. verified the yearly assessments has not been completed. Review of the facility policy titled Tuberculosis Screening revised 2017 revealed an annual risk assessment will be completed each year in January. Employees will complete a questionnaire annually in January.

Based on review of the medical record, staff interview, and policy review the facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects and adverse effects. This affected three (#15, #35, and #10) of five residents reviewed for unnecessary medications. The facility identified 66 residents receiving psychotropic medications. The facility census was 87.Findings include:1. Review of the medical record for Resident #15 revealed an admission date of 01/14/26. Diagnoses included psychosis, mood disorder, anxiety, frontotemporal neurocognitive disorder, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the plan of care initiated 10/02/25 revealed Resident #15 received psychotropic medications. Further review of the plan of care revealed an intervention to administer psychotropic medication as ordered by the physician and to monitor for side effects and effectiveness every shift. Also for staff to monitor/document/report as needed any adverse reactions of psychotropic medications. Review of the physician orders dated 10/02/25 revealed orders for escitalopram oxalate table 20 milligrams (mg) by mouth daily for mood, olanzapine tablet 2.5 mg daily for psychosis, and mirtazapine 15 mg tablet daily for depression with weight loss. There were no orders for monitoring for medication effectiveness, adverse effects and side effects. Review of the nurses' notes, medication administration records (MARs) and treatment administration records (TARs) from 02/01/26 through 03/09/26 revealed no documentation the resident was monitored for medication effectiveness, adverse effects, and side effects of the psychotropic medications. Interview of 03/10/26 at 9:20 A.M., the Director of Nursing (DON) verified there was no documentation Resident #15 was monitored for adverse effects and side effects of the psychotropic medications. 2. Review of Resident #35's medical record revealed and admission date of 09/11/25, with diagnoses including dementia, hallucinations, anxiety, restlessness and agitation. Review of the MDS assessment, dated 12/17/25, revealed Resident #35 received antipsychotic, antianxiety, and antidepressants medications. The medical record indicated Resident #35 was prescribed Clonazepam 0.5 mg, give half tablet (0.25 mg) by mouth every eight hours as needed for agitation. Review of the Controlled Drug Receipt/Record/Disposition Form revealed that the medication was administered six times in the month of February. Review of the medical records showed no documentation for the monitoring of potential side effects or effectiveness. Interview on 03/11/26 at 1:30 P. M. with MDS Coordinator #471 confirmed Resident #35's record contained no evidence of monitoring for side effects or efficacy of clonazepam. 3. Review of the medical record revealed Resident #10 admitted to facility on 08/14/25 with diagnoses including, dementia, Type II diabetes mellitus, lumbar vertebra fracture, neurocognitive disorder with Lewy bodies, hypertension, post traumatic stress disorder, depression, transient ischemic attack, and cerebral infarction. Review of the MDS assessment, dated 02/13/26, revealed Resident #10 was severely cognitively impaired and had delusions. Resident #10 received antipsychotic and antidepressant medications. Review of the plan of care, dated 08/15/25, revealed Resident #10 used prescribed psychotropic medications with a goal noting the resident would remain free of psychotropic drug related extrapyramidal symptoms (EPS - shuffling gait, rigid muscles, shaking) through the next review date. Interventions included the following: monitor/document/report as needed (PRN) any adverse reactions of psychotropic medications: tardive dyskinesia, EPS, suicidal ideations, and behavior symptoms not usual to the person. Review of the physician orders revealed on 01/23/26, Resident #10 was prescribed mirtazapine oral tablet, give 15 mg by mouth at bedtime for depression with weight loss and on 12/05/25, the resident was prescribed clozapine oral tablet, give 100 mg by mouth at bedtime related to violent behavior, hallucinations, post-traumatic stress disorder. Further review of the medical record revealed no evidence indicating the facility monitored for side effects for any adverse reactions of psychotropic medications, tardive dyskinesia, EPS, suicidal ideations, or behavior symptoms not usual to the person. Interview on 03/11/26 at 10:36 A.M. with the Director of Nursing (DON) verified no documentation was contained in Resident #10 medical record indicating the use of psychotropic medications were being monitored for side effects. Review of the undated facility policy titled, Free from Unnecessary Psychotropic Medications Use, revealed the facility would monitor for medication efficacy, medication side-effects, and adverse consequences.

Based on observations, record reviews, staff interviews, and policy reviews, the facility failed to ensure dependent residents received assistance with activities of daily life. This affected five (#65, #82, #73, #53, and #11) of six residents reviewed for activities of daily living (ADLs). The facility census was 87.Findings include:1. Review of the medical record for Resident #65 revealed an admission date of 06/07/23 with diagnoses of dementia, Type II diabetes mellitus, epilepsy, anxiety, and traumatic brain injury. Review of the quarterly Minimum Data set (MDS) assessment, dated 02/11/26, revealed Resident #65 was rarely/never understood and was dependent on staff for eating. Review of a physician order dated 01/07/26 revealed Resident #65 received a regular diet with pureed textures and thin liquids, with double portions. Review of the medical record for Resident #82 revealed an admission date of 11/08/23 with diagnoses of dementia and aphasia. Review of the significant change comprehensive MDS assessment, dated 01/21/26, revealed Resident #82 was rarely/never understood and was dependent on staff for eating. Review of a physician order dated 09/09/25 revealed Resident #82 received a custom diet, regular texture, with regular/thin liquid consistency. Interview on 03/09/26 at approximately 6:15 A.M. with Dietary Aide (DA) #495 revealed breakfast service began at approximately 7:00 A.M. to 7:15 A.M. and hall trays, for residents who ate in their rooms, were delivered first. Observation on 03/09/26 at 7:36 A.M. revealed [NAME] #462 was observed walking down the hallway. Concurrent interview with [NAME] #462 revealed she had completed plating all resident meals. Observation on 03/09/26 at 8:40 A.M. revealed Resident #82 in bed with her eyes closed. A breakfast tray, with all items covered and closed, was on the nightstand. Interview on 03/09/26 at 8:53 A.M. with Certified Nursing Assistant (CNA) #457, in the hallway near Resident #65's room and Resident #82's room (the residents did not share a room) revealed CNA #457 was collecting meal trays from residents who had already eaten breakfast in their rooms. CNA #457 stated a CNA called off for the day and nobody was reassigned to the residents in the rooms occupied by Resident #65 and Resident #82. CNA #457 stated some residents in the section needed assistance with eating and had not been fed. Continued observation revealed CNA #457 continued down the hall collecting breakfast trays from residents who had already consumed their meals. Observation on 03/09/26 at 9:07 A.M. revealed Resident #65 lying in bed with his eyes closed. A meal tray with breakfast foods was out of reach on Resident #65's dresser, with all food items covered and closed. Observation on 03/09/26 at 9:14 A.M. revealed Resident #82 was being assisted out of bed by Physical Therapist (PT) #523. Concurrent interview with PT #523 confirmed Resident #82's breakfast tray was on the nightstand and had not yet consumed. Observation on 03/09/26 at 9:28 A.M. revealed Resident #65 lying in bed with his eyes closed. The meal tray remained untouched on the dresser. Continued observation revealed at 9:34 A.M., Licensed Practical Nurse (LPN) #469 was feeding Resident #65. Concurrent interview with LPN #469 revealed a CNA called off and the section was not yet reassigned and, therefore, LPN #469 decided to feed Resident #65. Observation on 03/09/26 at 9:48 A.M. revealed CNA #457 feeding Resident #82 (one hour and eight minutes after the breakfast tray was first observed in the resident's room). 2. Review of the medical record for Resident #73 revealed an admission date of 06/29/23 with diagnoses of dementia, multiple sclerosis, epilepsy, and hypertension. Review of the quarterly MDS assessment, dated 01/21/26, revealed Resident #73 had impaired cognition, was able to eat with setup or clean-up assistance, and was dependent on staff for personal hygiene. Review of the care plan initiated 06/29/23 and revised 03/02/26 revealed Resident #73 had a potential ADLs self-care performance deficit. Interventions included checking nail length and trim and clean on bath day and as necessary. Observation on 03/09/26 at 8:05 A.M. revealed Resident #73 sitting alone at a table in the dining room. Resident #73 had a plate of food in front of her. Resident #73 used her right hand to feed herself pieces of sliced banana. Resident #73 had dark debris under each of her fingernails, visible from across the table. Interview on 03/09/26 at 8:17 A.M. with the Director of Nursing (DON) and concurrent observation of Resident #73's fingers, confirmed Resident #73's fingernails had dark debris under all fingers on her right hand, which she was using to pick up food to feed herself. 3. Review of the medical record revealed Resident #53 was admitted on [DATE], with diagnoses including dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the MDS quarterly assessment dated [DATE] revealed Resident #53 was dependent on staff for personal hygiene and grooming. Review of the care plan dated 01/12/26 revealed staff were to assist Resident #53 with grooming and hygiene to maintain personal cleanliness and dignity. Review of the shower schedule revealed Resident #53 received showers on Monday and Thursday evenings. Review of Resident #53's Shower and Skin Assessment, dated 03/09/26, revealed Resident #53 received a shower. Observation on 03/09/26 at 9:02 A.M. revealed Resident #53 was sitting in a wheelchair in the common area. Resident #53's fingernails were observed to contain visible dark debris under multiple fingernails. Interview on 03/09/26 at 9:02 A.M. with Resident Monitor/Activities (RMA) #408 revealed staff were responsible for assisting residents with grooming, including cleaning and maintaining fingernails. RMA #408 verified that Resident #53 had what appeared as feces under her fingernails on both hands. Staff did not address the resident's grooming needs during the observation period. Interview on 03/10/26 at 10:14 A.M. with LPN #469 confirmed that Resident #53 had her scheduled shower on the evening of 03/09/26, and the resident required assistance with grooming and should have had her fingernails cleaned during her scheduled shower. Interview on 03/11/26 at 5:55 A.M. with Registered Nurse (RN) #431, and concurrent observation of Resident #53, verified Resident #53 had a black substance under her fingernails on both of her hands, and verbalized Resident #53 needed her nails cut. Review of the undated facility policy titled, Bathing and Grooming, revealed skin and nail conditions were monitored with each bath. 4. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, unspecified severe protein calorie malnutrition, obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms. Review of the admission MDS assessment for Resident #11 dated 02/22/26, revealed a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive deficits. Further review of the MDS revealed Resident #11 had limited functional abilities and was dependent on staff for toileting hygiene, showering/bathing and upper/lower body dressing. Review of the initial care plan dated 02/10/26 revealed Resident #11 had a self-care performance deficit with interventions including a need for assistance with dressing and personal hygiene. Observation on 03/10/26 at 10:55 A.M., during care, revealed CNA #506 dressed Resident #11 in a blue-gray hoodie sweatshirt with a fish on the front and gray sweatpants. Observation on 03/11/26 at 7:23 A.M. revealed Resident #11 was lying in his bed wearing the same blue-gray sweatshirt and gray sweatpants he was dressed in the previous day. Observation on 03/11/26 at 10:15 A.M. revealed Resident #11 was sitting in his wheelchair in the common area wearing the same blue-gray hoodie sweatshirt with a fish on the front as well as gray sweatpants with a brown stain on the upper right leg. Interview on 03/11/26 at 10:28 A.M. with CNA #457 revealed the clothes Resident #11 was wearing were not placed by her. CNA #457 stated Resident #11 had the blue-gray hoodie sweatshirt and gray sweatpants on when she arrived for her shift this morning. CNA #457 stated she was told by third shift staff that Resident #11 was dressed and ready to go. CNA #457 stated she assumed third shift staff had dressed Resident #11 in the blue-gray sweatshirt and gray sweatpants. Interview on 03/11/26 at 10:31 A.M. with CNA #414 verified that she was working on 03/10/26 and had assisted with transferring Resident #11. CNA #414 stated Resident #11 had on a sweatshirt the previous day. CNA #414 observed Resident #11 sitting in his wheelchair in the common area and verified that the clothes worn by Resident #11 appeared to be the same clothes that resident was dressed in yesterday. CNA #414 also verified that the gray sweatpants being worn by Resident #11 had a dried brown mark to the right thigh area. Interview with on 03/11/26 at 10:40 A.M. with LPN #464 revealed resident clothing should be changed every morning upon waking and every evening in preparation for bed. Review of the facility policy titled, Activities of Daily Living (ADLs), revised December 2025, revealed a resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, personal hygiene, and oral hygiene.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure pressure reducing measures were implemented as ordered. This affected three (#22, #2, and #5) of four residents reviewed for pressure ulcer prevention. The facility census was 87.Findings include:1. Review of the medical record for Resident #22 revealed an admission date of 7/31/19 with diagnoses of unspecified dementia, hemiplegia, gastrostomy status, dysphagia, and epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/17/25, revealed Resident #22 was rarely/never understood, was at risk for skin breakdown, and was dependent on staff for all activities of daily living (ADLs) and mobility. Review of a physician order, initiated 05/14/24, revealed Resident #22 should be turned or repositioned every couple of hours around the clock to rotate pressure points. An order dated 03/20/25 revealed Resident #22 should have a washcloth inside of the left hand as tolerated. An order dated 12/03/25 revealed Resident #22 was to be up in chair for no longer than two hours at a time, to relieve pressure from buttock wound. Observation on 03/09/26 at 7:22 A.M. revealed Resident #22 lying in bed on his back. No pillows or offloading assistive devices were observed under Resident #22. No washcloth was observed in Resident #22's left hand. Interview on 03/09/26 at 8:53 A.M. with Certified Nursing Assistant (CNA) #457 revealed a CNA called off for the day and nobody was reassigned to the section Resident #22 resided in. Observation on 03/09/26 at 9:07 A.M. revealed Resident #22 was lying on his back. No pillows were observed under him to change his position. Observation on 03/09/26 at 9:34 A.M. revealed Licensed Practical Nurse (LPN) #469 was feeding breakfast to Resident #22's roommate. Concurrent interview with LPN #469 revealed a CNA called off and this section was not yet reassigned and, therefore, cares had not been provided to the residents. Further interview with LPN #469 confirmed Resident #22 would not have been repositioned since the beginning of the shift which started at 6:00 A.M. Observation on 03/10/26 at 7:35 A.M. revealed Resident #22 in bed with a pillow under the right side of his back. No washcloth was observed in Resident #22's left hand. Interview on 03/10/26 at 9:32 A.M. with CNA #457 revealed she was preparing to provide care to Resident #22 and then place him into the wheelchair. LPN #469 entered Resident #22's room and confirmed she would return to assist CNA #457 in using the mechanical lift to transfer Resident #22 from the bed to the chair. Observation on 03/10/26 at 1:09 P.M. revealed Resident #22 was in the wheelchair in his room. Resident #22's head was to the left of the headrest and was not being supported by the wheelchair's headrest Observation on 03/10/26 at 1:23 P.M. and concurrent interview with LPN #469 confirmed Resident #22's head was off the right side of the head support and was therefore not being supported by the headrest on the wheelchair. Further interview with LPN #469 confirmed she assisted CNA #457 with transferring Resident #22 to his wheelchair shortly after the interview and observation conducted on 03/10/26 at 9:32 A.M. Continued interview with LPN #469 confirmed she was aware Resident #22 had a physician order to be up in the wheelchair for only two hours and Resident #22 should have been transferred back to bed. Observation on 03/11/26 at 1:55 P.M. with LPN #469 revealed Resident #22's left palm was clean and the skin was intact. LPN #469 confirmed no washcloth was in Resident #22's left hand. Further interview and concurrent review of Resident #22's orders revealed the washcloth should be removed and Resident #22's hand should be cleaned on second shift (approximately 2:00 P.M. to 10:00 P.M.) and the washcloth should be replaced by staff on third shift (approximately 10:00 P.M. to 6:00 A.M.). Interview on 03/12/26 at 9:04 A.M. with Certified Occupational Therapy Assistant (COTA) #522 revealed she was familiar with Resident #22 and stated Resident #22's left hand was contracted, and the therapy team determined the best intervention to protect Resident #22's left palm from skin breakdown was a washcloth. 2. Review of Resident #2's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, cerebellar stroke syndrome, major depression, anxiety disorder, benign prostatic hyperplasia, and hypertension. Review of the MDS assessment dated [DATE] revealed Resident #2 had severe cognitive impairment, was dependent on staff for the completion of ADLs, was incontinent of bowel and bladder, and was at risk for pressure ulcer development with no skin breakdown. Review of the pressure ulcer assessment, dated 02/02/26, revealed Resident #2 was assessed with a risk score of 14, indicating moderate risk for the development of pressure ulcers. Review of the plan of care, dated 02/02/26 and revised on 02/09/26, revealed Resident #2 was at risk for pressure ulcer development related to (r/t) cognitive impairment/communication deficits/decreased sensory perception, incontinence, mobility/balance deficits, weak gait, confined to either bed or chair, prescribed medications which could influence sensory perception to pressure, decreased ability to change body positions on own, easily fatigued, terminal condition, and resisted staff assistance with care at times. Interventions included the following: monitor/document/report as needed (PRN) any changes in skin status, including appearance, color, wound healing, sign and symptoms (s/sx) of infection, wound size (length by (X) width X depth), stage; inform the nurse / physician (MD)/wound specialist/resident's responsible party of any new areas of skin breakdown; dietitian to assess nutritional needs to support skin health/wound healing; consult surgical wound care to manage wound healing which included providing treatment orders and monitoring the wound healing process/measurements; nurse to complete skin assessment weekly on shower day; apply house barrier cream topically to buttocks/coccyx after each incontinent episode and PRN; and turn or reposition the resident every couple of hours around the clock to rotate pressure points. Review of a physician order dated 02/18/26 revealed the use of heel protectors to bilateral heels at all times, as tolerated. Heels to be offloaded while in bed. Observations on 03/10/26 at 7:29 A.M., 7:51 A.M., 10:10 A.M., 12:14 P.M. and 1:37 P.M. and on 03/11/26 at 5:54 A.M., 9:29 A.M., and 12:34 P.M. revealed Resident #2 had a heel protector to the right heel. No heel protector was observed in place to the left heel. Interview with CNA #493 on 03/11/26 at 12:35 P.M., during observation of Resident #2, verified heel protectors had not been applied to the resident's left heel. CNA #493 stated she was unaware heel protectors were to be applied to both heels. 3. Review of Resident #5's medical record revealed an admission date of 02/09/24. Diagnoses included Lewy body dementia, diabetes mellitus, cellulitis of the abdominal wall, and lymphedema. Review of Resident #5's change in condition MDS, dated [DATE], revealed the resident was dependent on staff for transfers and bed mobility. Review of Resident #5's most recent care plan revealed she had a history of bilateral heel skin alteration. Interventions were to protect the heels from skin breakdown, to offload the heels at all times while in bed, as tolerated. Review of the physician orders revealed Resident #5 had an order dated 08/11/25 to offload bilateral heels/heel protectors while in bed as tolerated every shift for reddened skin of heels. Observation on 03/10/26 at 10:02 A.M. revealed Resident #5 was lying in bed without heel protectors applied. Interview with CNA #503 on 03/10/26 at 10:13 A.M. verified that Resident #5 was lying in bed and failed to have her bilateral heel protectors applied. CNA #503 found one heel protector under some clothing on a chair, but could not locate the second protector. Observation of Resident #5's heels on 03/10/26 at 10:16 A.M. revealed the skin was intact and without redness. Review of the facility policy titled, Skin Care Prevention and Pressure Management, revised October 2019, revealed, based upon the assessment and resident's clinical condition, choices and identified needs, basic or routine care may include but not limited to appropriate pressure-redistributing, support surfaces and provide non-irritating surfaces. Because the heels and elbows have relatively little surface area, it was difficult to redistribute pressure on these two surfaces. Therefore, it was important to pay particular attention to reducing the pressure on these areas for the resident at risk in accord with resident's overall goals and conditions. Additionally, for the resident at risk for developing, or who had a pressure ulcer, an individualized care plan that addressed prevention, care and treatment of any existing pressure ulcers, including specific interventions, measurable objectives and approximate time frames would be completed. This deficiency is continued non-compliance from the complaint survey dated 02/26/26.

Based on observations, record review, staff interview, recipe review, menu review, and policy review, the facility failed to ensure staff followed menus and recipes for residents on a pureed diet. This affected 10 (#8, #11, #19, #29, #39, #42, #49, #53, #60, and #65) residents who received the pureed diet. Additionally, the facility failed to ensure residents received double portions as ordered by the physician. This affected one (#65) of four residents reviewed for food and nutrition. The facility census was 87. Findings include:1. Review of the planned menu for the midday meal on 03/10/26 revealed residents would receive fried fish, parmesan pasta, seasoned vegetable blend, and fruit cobbler. Observation on 03/10/26 at approximately 10:40 A.M. revealed [NAME] #462 preparing to puree parmesan pasta for 10 residents on a pureed diet. [NAME] #462 portioned 10 servings of pasta into the mixer and poured in an unmeasured amount of hot water. [NAME] #462 obtained two more servings of pasta, added them to the mixer, and added an additional unmeasured amount of hot water. Concurrent interview with [NAME] #462 confirmed she used hot water to thin the pasta to the desired consistency.Review of the recipe for pureed parmesan pasta indicated chicken broth should be included in the preparation. The instructions noted: If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. Interview on 03/10/26 at 11:24 A.M. with Dietary Manager (DM) #418 revealed she directed [NAME] #462 to puree Philly cheesesteak meat leftover from the previous evening's meal rather than providing fried fish as indicated on the menu. DM #418 stated she liked to use up leftovers, and confirmed no pureed fish was prepared. Observation during meal service on 03/10/26 beginning at 11:25 A.M. revealed [NAME] #462 used a 4-ounce scoop for the pureed Philly cheesesteak. Interview at this time with [NAME] #462 confirmed the scoop size.Interview on 03/10/26 at 12:03 P.M. with [NAME] #462 revealed she added one hamburger bun to the Philly cheesesteak meat she prepared for the ten residents on a pureed diet.Review of the menu spreadsheet revealed the portion of Philly cheesesteak provided to residents on a pureed diet was five and 1/3 ounces. Review of the recipe for pureed Philly Cheesesteak revealed the whole sandwich should be prepared, then pureed for each resident. Interview on 03/10/26 at approximately 12:04 P.M. with DM #418 verified the serving size of the Philly cheesesteak and verified one whole sandwich for each resident should have been used to puree the entree rather than one hamburger bun for ten portions of meat. DM #418 verified the recipe for pureed parmesan pasta indicated chicken broth should be included in the preparation and the pureed mixture was not thinned according to the recipe. The facility identified ten (#8, #11, #19, #29, #39, #42, #49, #53, #60, and #65) residents who received the pureed diet. 2. Review of the medical record for Resident #65 revealed an admission date of 06/07/23. Diagnoses included dementia, type 2 diabetes mellitus, epilepsy, anxiety, and traumatic brain injury. Review of the Minimum Data set (MDS) assessment, dated 02/11/26, revealed Resident #65 was dependent on staff for eating.Review of the current physician order, initiated 01/07/26, revealed Resident #65 received a regular type diet with pureed textures, thin liquids, and with double portions.Observation and interview on 03/09/26 at 9:34 A.M. revealed Licensed Practical Nurse (LPN) #469 feeding Resident #65. LPN #469 stated Resident #65's meal ticket revealed he received a pureed diet with double portions. LPN #469 stated Resident #65 received one bowl of eggs, one bowl of an unidentified substance, potentially bread, a bowl of oatmeal, and a bowl of pureed fruit. LPN #469 stated Resident #65 did not receive double portions. Continued observation revealed Resident #65 consumed the food LPN #469 fed him without refusing the meal.

Based on observation, staff interview, record review, review of the wheelchair cleaning schedule, and policy review, the facility failed to ensure floor mats and wheelchairs were maintained in a clean sanitary condition. This affected three (#22, #65, and #82) of three residents reviewed for environment. The facility census was 87. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 7/31/19 with diagnoses of unspecified dementia, hemiplegia, gastrostomy status, dysphagia, and epilepsy.Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/17/25, revealed Resident #22 was rarely/never understood, had impairment to both sides and was dependent for all activities of daily life. Review of Resident #22's physician order, dated 11/12/24, revealed staff should place a bedside floor mattress next to bed when resident was in bed. Observation on 03/09/26 at 9:34 A.M. revealed Resident #22 lying in bed with his eyes closed. A fall matt was on the floor next to Resident #22's bed. The fall matt was discolored and stained over approximately three-fourths of the matt. Concurrent interview with Licensed Practical Nurse (LPN) #469 confirmed Resident #22's fall matt was stained and discolored and did not provide a homelike environment. LPN #469 stated fall matts were usually covered with a fitted sheet, but Resident #22's was uncovered.2. Review of the medical record for Resident #65 revealed an admission date of 06/07/23 with diagnoses of dementia, type 2 diabetes mellitus, epilepsy, anxiety, and traumatic brain injury. Review of the quarterly MDS assessment, dated 02/11/26, revealed Resident #65 was rarely/never understood, used a wheelchair for mobility and was dependent on staff for mobility. Observation of the posted Wheelchair Cleaning Schedule, posted at the nurses station, revealed Resident #65's wheelchair should have been cleaned during third shift on Tuesday nights. Observation on 03/09/26 at 2:47 P.M. revealed Resident #65 in his wheelchair in the common area. Further observation revealed the frame on both sides of Resident #65's wheelchair was dirty and covered in debris. Concurrent interview with Activities Director (AD) #445 confirmed Resident #65's wheelchair was dirty with buildup of debris on both sides of the wheelchair frame. Further interview confirmed the wheelchair would have been cleaned on third shift 03/03/26. AD #445 could not say if the debris appeared to be more than would accumulate over a week.3. Review of the medical record for Resident #82 revealed an admission date of 11/08/23 with diagnoses of dementia and aphasia.Review of the significant change comprehensive MDS assessment, dated 01/21/26, revealed Resident #82 was rarely/never understood, used a wheelchair for mobility, and was dependent on staff for wheelchair mobility. Review of the Wheelchair Cleaning Schedule posted at the nurse's station revealed Resident #82's wheelchair should have been cleaned on the previous night shift. Observation on 03/11/26 at 1:42 P.M. of Resident #82's wheelchair revealed a buildup of debris and food on both sides of the rails, including pieces of food in the space between the seat and the frame. Concurrent interview with AD #445 confirmed Resident #82's wheelchair was dirty with debris buildup and food pieces. AD #445 revealed Resident #82's wheelchair should have been cleaned on the previous night shift. Review of the facility policy titled Quality of Life - Homelike Environment, dated 04/2014, revealed the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: cleanliness and order.

Based on observation, record review, staff interview, and policy review the facility failed to ensure accurate resident assessments were completed. This affected one (#05) of six residents reviewed for accidents. The facility census was 87.Findings include:Review of Resident #05's medical record revealed an admission date of 02/09/24. Diagnoses included Lewy body dementia, diabetes mellitus, cellulitis of the abdominal wall, and left femur fracture.Review of Resident #05's Minimum Data Set (MDS) assessment, dated 01/21/26, revealed she had moderately intact cognition. She utilized a wheelchair and was dependent on staff for all activities of daily living (ADLs).Review of Resident #05's most recent care plan revealed she was at risk for falls related to cognitive impairment and a communication deficit. The resident was known to overestimate or forget her limits due to decreased safety awareness, decreased judgement, impulsivity, history of falling, mobility/balance deficits, incontinence, and prescribed medications. Review of Resident #05's Fall Risk Evaluation dated 02/10/26 revealed she was at risk for falls.Review of the physician orders revealed an order dated 02/27/26 for warfarin sodium (blood thinner) four milligrams (mg) to be administered once a day every Wednesday and Sunday for atrial fibrillation.Review of Resident #05's Weekly Skin assessment dated [DATE] revealed Licensed Practical Nurse (LPN) #463 completed the assessment and the resident was free of chest bruising.Observation of Resident #05 on 03/12/26 at 7:14 A.M. revealed she was lying in bed with the blankets up to her chest. Further observation revealed a large healing bruise just below the mid clavicular area, which was green and yellow in color. The bruise measured approximately four by four inches. The resident had no shirt on and was covered only with her blanket, which was tucked in under her arms.Interview with Resident #05 on 03/12/26 at 7:15 A.M. revealed she was unaware of having a bruise and did not know how she received it, denying any injury. Interview with LPN #421 on 03/12/26 at 7:15 A.M. revealed she was Resident #05's nurse that day, but was unaware of the chest bruise and had not received any information in the report from the previous shift nursing staff.Interview with Certified Nursing Assistant (CNA) #457 on 03/12/26 at 7:20 A.M. revealed she was Resident #05's CNA for the day and was unaware of any bruising to her chest. Interview with the Director of Nursing (DON) on 03/12/26 at 7:26 A.M., an concurrent observation of Resident #05, confirmed the resident had a large, healing bruise. The DON was unaware of the bruising.Interview with LPN #463 on 03/12/26 at 2:22 P.M. revealed she completed Resident #05's skin assessment on 03/10/26 and verified no bruising was noted to the resident's upper chest.Review of the DON's nursing note dated 03/12/26 8:32 A.M. revealed it was brought to nurse's attention by the State surveyor, that Resident #05 had a discoloration to her chest. Upon exam, a somewhat circular area of yellow/green discoloration was noted to the upper chest. The area was approximately four by four inches. When the resident was asked how this happened she stated, I didn't even know it was there. She further stated she didn't know what could have caused it. She was not aware of an injury. No first aid was required. The incident was reported to The Administrator and her power of attorney (POA) was notifed. Review of the facility policy titled, Skin Care Prevention and Pressure Management, revised October 2019, revealed weekly skin assessments were completed on admission and then weekly to reassess. Bi-weekly showers with completion of a shower sheet by the State Tested Nursing Aide (STNA) was to be completed. The nurse must visualize each shower and document a skin assessment in the medical record. This deficiency is continued non-compliance from the complaint survey dated 02/26/26.

Based on observations, medical record review, staff interview, and policy review the facility failed to implement fall safety precautions. This affected one (#5) of three residents reviewed for falls. The facility census was 87. Findings included:Review of Resident #5's medical record revealed an admission date of 02/09/24. Diagnoses included Lewy body dementia, diabetes mellitus, cellulitis of the abdominal wall, and lymphedema. Review of Resident #5's change in condition Minimum Data Set (MDS) assessment, dated 01/21/26, revealed she had a moderate cognition. The resident was dependent on staff for transfers and bed mobility. Review of Resident #5's most recent care plan revealed the resident was at risk for falls related to cognitive impairment and communication deficits. The resident overestimated or forgot limits due to decreased safety awareness, decreased judgement, impulsivity, history of falling, mobility/balance deficits, weakness, incontinence, prescribed medications which could affect balance, requirement for assistive device for balance/mobility, easily fatigued, and wheelchair bound/non-ambulatory. Interventions included a bedside mattress to the floor when in bed. Review of Resident #5's Fall Risk Assessment completed 02/10/26 revealed the resident was at high risk for falls. Review of the physician orders revealed Resident #5 had an order dated 10/16/25 to place a floor mat next to the bed when the resident was in bed every shift due to poor safety awareness. Observation on 03/10/26 at 10:02 A.M. revealed Resident #5 was lying in bed awake. The bedside mat was observed leaning against a chair on the opposite side of the room. Interview with Certified Nursing Assistant (CNA) #503 on 03/10/26 at 10:13 A.M. verified that Resident #5 was lying in bed and the fall prevention/floor mat was not in place at bedside. The CNA stated the staff probable took up the mat when the resident was served breakfast and failed to replace it. Review of the facility policy titled, Falls - Clinical Protocol, revised September 2012, revealed the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

Based on observation, medical record review, staff interview, review of the Centers for Disease Control (CDC) recommended guidelines for indwelling urinary catheter insertion and maintenance, and policy review, the facility failed to provide an indwelling urinary catheter (IUC) securement device. This affected one (#42) of one resident reviewed for indwelling urinary catheters. The facility identified one resident with an indwelling urinary catheter. The facility census was 87.Findings include:Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, unspecified severe protein calorie malnutrition, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms.Review of the admission Minimum Data Set (MDS) assessment for Resident #11, dated 02/22/26, revealed a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive deficits. Further review of the MDS revealed Resident #11 had limited functional abilities and was dependent on others for toileting hygiene, showering/bathing and upper/lower body dressing. Review of the initial care plan dated 02/11/26 revealed Resident #11 had an IUC due to a history of urinary retention and obstructive uropathy. There were no interventions for securing the catheter tubing.Review of a physician order dated 02/10/26 revealed the resident had orders for an 18 French IUC due to obstructive and reflex uropathy. Review of a nurses note dated 02/18/26 at 4:41 A.M. revealed the resident continued to disconnect the catheter bag and was physically combative with staff during care. Observation on 03/10/26 at 10:43 A.M. revealed Licensed Practical Nurse (LPN) #464 performing IUC care per physician orders for Resident #11. Further observation revealed Certified Nursing Assistant (CNA) #506 then began to dress Resident #11. No IUC securement device was observed in place. Interview on 03/10/26 at 10:50 A.M. with LPN #464 verified Resident #11 had no IUC securement device in place. LPN #464 also verified that Resident #11, and any resident having an IUC, should have an IUC securement device in place. LPN #464 then obtained and applied a securement device. Interview on 03/11/26 at 2:16 P.M. with the Director of Nursing (DON) revealed an IUC securement devices was not necessarily needed. The DON stated if a resident arrived to the facility with a securement device in place, then the facility would continue its use. The progress note dated 02/18/26 regarding the resident disconnecting the catheter bag was reviewed with the DON. The DON confirmed if Resident #11 was pulling at his IUC, then a securement device should have been in place.Interview on 03/11/26 at 2:13 P.M. with Registered Nurse (RN) Supervisor #471 revealed he was unsure of the standards of care for IUC securement devices. RN Supervisor #471 continued to state that he felt IUC securement devices would cause more discomfort to residents with cognitive deficits and if the resident was not pulling on the IUC device then no securement device was needed. Review of a CDC power point with guidelines for Indwelling Urinary Catheter Insertion and Maintenance, revealed maintenance of an IUC included proper securement of catheters to prevent movement and urethral traction. Review of the facility policy titled, Catheter Care, revised 2023, provided no direction on the use of IUC securement devices.

Based on observation, record review and staff interview, the facility failed to ensure residents received enteral nutrition (tube feeding) as ordered by the physician. This affected one (#22) of two residents reviewed for tube feedings. The facility census was 87.Findings include:Review of the medical record for Resident #22 revealed an admission date of 7/31/19 with diagnoses of unspecified dementia, hemiplegia, gastrostomy status, dysphagia, and epilepsy.Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/17/25, revealed Resident #22 was rarely/never understood, had a gastrostomy tube, and relied on enteral nutrition to meet 51 percent (%) or more of his fluid and nutrition needs.Review of the current physician order dated 06/13/25 revealed Resident #22 received Isosource HN (high nitrogen) (a tube feeding formula) at 80 milliliters (ml) per hour. Observation on 03/10/26 at 1:09 P.M. revealed Resident #22 had tube feeding Fibersource HN running at 80 ml per hour. Further observation revealed the tube feeding bag was dated 03/10/26 at 4:00 A.M. Concurrent interview with Licensed Practical Nurse (LPN) #469 confirmed Resident #22 was receiving the wrong tube feeding formula. LPN #469 stated the bag was hung by the previous shift. LPN #469 stopped the tube feeding pump and proceeded to obtain and hang a bag of Isosource HN.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure a resident was receiving oxygen therapy per physician orders. This affected one (#56) of one resident reviewed for respiratory. The facility identified six residents who required supplemental oxygen. The facility census was 87.Findings include:Review of Resident #56's medical record revealed an admission date of 04/24/25. Diagnoses included vascular dementia, emphysema, Raynaud's syndrome, and peripheral vascular disease. Review of Resident #56's quarterly Minimum Data Set assessment, dated 01/07/26, revealed the resident required continuous oxygen therapy. Review of Resident #56's most recent care plan revealed she had emphysema and had a history of shortness of breath on exertion, when sitting, and laying flat. Interventions included oxygen per nasal canula per physician orders. Review of Resident #56's medical record revealed a physician's order dated 04/25/25 to apply oxygen at two liters per minute per nasal canula every shift for chronic respiratory deficit/shortness of breath/oxygen saturations less than 90% related to emphysema. Observation on 03/09/26 at 7:27 A.M. revealed Resident #56 was lying in bed with her nasal canula in place attached to a concentrator. Observation of the oxygen setting revealed it was running at five liters of oxygen per minute. Interview with Certified Nursing Assistant (CNA) #414 on 03/09/26 at 7:29 A.M. revealed she was just assigned to the hall and was unaware of what setting Resident #56's oxygen was ordered. Interview with Licensed Practical Nurse (LPN) #405 on 03/09/26 at 7:34 A.M. verified that Resident #56's oxygen was not at the liters ordered by the physician. Observation of Resident #56 on 03/12/26 at 7:10 A.M. revealed the resident was walking down the hall with a rollator walker and a portable oxygen concentrator sitting on the seat of the walker. Observation of the concentrator settings revealed the resident was receiving four liters of oxygen per minute. Interview with LPN #463 on 03/10/26 7:14 A.M. verified Resident #56's portable oxygen setting was not at the liters ordered by the physician. Review of the facility policy titled Oxygen Therapy - Mask and Nasal Canula, revised 02/13/23, revealed oxygen is administered by a licensed nurse and required a physician order. Oxygen is administered appropriately to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulties.

Based on medical record review, staff interview and policy review, the facility failed to secure a provider agreement with a hemodialysis provider prior to the current annual survey. Additionally, the facility failed to ensure collaborative communication was shared between the facility and the hemodialysis center. This affected one (#12) of one resident reviewed for dialysis. The facility identified one resident receiving dialysis services The facility census was 87. Findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia with other behavioral disturbances, end stage renal disease, type two diabetes, and hypertensive chronic kidney disease. Review of the Resident #12's care plan for end stage renal disease, revised 11/13/25, revealed interventions, including the assessment of central line site used for hemodialysis, to be completed every shift. Dialysis on Tuesdays, Thursdays and Saturdays. Resident to leave the facility around 10:00 A.M. for an 11:00 A.M. chair time. There were no interventions for communication with the dialysis center. Review of dialysis communication notes from 01/01/26 to 03/12/26 revealed communication forms for dialysis treatment for 01/13/26, 01/17/26, 02/05/26, 02/28/26, and 03/10/26. There was no communication forms from the dialysis center for dialysis treatments completed on 01/01/26, 01/03/26, 01/06/26, 01/08/26, 01/10/26, 01/15/26, 01/20/26, 01/22/26, 01/24/26, 01/27/26, 01/29/26, 02/03/26, 02/07/26, 02/10/26, 02/12/26, 02/14/26, 02/17/26, 02/19/26, 02/21/26, 02/26/26, 03/03/26, 03/05/26, and 03/07/26. Interview on 03/10/26 at 7:17 A.M. Licensed Practical Nurse (LPN) #464 revealed no knowledge of the communication process with dialysis and was not aware of a dialysis communication book. Interview on 03/10/26 at 7:21 A.M. with LPN #469 revealed there was a dialysis communication book at one time but that she was unsure of what happened to the book or what the new process was for communication between the facility and the dialysis center. Interview on 03/10/26 at 7:37 A.M., the Director of Nursing (DON) revealed the facility had a dialysis communication book. The DON stated she would find the book so that communication sheets could be reviewed. Interview on 03/11/26 at 3:22 P.M. with Registered Nurse (RN) Supervisor #471 revealed there were no further dialysis communication forms other than the five that were found on 03/10/26. RN Supervisor #471 also revealed the current process for the facility communicating with the dialysis center was to send a face sheet, a blank progress note, a medication list and a blank order form. These items were placed in a folder and sent with the caregiver that sits with Resident #12 on dialysis days. RN Supervisor #471 further revealed if Resident #12 had a change in condition of any kind nursing staff at the facility would send this information to the dialysis center using a progress note. Interview on 03/11/26 at 3:44 P.M. the DON revealed a call was made to the dialysis facility to request copies of past communication forms. The DON was told copies were not kept. The DON also stated many times the dialysis center would not send communication forms back with Resident #12. The DON verified she has not called the dialysis center requesting communication forms be sent daily. Interview on 03/12/26 at approximately 12:00 P.M. with the Administrator revealed that prior to the effective date of 03/12/26 listed on the dialysis agreement, there was no previous agreement between the facility and the dialysis provider used by Resident #12. Review of the facility policy titled Hemodialysis, revised on 01/2026, revealed the facility would coordinate and collaborate with the dialysis facility including dialysis treatment provided and the resident's response to treatment. Also included within the policy is the licensed nurse will communicate to the dialysis facility via telephonic communication or written format such information as: timely medication administration, physician/treatment orders, nutritional/fluid management including compliance with food/fluid restrictions, changes and/or declines in condition as well as the occurrence or risk of falls.

Based on observation, medical record review, resident representative interview, and staff interview, the facility failed to ensure specific interventions were provided to address triggers and care for post-traumatic stress disorde (PTSD). This affected one (#10) of one resident reviewed for PTSD care and treatment. The facility census was 87. Findings include:Review of the medical record revealed Resident #10 admitted to facility on 08/14/25. Diagnoses included dementia, type 2 diabetes mellitus, lumbar vertebra fracture, neurocognitive disorder with Lewy bodies, hypertension, PTSD, depression, transient ischemic attack, and cerebral infarction. Review of the Minimum Data Set assessment, dated 02/13/26, Resident #10 had severely impaired cognition, delusions, rejection of care one to three days during assessment period, and received antipsychotic and antidepressant medications. On 08/14/25 a Social History and Assessment was completed and signed by Social Services Director #408. Diagnoses included PTSD. No additional documentation contained in the medical record indicated the cause or treatment regarding PTSD. Review of the social services plan of care dated 11/12/25 addressed Resident #10's mood problem related to (r/t) cognitive impairment, diagnosis mood disorder: hallucinations, unspecified PTSD, unspecified major depressive disorder, and recurrent anxiety disorder. No specific triggers, causes, behaviors, interventions to address Resident #10 diagnosis of PTSD were documented. Review of current physician medication orders noted the following; 12/05/25 clozapine 100 milligram (mg) at bedtime related to violent behavior, hallucinations, and unspecified PTSD. Interview on 03/11/26 at 12:25 P.M. Resident #10's Power Of Attorney (POA) revealed Resident #10 experienced PTSD related to an assault while serving in the military. The POA stated they had previously informed the Director of Nursing (DON), indicating only female care givers should be provided due to potential behavior trigger related to male caregivers.Review of the medical record revealed no documentation instructing caregivers to be female in order to prevent PTSD behaviors. Interview on 03/11/26 at 12:33 P.M. the DON verified no knowledge of Resident #10's PTSD triggers related to male assault in military. The DON confirmed Resident #10 had previously received care by male caregivers. The DON also confirmed the PTSD plan of care did not indicate specific interventions related to Resident #10 and interventions to address potential cause. Interview on 03/11/26 at 1:14 P.M. Social Services Director #408 revealed they were unaware of Resident #10's cause for PSTD or potential triggers. Social Service Director #408 verified no specific plan of care or assessment was completed addressing Resident #10's diagnosis of PTSD. Observation on 03/12/26 at 6:48 A.M. noted male Certified Nurse Aide (CNA) #520 in Resident #10's room providing morning activities of daily living, including personal care. Interview with CNA #520 on 03/12/26 at 6:51 A.M. revealed he was unaware of Resident #10's request for female direct care staff or care related to the diagnosis of PTSD. CNA #520 stated he worked with Resident #10 during the night shift between 10:00 P.M. and 6:30 A.M.

Based on record review and staff interview, the facility failed to ensure nutrition assessments were completed accurately and updated with new diet orders. This affected one (#65) for four residents reviewed for food and nutrition. The facility census was 87. Findings include:Review of the medical record for Resident #65 revealed an admission date of 06/07/23. Diagnoses included dementia, type 2 diabetes mellitus, epilepsy, anxiety, and traumatic brain injury. Review of the quarterly Minimum Data set (MDS) assessment, dated 02/11/26, revealed Resident #65 was rarely/never understood and was dependent on staff for eating.Review of the current physician order, initiated 12/14/23, revealed Resident #65 should receive a cream cookie twice daily for nutritional adequacy.Review of Resident #65's progress notes, dated 01/01/26 through 03/12/26, revealed no incidents or concerns regarding eating, swallowing, or choking.Review of the Speech Language Pathology Evaluation and Plan of Treatment, dated 01/07/26, revealed Resident #65 was referred for therapy due to pocketing food.Review of the current physician order, initiated 01/07/26, revealed Resident #65 received a regular type diet with pureed textures and thin liquids, with double portions.Review of the quarterly Nutritional Assessment, dated 02/06/26, revealed Resident #65 was on a regular textured diet and received a cookie for a snack. Interview on 03/10/26 at 2:33 P.M. with Licensed Practical Nurse (LPN) #423 confirmed Resident #65 would still receive an oatmeal cookie for snacks even though he was on a pureed diet.Interview on 03/12/26 at 9:46 A.M. with Registered Dietitian (RD) #487 confirmed she completed Resident #65's nutrition assessment, dated 02/06/26, inaccurately. RD #487 stated she was unaware Resident #65 was on a pureed diet at the time of the assessment. Additionally, RD #487 stated it was inappropriate for Resident #65 to continue to receive an oatmeal cookie on a pureed diet. Follow-up interview on 03/12/26 at 10:26 A.M. with RD #487 revealed the facility did not notify her regarding the change in Resident #65's diet. She stated she did not have access to speech therapy notes through the electronic medical record (EMR) and further confirmed Resident #65's progress notes revealed nothing regarding difficulty chewing or swallowing on or around 01/07/26.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure interventions were implemented to prevent a pressure ulcer from increasing in size and stage. This resulted in actual harm beginning on 12/22/25 when one resident (#01), who was identified at low risk for pressure ulcer development, was discovered with a Stage II pressure ulcer which increased in size and depth and was assessed as an unstageable pressure ulcer with malodorous necrotic tissue 19 days after being discovered. The facility failed to provide any reassessment of the resident's condition and for a possible source of the pressure ulcer and no nutritional assessments had been completed from the time when the pressure ulcer was initially identified. This affected one (#01) of three residents reviewed for pressure ulcer prevention and wound healing. The facility census was 89. Findings include: Review of the medical record revealed Resident #01 admitted to the facility on [DATE]. Diagnoses included hypertension, edema, autonomic neuropathy disease, Vitamin D deficiency, dementia, persistent mood disorder, major depression, Alzheimer's disease, and bacterial pneumonia. Review of the Minimum Data Set assessment dated [DATE] assessed Resident #01 with severely impaired cognition, rejection of care one to three days during the assessment, dependent on staff for the completion of activities of daily living. The resident required substantial to maximal assistance with rolling left to right on bed, supervision and/or touching assistance with standing or chair to bed transfer, and was independent with ambulation. The resident was always incontinent of bowel and bladder and developed an in-house acquired unstageable pressure ulcer. Review of the nursing care plan dated 08/07/25 addressed Resident #01 was at risk for pressure ulcer development related to cognitive impairment/communication deficits/decreased sensory perception, incontinence, mobility/balance deficits, weak gait, prescribed medications which can influence sensory perception to pressure, and sits frequently during the day/ decreased activity levels. Interventions included to monitor/document/report as needed (PRN) any changes in skin status such as appearance, color, wound healing, signs/symptoms of infection, wound size (length X width X depth), and stage. Inform the nurse / physician / wound specialist consultant/resident's responsible party of any new areas of skin breakdown. Dietitian to assess nutritional needs to support skin health/wound healing. Wound Specialist Center to manage wound healing which includes providing treatment orders and monitoring the wound healing process/ measurements. Nurse to complete Skin Assessment due weekly on shower day. Apply House Barrier Cream topically to buttocks/coccyx after each incontinent episode and as needed. Review of the physician order dated 08/13/25 instructed nursing staff to conduct skin assessments on scheduled shower days twice weekly on Wednesday and Saturday. Review of the nutritional assessment dated [DATE] evaluated Resident #01 as having a potential nutritional problem related to cognitive impairment/decreased hunger perception, terminal condition of dementia, and diet restrictions related to mechanically altered diet. The resident was receiving regular, mechanically altered diet with fair to sufficient intakes per nursing and was at risk for malnutrition. No additional nutritional interventions were documented in the medical record. Review of the skin assessment dated [DATE] revealed Resident #01 was assessed at low risk for developing a pressure ulcer. Review of the shower/skin assessment dated [DATE] at 8:25 P.M. identified no area of skin breakdown with skin intact. Review of progress notes dated 12/04/25 at 7:09 A.M. revealed at 5:15 A.M. the certified nurse aide (CNA) notified nurse Registered Nurse (RN) #500 Resident #01 had an open area to the coccyx. RN #500 assessed the area, barrier cream was applied, the on coming supervisor was notified, and the wound care nurse to assess today. Review of the Wound/Skin Care Management Documentation Form dated 12/04/25 identified a coccyx wound identified as a Stage II pressure ulcer measuring 1 centimeter (cm) long by 1.5 cm wide by 0.1 cm deep, draining a scant amount of serosanguinous (blood tinge) drainage, with 100% epithelial tissue. No additional interventions including nutritional support/evaluation was contained in the medical record. There was no evidence a reassessment of the resident's condition and possible source of the pressure ulcer was conducted. On 12/05/25 a nursing plan of care was developed to address Resident #01's current coccyx skin alteration. Interventions on 12/05/25 included: apply triad paste, may use chamosyn with honey apply two times a day for open/redness and as needed for after showering or episodes of incontinence. Review of Wound/Skin Care Management Documentation Form dated 12/11/25 identified the coccyx wound to be a Stage II pressure ulcer measuring 1.5 cm long by 1.5 cm wide by 0.1 cm deep, draining a scant amount of serosanguinous drainage, with 50% granulation tissue and 50% epithelial tissue. No additional interventions including nutritional support/evaluation was contained in the medical record. There was no evidence a reassessment of the resident's condition and possible source of the pressure ulcer was conducted. Review of Wound/Skin Care Management Documentation Form dated 12/18/25 identified the coccyx wound to be a Stage II pressure ulcer measuring 2.0 cm long by x 1.5 cm wide by 0.1 cm deep, draining a scant amount of serosanguinous drainage, with 60% granulation tissue and 40% slough tissue. There was no evidence of a reassessment of the resident's condition due to the increasing size of the pressure ulcer. No additional interventions including nutritional support/evaluation was contained in the medical record. Review of the Wound/Skin Care Management Documentation Form dated 12/22/25 identified the coccyx wound to be a an unstageable pressure ulcer measuring 3.0 cm long by 4.0 cm wide by 2.0 cm deep with a foul odor and moderate amount of necrotic tissue. The treatment order was revised to include cleansing the open area with normal saline, pat dry, pack with wound cleansing moistened gauze and cover with foam dressing. There was no evidence any interventions to include a reassessment of the resident's condition to identify a possible source of the pressure ulcer, mechanical pressure relief devices, off-loading strategies, or nutritional support/evaluation were completed. Review of the record revealed on 12/23/25 the Wound Specialist Certified Nurse Practitioner evaluated the pressure ulcer. The documentation revealed nursing reported the coccyx pressure ulcer had worsened since yesterday. The note stated Resident #01 ambulates with a walker throughout the facility or sits in a chair all day. Nursing reports resident will put herself back into bed. Nursing reports due to her size she does not have good bed mobility. She has a fair appetite and incontinent of bowel and bladder. Muscluloskeletal and neurological assessment identified generalized muscle weakness with poor bed mobility. The skin area was described as an unstageable wound with 100% malodorous necrotic tissue measuring 3 cm by 4 cm by 2 cm with moderate serosanguinous drainage. Unable to stage due to inability to see wound bed and all tissue is necrotic. Suspect chronic incontinence, pressure from sitting and poor bed mobility has caused unstageable pressure ulcer. Plan orders included an air pressure mattress, reposition every two to three hours as tolerated, skin assessments and ongoing risk assessments by nursing per policy. Monitor wound for signs and symptoms of infection, frequent incontinence checks, monitor nutrition and optimize protein intake. Will debride to remove biofilm weekly to aide in wound healing and decrease bioburden. Treatment order to cleanse with normal saline and pat dry. Pack wound loosely with 1/4 strength Dakins moistened gauze packing to wound bed and fill any dead space with fluff gauze. Cover with foam dressing and change twice daily and PRN. Further review of the medical record lacked documentation indicating the recommendations were promptly implemented as ordered. On 12/23/25 the plan of care was updated to include the Wound Specialist Center is managing the healing process and completing wound measurements. Interventions included to notify them of significant wound changes. Further review of the medical record revealed no additional interventions to address mechanical off-loading interventions, or nutritional evaluation with support were documented. Review of the progress notes on 12/26/25 at 2:52 P.M. revealed Resident #01 was sent to emergency room per physician order and admitted to local hospital at 10:00 P.M. for diagnosis of pneumonia. Resident #01 did not return to the facility. Review of facility policy titled Skin Care Prevention and Pressure Management Policy, revised 10/2019, revealed any new pressure ulcer suggests a need to reevaluate the adequacy of the plan for preventing pressure ulcers. Based upon the assessment and resident's clinical condition, choices and identified needs, basic or routine care may include but not limited to interventions to redistribute pressure, minimize exposure to moisture and keep skin clean, especially fecal contamination. Provide appropriate non-irritating surfaces and maintain or improve nutrition and hydration status where feasible. The resident should be monitored for condition changes that might increase the risk for breakdown and the defined interventions should be implemented and monitored for effectiveness. Interview on 02/26/26 at 7:34 A.M. RN #501, the Infection Preventionist/Staff Development/Wound Care nurse, verified the pressure ulcer went from a Stage II pressure ulcer on 12/04/25 to an unstageable pressure ulcer on 12/23/25. RN #501 verified no documentation was present to indicate the facility attempted to determine the origin of the pressure ulcer and nutritional interventions had been implemented to address Resident #01's skin breakdown as identified interventions on the care plan and per facility policy. This deficiency represents non-compliance investigated under Master Complaint Number 2718218 and Complaint Number 2717144.

Based on medical record review, staff interview, review of facility documentation, and review of facility policy, the facility failed to ensure the physician and responsible party were timely notified when a resident was discovered unresponsive on the floor with a laceration to the head. This affected one (#2) of three residents reviewed for timely notification in a facility census of 89. Findings include:Review of the medical record revealed Resident #2 admitted to the facility on [DATE]. Diagnoses included dementia, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic neuropathy, malignant neoplasm of bladder wall, coronary artery disease, major depression with severe psychotic symptoms, anxiety disorder, osteoarthritis, history of transient ischemic attack, and hypertension. Review of the Minimum Data Set assessment dated [DATE] assessed Resident #2 with severe cognitive impairment, no range of motion impairment, independent with ambulation and transfer, and no falls since admission. Review of the nursing care plan dated 10/01/25 was revised to address Resident #2 risk for falls related to cognitive impairment/communication deficits, overestimates or forgets limits/decreased safety, awareness, decreased judgement impulsiveness, incontinence, and prescribed medications which can affect balance. Interventions included: If the resident falls or is found on the floor, assess for injury, notify the medical doctor (MD) and the responsible party if resident has fallen. Review of the facility incident report dated 01/13/26 at 8:00 A.M., and linked nurses' notes documented on 01/13/25 at 2:16 P.M., revealed at 8:00 AM Licensed Practical Nurse (LPN) #200 was informed by a certified nurse aide (CNA) Resident #2 had an unwitnessed fall and was laying on the bathroom floor of his room. LPN #200 went to check the resident and observed the resident laying on the bathroom floor with his head underneath the bathroom sink and feet towards the bathroom door. Resident #2 was diaphoretic, sweaty, and clammy. LPN #200 noticed the resident had hit his head and observed a laceration to the top of the resident's head. Resident #2 was unable to perform range of motion (ROM) due to lack of consciousness. Neurological (neuro) checks were started. Called the Power of Attorney (POA) at 10:45 A.M. to inform of the fall. Faxed the MD regarding the fall at 9:00 A.M., awaiting response. The Director of Nursing (DON) was notified of the resident fall and change in condition at 11:30 A.M. The supervisor called a private ambulance transportation to set-up transportation to the local hospital emergency room for evaluation. Supervisor called the POA to inform of the resident going to the emergency room at 11:45 A.M. The resident left with transportation at 12:11 P.M. At 12:45 P.M. the MD faxed response to send the resident to the emergency room. LPN #200 faxed back to the MD the resident was already gone to hospital. Review of the facility policy titled Notification of Change: Policy and Procedure, reviewed 12/01/25, revealed it is the policy of the facility to notify the resident, physician, and resident representative when there is a change in treatment, accident, significant change in status and/or the decision to transfer or discharge the resident. The facility staff will immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is: An incident involving the resident which results in injury and has the potential for requiring physician intervention or a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications. Physician notification will occur when a resident experiences symptoms such as loss of consciousness. On 02/02/26 at 10:40 A.M. interview and record review with the DON verified the physician was not contacted immediately when the resident was found unresponsive. The DON stated they should have been contacted the physician by telephone and not through facsimile, which resulted in a four hour and 45 minute delay in physician response. The DON also verified the resident representative was not notified of the fall until two hours and 45 minutes following the incident.This deficiency represents non-compliance investigated under Master Complaint Number 2718218 and Complaint Number 2717144.

Based on medical record review, staff interview, review of facility incident report, review of hospital documentation, and review of facility policy, the facility failed to provide appropriate treatment and neurological assessments following the discovery of a resident on the floor unresponsive with a laceration to the head. This affected one (#2) of three residents reviewed for timely care and treatment. The facility census was 89. Findings include: Review of the medical record revealed Resident #2 admitted to the facility on [DATE]. Diagnoses included dementia, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic neuropathy, malignant neoplasm of bladder wall, coronary artery disease, major depression with severe psychotic symptoms, anxiety disorder, osteoarthritis, history of transient ischemic attack, and hypertension. Review of the Minimum Data Set assessment dated [DATE] assessed Resident #2 with severe cognitive impairment, no range of motion impairment, independent with ambulation and transfer, and no falls sinceadmission. Onn 11/24/25 Resident #2 was assessed with intermittent confusion, no falls in the past three months, independent with ambulation, and balance normal. Review of the nursing care plan dated 10/01/25 was revised to address Resident #2 risk for falls related to cognitive impairment/communication deficits, overestimates or forgets limits/decreased safety, awareness, decreased judgement impulsiveness, incontinence, and prescribed medications which can affect balance. Interventions included: If the resident falls or is found on the floor, assess for injury; Review the information of the fall and attempt to determine the cause of the fall; Complete neurological (neuro) checks for post fall head injury or unwitnessed fall, and notify MD of any abnormalities identified. Review of the facility incident report dated 01/13/26 at 8:00 A.M., and linked nurses' notes documented on 01/13/25 at 2:16 P.M., revealed at 8:00 AM Licensed Practical Nurse (LPN) #200 was informed by a certified nurse aide (CNA) Resident #2 had an unwitnessed fall and was laying on the bathroom floor of his room. LPN #200 went to check the resident and observed the resident laying on the bathroom floor with his head underneath the bathroom sink and feet towards the bathroom door. Resident #2 was diaphoretic, sweaty, and clammy. LPN #200 noticed the resident had hit his head and observed a laceration to the top of the resident's head. Resident #2 was unable to perform range of motion (ROM) due to lack of consciousness. Neurological (neuro) checks were started. Called the Power of Attorney (POA) at 10:45 A.M. to inform of the fall. Faxed the MD regarding the fall at 9:00 A.M., awaiting response. The Director of Nursing (DON) was notified of the resident fall and change in condition at 11:30 A.M. The supervisor called a private ambulance transportation to set-up transportation to the local hospital emergency room for evaluation. Supervisor called the POA to inform of the resident going to the emergency room at 11:45 A.M. The resident left with transportation at 12:11 P.M. At 12:45 P.M. the MD faxed response to send the resident to the emergency room. LPN #200 faxed back to the MD the resident was already gone to hospital. Review of the neurological observation form, dated 01/13/26 at 8:00 A.M., documented vital signs at 8:15 A.M., 8:30 A.M., 8:45 A.M., 9:00 A.M., 9:30 A.M., 10:00 A.M. The form listed areas to document the pupillary response for the right and left eye and hand grasps for the right and left hand. No pupillary response or hand grasps were assessed on any of these times. The medical record contained no additional assessment or further documentation was recorded.Review of the progress notes dated 01/13/26 at 7:17 P.M. noted Registered Nurse (RN) #502 contacted the local hospital to inquire about Resident #2. The emergency room nurse reported the resident would not be returning to the facility and will instead be discharged to Hospice due to significantly large intracranial hemorrhage that cannot be operated on. Review of the hospital computed tomography (CT) scan results dated 01/13/26 revealed substantial intraventricular hemorrhage as well as hemorrhage into the cerebellum with mass effect. Given the location of hemorrhage suspect this is likely a spontaneous hemorrhage, not traumatic. Unfortunately, this is a catastrophic hemorrhage and prognosis is grave. No intervention is likely to be of any benefit. Patient will die as a result of this. Patient is a Do Not Resuscitate (DNR) comfort care, initiate comfort care protocol at this time. Recommend palliative care/hospice consultation. Discussed with trauma team. As above, prognosis grave and no intervention likely to be of benefit. Interview on 02/25/26 at 10:45 A.M. CNA #300 stated CNA #303 found Resident #2 on the floor of his bathroom unresponsive at approximately 8:00 A.M. on 01/13/26. CNA #300 was called to the room, and observed the resident was on the floor, unconscious and non-responsive. Unit Manager LPN #201, LPN #200, CNA #300, and CNA #303 proceeded to lift the resident from the floor and placed him to his bed. Emergency medical services (EMS) was not observed to be contacted. The resident remained unresponsive. Interview on 02/02/26 at 10:40 A.M. the DON stated the resident never regained consciousness. The DON verified the post fall neurological assessment only contained vital signs and did not document the resident's pupillary response or hand grasps. In addition, facility staff failed to contact EMS when the resident was discovered on the floor unresponsive with an observed head injury, instead moving him back into the bed. This deficiency represents non-compliance investigated under Complaint Number 2717144.

Based on closed medical record review, staff interview, review of a written staff statement and review of the facility policy, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call nine-one-one (911) for Emergency Medical Services (EMS) assistance for Resident #100, who was found unresponsive, absent of breaths, without a pulse/heartbeat and was identified to have advance directives reflecting the resident was a Full Code (full life-saving measures to be taken in the event of cardiac/respiratory arrest) status. This resulted in Immediate Jeopardy and serious life-threatening harm/death on [DATE] when Licensed Practical Nurse (LPN) #400 went to Resident #100's room to check his blood sugar levels and found the resident to be unresponsive and absent of vital signs. LPN #400 called for the shift supervisor, LPN #410, who confirmed Resident #100 was absent of vital signs and neither nurse initiated CPR, called 911 for EMS assistance, or contacted the physician for direction. Resident #100 subsequently passed away in the facility, without life-saving measures being implemented, without 911 being called, and without the physician being contacted. This affected one (#100) of five residents reviewed for death in the facility. The facility census was 86. On [DATE] at 2:13 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 5:35 A.M. when LPN #400 entered Resident #100's room to obtain his morning blood sugar level and found the resident was absent of vital signs. LPN #400 called for LPN #410 to confirm Resident #100, who was a Full Code status, was not breathing and did not have a pulse/heartbeat. LPN #400 and LPN #410 failed to initiate life-saving measures, including CPR, did not contact 911 for assistance, and further failed to seek direction from a physician. Resident #100 passed away in the facility. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], the Unit Manager LPN #445, provided verbal educational counseling to LPN #400 and LPN #410 on how to respond to a Full Code status. On [DATE], the DON reviewed all resident code statuses to verify physician orders for residents with a Full Code status were up to date. On [DATE], the DON or designee educated all licensed nursing staff on reviewing code status and initiating CPR for residents who required such care prior to the arrival of EMS. The education was provided via in-person, text message, and phone. On [DATE], the DON completed an audit of all in-facility deaths for the past 60 days, with no negative findings. On [DATE], the DON placed a list of all residents who have a Full Code status at the nurses' stations. The DON will ensure the list is updated as needed. On [DATE], an Ad-hoc Quality Assurance Performance Improvement (QAPI) meeting was held to identify issues and help prevent this incident from recurring. Members present included the Administrator, DON, Registered Nurse (RN) #460, Business Office Manager (BOM) #500, Activities Director (AD) #501, Dietary Manager (DM) #502, Maintenance Director (MD) #503, Therapy Director (TD) #504, Medical Records Clerk (MRC) #505, Social Service Director (SSD) #420, RN #506, LPN #450, LPN #507, and LPN #508. On [DATE], as identified by the Ad Hoc QAPI meeting, RN #460 performed an audit of CPR certifications for all licensed nurses. Any nurse identified to not have current CPR certification will be offered CPR certification by the facility. Beginning on [DATE], the DON will ensure all licensed nurses sign a staff education confirming receipt and understanding of education prior to their next scheduled shift related to identifying code status, verifying vital signs, initiating CPR and calling 911 for residents with a Full Code status, and continuing CPR until EMS arrives and assumes care of the resident. Beginning on [DATE], Human Resources (HR) #700 will verify CPR verification for all licensed nurses upon hire and a yearly CPR course will be offered to maintain certification. Beginning on [DATE], the DON or designee will audit all full code statuses three times a week for four weeks, then weekly for eight weeks to ensure resident code statuses are accurate. Beginning on [DATE], the DON or designee will provide education two times weekly on each shift for four weeks to ensure nursing staff understand how to verify resident code status and that residents with a Full Code must have CPR initiated and EMS called. Beginning on [DATE], the Administrator or designee will audit, upon occurrence for four months, all Full Code residents who experience an event in the facility that requires CPR to ensure advanced directives are followed, CPR was performed, and EMS was notified. Any identified issues will be corrected immediately and reported to the QAPI committee monthly for further review. Telephone interviews on [DATE] with LPN #400 and LPN #410 verified education was received on Full Code status, initiation of CPR, and notifying EMS when a resident with a Full Code status experienced cardiac or respiratory arrest. On [DATE] at 7:35 A.M., the DON reported LPN #400 and LPN #410 to the Ohio Board of Nursing for failing to initiate CPR for Resident #100. Review of four (#101, #102, #103, and #104) additional closed resident medical records, reviewed for death in the facility, revealed no additional concerns. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective actions and monitoring for effectiveness and on-going compliance. Findings include: Review of the closed medical record for Resident #100 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included dementia with behaviors, diabetes mellitus (DM), peripheral vascular disease (PVD), chronic heart failure, chronic kidney disease (CKD) stage four, atrial fibrillation (A-fib) [abnormal heart rhythm], and atherosclerotic heart disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #100 was cognitively impaired. Review of the plan of care, initiated on [DATE], revealed Resident #100 had an advanced directive for Full Code status. Interventions included: if the resident was found unresponsive, staff were to call a stat (immediate assistance) to the room, initiate CPR and call 911, and notify the family of changes of condition. Review of the physician orders for [DATE] revealed Resident #100 had an order for a Full Code Status. Review of a nursing progress note dated [DATE] at 7:26 A.M. and authored by LPN #400 revealed LPN #400 went to obtain Resident #100's morning blood sugar and found him to be absent of vital signs. Further review of Resident #100's medical record revealed no additional information related to an assessment or action taken by facility staff when the resident was found unresponsive. An interview on [DATE] at 9:06 A.M. with the DON verified Resident #100 was a Full Code status and staff failed to initiate CPR or call 911 when the resident was found without vital signs on [DATE]. A telephone interview on [DATE] at 9:36 A.M. with LPN #400 verified she worked on [DATE] (night shift) into the morning of [DATE] and was assigned to care for Resident #100. LPN #400 stated she went into the resident's room at approximately 5:35 A.M. to complete his morning blood sugar check and found that Resident #100 appeared to have passed away in his sleep. LPN #400 further stated she called her supervisor, LPN #410, to check on Resident #100, and it was LPN #410 who confirmed the resident had no vital signs. LPN #400 stated she then went to check the code status for Resident #100 and discovered he was a Full Code and asked LPN #410 what she should do since the resident had no vital signs. LPN #400 stated she was advised by LPN #410 to call Resident #100's family and notify them he had passed and ask what funeral home to use. LPN #400 verified CPR was not initiated for Resident #100 and 911 was not called for emergency medical services to be provided. LPN #400 stated this was her first encounter with a resident having a Full Code status and being found without any vital signs and she was unsure of what to do. A telephone interview on [DATE] at 10:21 A.M. with LPN #410 verified she worked the night shift on [DATE], into the morning of [DATE]. LPN #410 stated LPN #400 called her for assistance with Resident #100 because he was found to be absent of vital signs. LPN #410 stated she assessed Resident #100 and confirmed he did not have any vital signs. LPN #410 verified CPR was not performed and 911 was not called for Resident #100. LPN #410 stated the protocol for a resident with a Full Code status who was found without vital signs would have been to get the crash cart, start CPR, and call 911. A telephone interview on [DATE] at 9:49 A.M. with Registered Nurse (RN) #415 revealed she worked the night shift on [DATE], into the morning of [DATE]. RN #415 stated she did not have knowledge at the time of Resident #100 being found unresponsive but, had she been aware, she would have initiated CPR and called 911 because the resident was a Full Code Status. Review of LPN #410's written statement, dated [DATE], confirmed CPR was not initiated for Resident #100. Further review revealed LPN #410 asked LPN #400 what she was going to do being's he was a full code. The statement revealed LPN #400 gave permission to the Certified Nursing Assistant (CNA) to provide post-mortem care and LPN #410 gave direction to LPN #400 to notify the family and physician. Review of the facility policy titled, Policy and Procedure: CPR/Advanced Directives, undated, revealed it was the policy of the facility that each resident would have an advanced directive in place at admission and the staff would provide basic life support, including CPR, to him/her in an emergency prior to the arrival of emergency medical personnel according to the physician's order and the resident's advanced directives. The facility would ensure and maintain records that licensed staff were trained and certified/recertified in CPR and were available immediately, 24 hours per day, to provide basic life support, including CPR, in an emergency before emergency personnel arrived. All licensed staff must be aware of a resident's code status and immediately act accordingly. This deficiency represents non-compliance investigated under Complaint Number 2571943.

Based on observations, medical record review, staff interview, and review of facility policy, the facility failed to ensure a visually impaired resident who was at risk for falls, was provided a proper room set up to prevent falls. This resulted in actual harm when Resident #10 had a room change on 08/03/23 at 11:45 A.M., fell in the new room on 08/03/23 at approximately 3:50 P.M., was transported to the hospital and found to have a fracture of the right humerus (shoulder). This affected one (Resident #10) of three residents reviewed for falls. The facility census was 88. Finding include: Review of the medical record for Resident #10 revealed an admitted [DATE]. Diagnoses included dementia with behavioral disturbance, skin cancer, fracture of right arm humerus (08/03/23), fracture of lower end of left radius (07/27/23), fracture of left ulna styloid process (07/27/23), paranoid schizophrenia, bilateral cataracts, and macular degeneration. Review of Resident #10's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was not able to be completed. Staff assessment for mental status was completed and indicated Resident #10 had memory impairment and had short and long-term memory problems. Resident #10 was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. Resident #10's vision was severely impaired. Resident #10 displayed verbal behavioral symptoms directed toward others four to six days during the review period and rejection of care behaviors daily during the review period. Resident #10 had two or more falls since admission with major injury. Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively impaired and required supervision set up only with walking in her room, walking in the corridor, and locomotion on and off the unit. It was noted Resident #10 required supervision with toilet use. Resident #10 was noted to be steady (at all times) with moving from the seated to standing position, walking, turning around and facing the opposite direction, moving on and off the toilet and transferring surface to surface. Resident #10 utilized a walker. Review of Resident #10's Care Plan revised 08/30/23 revealed supports and interventions for seeing smoke everywhere related to cataracts, self-care deficit, resistive to care, potential for verbal and physical aggression, impaired cognitive function, and risk for falls. Resident #10's risk for falls was related to her cognitive impairment, decreased safety awareness, decreased judgement, impulsiveness, visual deficits, and terminal condition. Review of Resident #10's Fall Risk Assessments completed 04/24/23, 07/24/23, 07/26/23, 08/06/23, and 08/08/23 revealed Resident #10 was at high risk for falls. It was noted Resident #10 over estimated or forgot her limits and had an impaired gait. Review of Resident #10's progress notes revealed on 07/31/23 the Administrator noted he spoke with Resident #10's daughter about moving Resident #10 to a private room as Resident #10 had not been able to have a roommate for years due to her behaviors and paranoia. Resident #10's daughter was in agreement but wanted a room that was the same as Resident #10's prior room due to Resident #10's vision impairment. Review of Resident #10's Census Information revealed Resident #10 resided in the same room since 2018 and moved rooms two times on 08/03/23. Further review of Resident #10's medical record revealed Resident #10 had a fall on 08/03/23, which resulted in a fracture. Review of Resident #10's Fall Investigation dated 08/03/23 revealed Resident #10 had an unwitnessed fall in her new room at approximately 3:15 P.M. Resident #10 was found on the floor in her room with her right hand extended against her back. Resident #10 was assisted up from the floor and she complained of pain in her right shoulder. Range of motion was performed, and Resident #10 continued to complain of pain in her right shoulder. Resident #10's Power of Attorney (POA) and physician were notified. The Assistant Director of Nursing (ADON) called Emergency Medical Services (EMS) to transport Resident #10 to the hospital for proper evaluation. When interviewed, Resident #10 stated she fell . Resident #10 had been assessed and helped from the floor. Resident #10 reported pain to her right shoulder and her vitals were within normal limits. Resident #10 was transferred to the hospital for evaluation. Resident #10 was orientated to person only. Predisposing factors included confusion, impaired memory, and recent room change. Resident #10's care plan was reviewed and updated. Review of Resident #10's 08/03/23 hospital visit documentation revealed Resident #10 was diagnosed with a closed fracture of proximal end of the right humerus (shoulder). It was noted Resident #10 presented to the hospital following a fall. Resident #10 declined any labs or medications. Resident #10 was only agreeable to an x-ray of her shoulder. Resident #10 declined any further interventions, and a sling was placed. Resident #10's daughter was present and agreed with the current treatment plan. At the time of discharge, Resident #10 was stable. Resident #10 was to take over the counter Tylenol as needed and wear the sling for comfort. Interview on 08/29/23 at 2:06 P.M. with Resident #10's family (Family Member #500) verified Resident #10 had a fall resulting in a fracture due to the resident's recent room change. Family Member #500 reported the family requested and had the impression the resident's new room would be the exact same set up as the original room, which is the only reason the family was agreeable to the room change. Observation on 08/30/23 between 10:35 A.M. and 10:43 A.M. of Resident #10's original room and new room Resident #10 was moved to on 08/03/23, revealed upon entering the original room, the bathroom was located on the right side and the closet was on the left. Upon entering the new room, the bathroom was located on the left side and the closet was on the right. Coinciding interview with Floor Monitor (FM) #208 verified the rooms were different, stating the closets and bathrooms were located on different sides of the room. Observation on 08/30/23 at 10:43 A.M. of Resident #10 found her in a room with the same set up as her original room (with the bathroom located on the right side of the room). An interview was attempted with Resident #10, but she was unable to be interviewed. Interview on 08/30/23 at 10:49 A.M. with the Assistant Director of Nursing (ADON) verified Resident #10 had an unwitnessed fall in her room on 08/03/23. The ADON verified factors that contributed to Resident #10's fall were confusion and a recent room change. The ADON reported Resident #10 was found in the entry area between the bathroom and closet and the bathroom was on the opposite side of the room from her previous room. Resident #10 was transferred to the hospital and returned to a different room, which had the same layout as her original room. Resident #10 returned from the hospital with a fractured right arm. Interview on 08/30/23 at 11:01 A.M. with the Administrator revealed Resident #10's daughter provided permission for Resident #10 to be moved from a semi-private room to a private room. Resident #10's daughter agreed with the move but requested the room be the same as the room her mom had resided in for the last few years. The Administrator verified the room Resident #10 was moved to was a mirror image of the room Resident #10 had resided in with the bathroom on the opposite side. The Administrator reported the room was on the same hallway and had the same staff Resident #10 had been used to having. The Administrator verified after Resident #10 returned from the hospital she was moved to a room at the end of the hallway which had the bathroom on the same side as her original room. The Administrator verified Resident #10 had vision impairment. Follow up interview on 08/30/23 at 1:56 P.M. with the Administrator revealed the Maintenance Director reported to him Resident #10's room change was completed on 08/03/23 at approximately 11:45 P.M. Resident #10 was then found on the floor on 08/03/23 at approximately 3:45 P.M. Review of the undated facility policy titled, Free of Accidents/Hazards/Supervision, Devices, revealed the facility would assess the environment to ensure it remained free from accident hazards to which the facility had control including identifying risks and implementing resident-centered interventions to reduce hazards and risk. This deficiency represents non-compliance investigated under Complaint Number OH00145574.

Based on medical record review, staff interview, review of the facility's incident report, review of the hospital record, and review of a personnel file, the facility failed to ensure a resident was provided with sufficient staff supervision when positioned in bed during direct care. This resulted in Actual Harm when Resident #74 sustained multiple fractures, when State tested Nursing Assistant (STNA) #117 rolled the resident away from the STNA during care, the resident rolled off the bed, landed on the floor, and was subsequently sent to the local hospital where the resident was diagnosed with a fractured right hip, pelvis, and right knee. This affected one resident (#74) of five residents reviewed. The facility census was 80. Findings include: Review of the medical record for Resident #74 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, fractured neck of the right femur (02/27/23), fracture of the right tibia (03/03/23), multiple fractures of the pelvis (03/03/23), and a displaced fracture of right femur (03/03/23). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 required total assistance of one person for bed mobility. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #74 was rarely/never understood and was totally dependent on one person for bed mobility, transfers, toilet use, and hygiene. Review of the current care plan for Resident #74 revealed she had an activities of daily life (ADL) self-care performance deficit and was dependent for bed mobility. Review of a progress note dated 02/25/23 at 6:00 P.M. revealed Resident #74 was receiving care from staff when Resident #74 tumbled out of the bed onto the floor and sustained a hematoma (bruise) on the back of her head. Resident #74 was alert and gave no indication of pain at that time. Review of a progress note dated 02/26/23 at 4:48 A.M. revealed Resident #74 was grimacing during care. Review of a progress note dated 02/26/23 at 8:47 P.M. revealed an X-Ray of Resident #74 was ordered. Review of a progress note dated 02/27/23 at 2:00 P.M. revealed Resident #74 continued to show facial grimacing during care and staff were still awaiting an X-Ray. Review of a progress note dated 02/27/23 at 3:08 P.M. revealed Resident #74's right leg and hip were turned facing inward, and Resident #74 was grimacing and moaning upon touch. The right hip was swollen without bruising. Non-emergency transportation was called and Resident #74 was transported to the hospital. Review of the hospital progress note dated 03/02/23 revealed X-Ray and computed tomography (CT) records, revealed Resident #74 had a right hip fracture, a right femur fracture, a right knee fracture, a right tibia fracture, and a pelvic fracture. Review of the facility's incident report created by Registered Nurse (RN) #116, dated 02/25/23 at 6:00 P.M., revealed State tested Nurse Aide (STNA) (#117) was providing personal care to Resident #74 when STNA #117 rolled Resident #74 onto her right side and Resident #74 tumbled out of bed hitting the right side of her head on the floor. No bleeding or loss of consciousness occurred. Further review revealed STNA #117 was educated to keep the bed next to the wall instead of pulling it out from the wall. Interview on 06/15/23 at 12:29 P.M., with the Administrator revealed STNA #117 was educated after the fall with Resident #74. The Administrator terminated STNA #117's employment after the hospital determined Resident #74 suffered fractures. Telephone interview on 06/15/23 at 2:01 P.M., with RN #116 revealed she was the shift supervisor at the time of Resident #74's fall on 02/25/23. RN #116 stated STNA #117 was providing care alone to Resident #74 and pulled her bed away from the wall so STNA #117 could access Resident #74 from both sides. RN #116 stated STNA #117 was providing a bed bath and changing Resident #74's sheets while Resident #74 laid in bed. RN #116 stated STNA #117 rolled Resident #74 away from her and Resident #74 continued to roll and STNA #117 could not catch her. Resident #74 fell off the bed toward the open room and did not fall between the bed and the wall. RN #116 educated STNA #117 to either have one person on each side of the bed when providing care, or to not pull the bed away from the wall. Review of the personnel file for STNA #117 revealed a hire date of 11/02/22 as an activities monitor and the facility completed background checks for STNA #117. The file revealed STNA #117 became an STNA on 12/09/22 and was in good standing. Review of the competency check-off sheet dated 01/17/23 revealed STNA #117 was observed to perform shower/bath/foot care, range of motion and positioning, and bed making. Further review revealed STNA #117 was terminated on 03/03/23 for causing a resident to roll off the bed and onto the floor resulting in a broken hip, pelvis, and knee. Interview on 06/15/23 at approximately 5:15 P.M., with the Director of Nursing revealed the facility did not have a policy or procedure guidance for how to turn and reposition residents while providing care. This was an incidental finding during the complaint investigation completed on 06/20/23.

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on staff interview, medical record review, review of the facility's Self-Reported Incident (SRI) and investigation, and review of the facility's policy for abuse, the facility failed to ensure one female resident (#100), who had severe cognitive impairment and wandered, was free from sexual abuse from one male resident (#110), who displayed signs of sexual inappropriacy and whose plan of care was absent for interventions related to sexual behaviors. This resulted in Immediate Jeopardy and the likelihood of serious harm on 05/09/21 at 11:08 A.M. when staff found Resident #110 on top of Resident #100 in Resident #110's bed. The residents were found unclothed from the waist down, and Resident #110 had been observed licking and sucking Resident #100's face. Staff described the position of Resident #110 as holding Resident #100 down and attempting to penetrate the resident vaginally. This affected one (#100) of four residents reviewed for abuse. The facility identified 14 female residents who were cognitively impaired that wander throughout the facility. The facility census was 87. On 06/02/21 at 2:56 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 05/09/21 at 11:08 A.M. when staff responded to a yell for help from Resident #100. Staff found Resident #110 on top of Resident #100 in Resident #110's bed. The residents were found unclothed from the waist down, and Resident #110 had been observed licking and sucking Resident #100's face. Staff described the position of Resident #110 as holding Resident #100 down and attempting to penetrate the resident vaginally. Facility staff interviews and medical record review revealed Resident #110 had previous signs of sexual inappropriacy toward female residents such as lifting their shirts, attempting to touch them below the waist in the buttocks area, attempting to encourage female residents into his room, and standing in his doorway to look at women. The facility had no identified interventions in place in the resident's plan of care. Resident #100 had frequent wandering behaviors and was described by staff as entering other resident rooms frequently, including the room of Resident #110. The Immediate Jeopardy was removed on 05/13/21 and the deficiency continued at a Severity Level 2 (no harm with the potential for more than minimal harm that is not immediate jeopardy) until the deficiency was corrected on 05/20/21, when the facility implemented the following corrective actions: · On 05/09/21 immediately following the incident, Resident #100 and Resident #110 were separated. Resident #110 was placed on close supervision and Resident #100 was placed on 15-minute observation. Resident #100 was examined by a nurse with no trauma noted, the residents clothing and brief were preserved, and the Administrator and DON were notified. An SRI report was submitted to the Ohio Department of Health. The police were contacted, the Medical Director designee and family's of the affected residents were notified, and both residents were sent to the hospital for evaluation. · On 05/09/21 at 9:10 P.M., Resident #110 returned to the facility from the hospital after a determination was made, he did not need psychiatric evaluation. The resident's room was changed and located next to the nursing station. His care plan was revised to include continued close observation, keeping the door closed per resident preference, placing a stop sign on the resident's door, and notifying the physician of any sexually inappropriate behavior. The physician also ordered a medication change to decrease his sexual behaviors. · On 05/09/21 at 9:30 P.M., Resident #100 returned to the facility from the hospital. Resident #100 was placed on 15-minute checks. The resident's care plan was updated to include redirecting any sexual behaviors, notifying the physician of any sexual behaviors, and a referral to psychiatric services as needed. The hospital indicated the resident's behaviors prevented the nurse from completing a sexual assault assessment. · On 05/09/21, the Administrator began interviews with female residents on Station One with a Brief Interview for Mental Status (BIMS) higher than eight. All 16 resident interviews were completed on 05/10/21 with no identified concerns. · On 05/10/21, the facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting to discuss the action plan and follow up for both residents related to the incident. The Medical Director, Administrator, DON, and all department heads were present for the meeting. The action plan was approved, which included the previous corrective actions the facility took including assessments of the residents, interviews of the residents, notifications to the family and physician and staff education. · On 05/10/21, the facility's Psychiatric Services #500 addressed Resident #100 and #110. Both residents were assessed, and medical interventions were made including placing both residents on 15-minute checks. Follow-up appointments were made for 05/28/21 for both residents. · On 05/10/21, the Administrator and designee began in-services for all 91 staff members on the facility's abuse policy with a special focus related to sexual abuse. All staff had previously been educated on 05/03/21 and it was determined they responded appropriately to the incident by protecting residents, assessing the residents, and completing required notifications. In-services addressed education on resident behaviors, sexual behaviors, and the identification and reporting immediately. All staff education was completed on 05/13/21. · On 05/11/21, the DON and designees began skin checks for all 11 female residents at Station One with a BIMS of eight or lower. All skin checks were completed on 05/12/21 with no identified concerns. · On 05/12/21, the Administrator followed-up with the police detective who stated that the case would not be pursued due to a lack of physical evidence, and the resident's inability to recall the event. · On 05/12/21, Nurse Consultant #600 and the Administrator reviewed records for all residents identified as wandering and having behaviors. There were no additional residents identified that displayed sexual behaviors or were affected by sexual behavior. Care plans for all residents with behaviors were reviewed to ensure interventions were in place. · On 05/13/21, the DON or designee began monitoring four resident records daily for evidence of sexual behavior and staff response to the same. The DON also began daily observations to ensure resident behaviors were being addressed in accordance with the plan of care and that all behaviors were reported per the facility's policy. Review of the monitoring revealed it was completed daily beginning on 05/13/21. · Interviews on 06/02/21 from 8:11 A.M. to 8:28 A.M. with State tested Nursing Aide (STNA) #320, STNA #330, Licensed Practical Nurse (LPN) #300, and Registered Nurse (RN) #310 revealed they received education by the management team regarding the facility's abuse policy by 05/13/21. The staff interviewed demonstrated knowledge on the facility's abuse policy. Findings include: Review of the medical record for Resident #100 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/07/21, revealed Resident #100 was severely cognitively impaired. Resident #100 did not complete a Brief Interview for Mental Status (BIMS) assessment. The resident was rarely or never understood. The resident's self-performance with locomotion on the unit required supervision. The level of support for locomotion on the unit was independent. The resident was also assessed to wander daily. Review of the care plan for Resident #100, last revised on 03/08/21, revealed the resident had impaired cognitive function related to Alzheimer's disease and unspecified [CONDITION(S)]. Interventions included reorienting, cueing, and supervising the resident as needed. Further review revealed the resident liked to walk around the facility. Interventions included observing the resident for her safety. Review of the progress note, dated 05/09/21 for Resident #100, revealed the resident's husband was contacted by the facility. Resident #100's husband was notified that there was a witnessed incident between Resident #100 and another male resident. Both residents had their pants off and the male resident was on top of Resident #100. Review of the medical record for Resident #110 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS 3.0 assessment for Resident #110, dated 02/21/21, revealed the resident had intact cognition, scoring a 14 out of 15 on the BIMS assessment. The resident did not have any abusive behaviors towards other residents. The resident had no impairment to his upper and lower extremities and was always steady with walking with an assistive device. Review of the behavior progress note for Resident #110 revealed a note dated 05/09/18. The note documented the resident had to be redirected from a female resident, who he was getting too close to and appeared that he was going to kiss her. The incident occurred in the hallway after lunch. Review of the behavior progress note, dated 03/12/19, revealed the resident was observed frequently attempting to encourage female residents into his room and was redirected. Fifteen (15)-minute visual checks were continued. Review of the behavior progress note, dated 12/18/20, revealed it was noted by staff the resident lead a female resident into his room. Staff removed the resident quickly. The resident continued to stand in the door to look for the female resident. Staff placed him in bed and placed him on 15-minute visual checks. Review of the care plan for Resident #110, dated 02/22/21, revealed the resident had impaired cognitive function due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the care plan revealed there were no interventions in place for inappropriate sexual behaviors. Further review of the progress notes for Resident #110, dated 05/09/21, revealed the residents' family member was notified that Resident #110 was found on top of a female resident and that it may have been a sexual assault. The family was notified, the police had been called, and the resident would need to be sent out for a psychiatric evaluation. Review of the facility's SRI submitted to the State Survey Agency on 05/09/21 at 3:25 P.M. revealed an allegation of sexual abuse. The residents identified in the allegation were Resident #100 and Resident #110. The witness to the incident was Licensed Practical Nurse (LPN) #200. Review of the narrative summary of the incident revealed Resident #100 was found in Resident #110's room and in bed at 11:00 A.M. Both residents were unclothed from the waist down, and Resident #110 was on top of Resident #100. Review of the facility's summary investigation revealed the police were contacted and Resident #100 and Resident #110 were sent to the hospital for evaluation. The facility investigation revealed it was unclear who instigated sexual contact between the two residents and that neither of the residents had any identified sexual behavior prior to the incident. Further review of investigation reports revealed staff who worked that day were not able to recall any unusual behaviors from Resident #100 or Resident #110. Review of the summary of hallway video footage was provided by the facility for 05/09/21. The video footage was reviewed by the Licensed Nursing Home Administrator (LNHA) who signed the summary. The summary revealed that at approximately 10:47 A.M., Resident #100 entered Resident #110's room from the hallway. Nothing else of interest was noted until 10:59 A.M. At 10:59 A.M., LPN #210 entered Resident #110's room while Resident #100 was still in the room. LPN #210 stayed for a minute and exited the room. At approximately 11:08 A.M., LPN #200 entered Resident #110's room. A minute later, LPN #200 exited the room with Resident #100. Observation on 06/01/21 at 12:39 P.M. of Resident #100 revealed the resident was in a resident room that was not hers. Resident #100 was redirected by a staff member out of the room and into the hallway. Attempted interview with Resident #100 at the time of observation revealed the resident was unable to respond to questions or provide meaningful information. Observation and interview on 06/01/21 at 12:43 P.M. with Resident #110 revealed the resident in his room resting in bed. The resident was asked what his name was, what his date of birth was, who the current president of the United States was, and where he was currently located. Resident #110 answered each question correctly. Resident #110 denied any knowledge of a woman in his room in recent time. Resident #110 denied any knowledge of being on top of a woman in his bed. Resident #110 denied any recent sexual contact with other residents at the facility. Interview on 06/01/21 at 1:36 P.M. with LPN #210 revealed she was working on 05/09/21 from 6:00 A.M. to 2:30 P.M. and was assigned to Resident #110 that day. LPN #210 stated she entered Resident #110's room around 10:45 A.M. to pass his medication. LPN #210 stated the resident was sitting on the side of his bed, fully clothed, and not displaying any behaviors. LPN #210 stated she did not see or hear any other residents in the room at that time but noted the bathroom door was shut. LPN #210 stated her medication pass took a minute or two and she left the room. LPN #210 revealed that she had cared for Resident #110 in the past and he frequently stands in his doorway to look at women. LPN #210 described the resident's behavior as non-physical, but she has asked him before if he was checking out another resident or staff member and he will smile back at her when she asked this. Interview on 06/01/21 at 1:50 P.M. with LPN #200 revealed she was working on 05/09/21 from 6:00 A.M. to 2:30 P.M. in a supervisor role. LPN #200 stated that she was taking vital signs around 11:00 A.M. on 05/09/21 in a room across the hallway from Resident #110's room. LPN #200 stated she heard someone screaming Help me, help me, somebody help me, and exited the room she was in to see what the issue was. LPN #200 stated the screaming came from inside Resident #110's room. LPN #200 stated she entered Resident #110's room to find that Resident #110 and Resident #100 were in the bed together. LPN #200 revealed Resident #110 was on top of Resident #100, holding her down with both of his forearms, licking and sucking her face, and both residents had their pants and briefs around their ankles. LPN #200 stated she could not confirm vaginal penetration was occurring but stated Resident #110 was thrusting into Resident #100 as if to try to penetrate her vaginally. LPN #200 physically separated the two residents, escorted Resident #100 to safety, and instructed another staff member to sit with and monitor Resident #110. LPN #200 stated she has cared for both residents before and Resident #100 has been in Resident #110's room at times without any sexual interaction. LPN #200 stated she had received reports in the past from nursing assistants that Resident #100 will be found sitting in bed with Resident #110 and needs redirected out of the room. LPN #200 further revealed Resident #110 has been observed by staff checking out female residents and staff in the hallways. LPN #200 believed Resident #110 had been placed on 15-minute observation in the past for these types of behaviors. LPN #200 further revealed based on her experience caring for him, that Resident #110 had the cognition to know that type of behavior was inappropriate but will deceive those who question him, acting as though he did not know what happened. Interview on 06/01/21 at 3:32 P.M. with State tested Nursing Assistant (STNA) #225 revealed Resident #100 has frequent wandering behaviors and enters other resident rooms throughout the day. STNA #225 stated staff redirect the resident back into a common area or her own room when this happens. STNA #225 stated she had observed Resident #100 standing in Resident #110's room before but did not observe any sexual interaction. STNA #225 further revealed she had witnessed Resident #110 exhibit sexual behaviors toward other female residents in the past such as lifting their shirts and attempting to touch them below the waist in the buttocks area. STNA #225 stated the last time she observed this behavior was last year. STNA #225 further revealed she was unsure if these incidents were reported but remembered the resident was usually placed on 15-minute checks when this behavior was observed. Interview on 06/02/21 at 8:46 A.M. with the Administrator revealed the facility was not aware of any sexual behaviors for Resident #100 or Resident #110 since being at the facility. The Administrator stated the residents had not been on any increased monitoring at the time of the incident and were monitored per their care planned recommendations. The Administrator stated the facility alleges there was not an indication for increased monitoring prior to the incident because there was no known history of sexual behavior from either of the involved residents. He was not aware that staff had knowledge of Resident #110 touching female residents or lifting their shirts up. He stated that anything of that nature should have been reported and addressed at that time. He stated that Resident #110's chart was reviewed following the incident and that Resident #110's attempts to lead female residents to his room was not considered sexually inappropriate because no sexual contact was ever verified. Interview on 06/02/21 at 12:55 P.M. with Psychiatric Nurse Practitioner (PNP) #230 revealed the psychiatric team had been seeing Resident #110 and #100 regularly while at the facility. PNP #230 stated Resident #110 did not have any previous sexual behaviors documented that she was aware of. PNP #230 stated that since the incident took place with sexual behavior involving another resident, Resident #110 had been started on a new medication that decreases libido in males and was used with males to decrease sexual behaviors. PNP #230 stated based on her experience with Resident #110, the resident was a higher functioning form of dementia and has some cognition regarding decision making. He can hold simple conversation and answer questions. PNP #230 stated the psychiatric service was also following Resident #100. PNP #230 stated the service was unaware of any sexual behaviors regarding Resident #100. PNP #230 stated Resident #100 was severely cognitively impaired and was unable to have any meaningful conversation. Review of the facility's policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 2017, revealed residents had the right to be free from abuse. The policy defined sexual abuse as non-consensual sexual contact of any type with a resident. Review of the policy section for prevention and identification revealed procedures were to include identifying, correcting, and intervening in situations in which abuse is more likely to occur in accordance with the facility's QAPI plan; completing ongoing assessments and care planning for appropriate interventions and monitoring of residents with behaviors including sexually aggressive behaviors such as inappropriate grabbing, touching, or saying sexual things. This deficiency substantiates Control Number OH 538.

Based on medical record review, observation, staff interview, review of facility skin policy and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure individualized interventions were implemented to prevent pressure ulcer development resulting in the development of an avoidable pressure ulcer to Resident #02's coccyx. This resulted in actual harm when staff failed to implement pressure ulcer preventative measures and Resident #02 developed an avoidable stage III pressure ulcer on the coccyx. This affected one (#02) of two residents reviewed for pressure ulcers. The facility census was 102 Findings include: Review of the medical record revealed Resident #02 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] identified the resident had severe cognitive impairment. The resident was dependent on staff for the completion of activities of daily living (ADL) including incontinence care, turning and repositioning, incontinent of bowel and bladder, at risk for skin breakdown with no current open areas. Review of the skin risk assessment dated [DATE] noted the resident was at risk for the development of skin breakdown. On 06/25/19 a nursing plan of care was revised to address the residents skin breakdown risk. Interventions included alternating air mattress to bed, notify nurse of alterations in skin integrity, house barrier cream topically to buttocks three times daily and after each incontinent episode, dietitian to assess nutritional needs to support skin health/wound healing, monitor nutritional status, serve diet as ordered, monitor intake and record, nurse to complete skin assessment due weekly on shower day, pressure reducing device on wheelchair, administer treatments as ordered and monitor for effectiveness, inform the resident/family/caregivers of any new area of skin breakdown. On 10/04/19 at 9:36 P.M. nurses notes documented an open area was discovered to the coccyx. The wound care specialist was notified and a treatment was applied. There was no documentation to indicate the family representative was notified. No intervention was listed to address an offloading or repositioning frequency prior to the discovery of the wound. According to the wound management documentation form dated 10/04/19 the wound characteristics were as follows; stage III measuring 1.0 centimeters (cm) in length by (x) 0.6 cm in width and 0.5 cm in depth with moderate purulent drainage. Review of wound specialist certified nurse practitioner progress notes dated 10/08/19 revealed a request was submitted by the facility for the evaluation of a wound to the coccyx which was discovered on 10/05/19 (even though it was actually discovered on 10/04/19). An assessment noted the resident as wheelchair bound, and dependent for mobility. Nursing reported the resident tends to sit in the wheelchair most of the day and the resident slouches in the chair. The wound was described as a stage III pressure injury, with full thickness ulceration of the coccyx measuring 1.0 centimeter (cm) by 0.6 cm x 0.5 cm. The wound was draining a moderate amount of purulent, with edges adherent to the wound base. The resident demonstrated evidence of pain when affected area was palpated. On 10/18/19 at 11:30 [NAME]M. interview with Registered Nurse (RN) #10 (assessment nurse) revealed the resident had a serious kyphosis and frequently slid himself down in the wheelchair. Further review of the medical record lacked interventions to address potential sheering of the buttock or coccyx region. On 10/18/19 at 11:35 [NAME]M. interview with the Director of Nursing (DON) verified the record lacked documentation of repositioning, or frequency of incontinence monitoring. Additionally, there was no documentation indicating the family representative was notified of the wound occurrence. On 10/18/19 at 12:00 P.M. interview with state tested nurse aide (STNA) #100 revealed the area was discovered on 10/04/19 during incontinence care due to the resident experiencing a bowel movement. STNA #100 indicated the wound was reported during the the first shift (6:00 [NAME]M. to 2:30 P.M.) to the infection control nurse. There was no evidence a treatment being put into place until 10/04/19 at 9:36 P.M. Observation on 10/18/19 at 12:20 P.M. of the pressure area with RN #10 noted the wound to be located within one inch of the anus between the buttock. Moderate purulent drainage was observed on the existing dressing. On 10/18/19 at 12:35 P.M. interview with the DON verified the location of the wound and the lack of discovery prior to the development of a stage III pressure ulcer. The DON confirmed the resident was to be checked and changed for incontinence every two hours during which time the skin was to be inspected for breakdown. There was no documented evidence of the frequency of incontinence care. Review of the facility skin care prevention and pressure management policy revised 08/2018 noted prevention protocol to include position changes every two hours. Review of information from the NPUAP revealed a stage III pressure ulcer is full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This deficiency substantiates Master Complaint Number OH 756.

Based on medical record review, surveyor observation, review of facility policy and staff interview, it was determined that the facility failed to implement pressure relieving devices for two residents. This affected two (#70 and #34) of five residents reviewed for pressure ulcers. In addition, the facility failed to ensure the necessary treatment and services were provided to promote healing which resulted in actual harm for Resident #70 who developed one Stage III pressure ulcer to the left heel and one unstageable pressure ulcer to the right heel. The total facility census was 102. Findings include: 1. Review of Resident #70's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The resident was discharged from the facility to home with Hospice on 03/26/10. Upon admission on 02/02/10, Resident #70 was assessed at high risk for the development of pressure ulcers. Review of the admission nursing assessment dated [DATE] revealed Resident #70 was admitted with two small open areas with yellow centers on the coccyx. One of the areas was 1.0 centimeter (cm) in diameter and the other was 0.5 cm in diameter. Resident #70 was also assessed to have intact blisters to both heels. The blister on the left heel measured 8.0 cm by 10.0 cm and the blister on the right heel measured 5.0 cm by 7.0 cm by 0.1 cm. Review of admission physician orders [REDACTED]. A [MEDICATION NAME] (a topical dressing for maintaining moisture in the wound) was ordered to the sacral wound and to be changed every three days until healed. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed the resident was not assessed to have any wounds or pressure areas. Review of the resident assessment protocol (RAP) summary for pressure ulcers dated 02/11/10 indicated Resident #70 is severely impaired due to the [DIAGNOSES REDACTED]. The RAP noted the resident will be seen by wound care and staff is monitoring the healing process of the buttocks wound. A pressure relief mattress and pressure relief cushion is in place and the resident remains at risk for further skin integrity issues as she relies on staff for mobility and remains incontinent at times. The decision was to proceed with a care plan for skin integrity. Review of Resident #70's pressure ulcer care plan dated 02/02/10 revealed the resident was at risk for pressure ulcers. The goal was for the resident to remain free of alterations in skin integrity. Interventions included: applying barrier cream to the peri-area after each episode of incontinence; encourage meal and fluid consumption; monitor weight monthly and notify the doctor if weight fluctuates up or down of five pounds and inspect peri-area and bony prominences for signs and symptoms of redness, irritation and skin breakdown. The care plan did not reflect the resident's actual open areas or the treatments being provided, including the use of the pressure relieving mattress and cushions. The care plan remained unchanged until the resident was discharged on [DATE]. Review of nurses' notes from 02/27/10 revealed the sock on the left heel was observed with drainage. The note indicated the left heel had skin peeling with a large open area with slight bloody drainage. The nurse also documented Resident #70 displayed no pain or discomfort. A new treatment order was obtained at that time. Review of the "Wound/Skin Care Management Documentation Form" from 02/02/10 to 02/23/10 revealed the facility measured Resident #70's blisters weekly. The measurements and treatments were unchanged during that timeframe. However on 02/27/10, the left heel opened and on 03/09/10 the right heel increased in size and measured 7.0 cm by 15 cm by 0.1 cm. Further review of the medical record contained no documented evidence that the initial wound care consult the physician ordered on [DATE] was completed until 03/02/10, after Resident #70's heel ulcers worsened and opened. There was also no documented evidence that additional interventions were implemented to prevent the heels from worsening until the ulcers opened and advanced in Stage. Review of the wound care consultant notes dated 03/02/10 revealed Resident #70 was assessed to have a Stage III pressure ulcer to the left heel that measured 8.0 cm by 10.0 cm by 0.2 cm. The right heel was assessed to have an unstageable pressure ulcer that measured 5.0 cm by 7.0 cm by 0.1 cm. Both pressure ulcers were documented by the wound nurse to have an onset date of 02/27/10. The wound nurse ordered a treatment to the left heel and interventions for a pressure relief mattress to the bed, heel protectors and off loading of the heels when in bed. Review of the facility's undated policy entitled "Pressure Ulcer Management" indicated a resident will not develop pressure ulcers unless the resident's condition deems them unavoidable. The policy further noted any resident having a pressure ulcer or ulcers will receive appropriate treatment to promote healing and prevent further pressure ulcers from occurring. Review of the facility's undated policy entitled "Prevention and treatment of [REDACTED]. The minimum preventative measures included appropriate assessment and implementation of pressure reduction or relief/floating of heels when supine in bed. Interview with the Director of Nursing (DON) on 04/08/10 at 8:32 A.M. confirmed the facility's policy was not followed regarding Resident #70's pressure ulcers. The DON verified there was no documented evidence that interventions were implemented to prevent Resident #70's heels from further breakdown. The DON also verified the care plan did not reflect the resident's actual pressure ulcers or interventions/treatments of the ulcers and was not updated/revised until the resident came back from the hospital on [DATE]. 2. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. Review of the wound consultant progress note dated 04/06/10 indicated Resident #34 currently had a Stage II pressure ulcer to the right lateral ankle that measured 0.3 cm by 0.4 cm by 0.1 cm. Review of the care plan for pressure ulcers dated 06/28/05 revealed interventions of a pressure relieving device on the bed and wheelchair and bilateral off loading boots at all times. Observation of Resident #34 on 04/08/10 at 2:36 P.M., Resident #34 was observed lying in bed on a regular mattress and box spring that were on the floor. A blue mattress was noted next to her on the floor. The resident had her eyes closed and had the bilateral off loading boots on as ordered. On 04/09/10 at 2:03 P.M., Resident #34 was observed again lying in bed on a regular mattress with the bilateral off loading boots on. During interview with the DON on 04/08/10 at 3:12 P.M., she verified Resident #34's mattress was not an approved pressure relieving mattress.