Every finding on record at Fox Run Manor

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on closed medical record review, interviews, review of hospital records and review of the facility policy, the facility failed to adequately and accurately assess Resident #64's skin and further failed to identify a pressure ulcer (localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) until it had reached an advanced stage. Additionally, the facility failed to timely identify and implement interventions to prevent the deterioration of the pressure ulcer. This resulted in Actual Harm for Resident #64, who was dependent on staff for all activities of daily living (ADLs) and admitted to the facility with no pressure ulcers but was at risk for pressure ulcers, when the resident developed an avoidable, facility acquired stage III pressure ulcer (full-thickness loss of skin in which adipose [fat] is visible) that was identified by the outside wound care provider on 06/23/26. Furthermore, the facility failed to identify and implement any additional interventions until 07/07/26 to prevent decline and promote healing. Consequently, Resident #64 was admitted to the hospital for medical intervention, including intravenous (IV) antibiotics, surgical debridement and colostomy placement for wound healing. This affected one (#64) of three residents reviewed for pressure ulcers. The facility identified eight (#07, #30, #32, #33, #34, #41, #53, and #54) residents with pressure ulcers. The facility census was 63.Findings include:Review of the closed medical record for Resident #64 revealed an admission date of 06/13/26. Diagnoses included central cord syndrome (spinal cord injury), neuromuscular dysfunction of the bladder (lack of normal bladder control due to a disruption in the nerve signals), quadriplegia, intellectual disability, and Fragile X chromosome (mutation which prevents the body from producing a protein critical for normal brain development). Resident #64 discharged to the hospital on [DATE].Review of the Clinical admission Assessment, dated 06/13/26, revealed Resident #64's skin was warm and dry, skin color was within normal limits, turgor (elasticity) was normal, and the resident had no skin issues identified.Review of the Braden Scale for Predicting Pressure Ulcer Risk Evaluation, dated 06/13/26, revealed Resident #64 had a score of 14, indicating a moderate risk for pressure ulcer development. Identified risk factors included unable to communicate discomfort or the need to be turned or had some sensory impairment which limited ability to feel pain or discomfort in one or two extremities, skin was occasionally moist, chairfast with the ability to walk severely limited or non-existent, and completely immobile and did not make even slight changes in body or extremity position without assistance. Resident #64 was assessed to have adequate nutrition.Review of the Weekly Skin and Body Review, dated 06/13/26, revealed Resident #64 had no areas of skin impairment identified.Review of the physician order dated 06/13/26 revealed Resident #64 had a pressure reducing cushion to the chair and a pressure reduction mattress to the bed. Review of the care plan, dated 06/15/26, revealed Resident #64 had bowel and bladder incontinence. Interventions included checking and changing as required for incontinence and provide perineum (peri) care after each incontinence episode. Additionally, Resident #64 was at risk for skin breakdown or had known areas of skin breakdown. Interventions included the use of offloading devices (pressure reducing mattress, pressure reducing cushions, pillows), assistive devices for turning and repositioning in the bed or chair, and monitor/document/report to the physician changes in skin status. Review of the admission Minimum Data Set (MDS) assessment, dated 06/18/26, revealed Resident #64 was cognitively impaired. Resident #64 was dependent on staff for all ADLs. Further review of the MDS revealed Resident #64 was incontinent of bowel and bladder, did not have any pressure ulcers, and was at risk of developing pressure ulcers. Review of the Weekly Skin and Body Review, dated 06/19/26, revealed Resident #64 had an abrasion to the inner right buttocks and was being treated with Triad cream two times daily until healed. No further description of the wound was documented.Additional review of the physician orders confirmed an order dated 06/19/26 for Triad Hydrophyllic Wound Dressing, apply to the right inner buttock topically two times a day. No additional interventions were ordered. Review of the Medication Administration Record (MAR) from 06/19/26 through 06/22/26 revealed Triad was applied two times daily per physician orders.Further review of Resident #64's medical record from 06/19/26 through 06/22/26 revealed no documentation of monitoring, exacerbation, additional treatments/interventions, or decline related to the area on the resident's buttocks. Review of the Initial Wound Evaluation and Management Summary, dated 06/23/26 and authored by Wound Doctor (WD) #300, revealed Resident #64 had a stage III pressure ulcer that was present for greater than seven days and facility staff reported it to be present upon admission. The wound measured five centimeters (cm) by (x) five cm x 0.1 cm, with a surface area of 25 cm. The peri wound had excoriation and erythema (redness), had moderate serous exudate, with 100 percent (%) granulation tissue. There were no signs of infection. Treatment orders included a primary dressing of calcium alginate, apply once daily and as needed if saturated, soiled, or dislodged for 30 days, and a secondary dressing of gauze island with boarder, apply once daily and as needed if saturated soiled or dislodged for 30 days. General recommendations were to elevate legs, float heels in bed, off-load wounds, and reposition per facility protocol.Review of the Wound Evaluation and Management Summary, dated 06/30/26 and authored by WD #300, revealed Resident #64 had an unstable coccyx full thickness wound. The wound was unstageable with necrosis (dead tissue). The wound measured eight cm x four cm x 0.1 cm, with a surface area of 32 cm. The wound had moderate serous exudate with 100% slough. WD #300 completed a surgical excisional debridement and excised 16 cm of devitalized tissue, including slough, biofilm, and non-viable subcutaneous tissue to a depth of 0.1 cm and healthy bleeding tissue was observed. Treatment orders included a calcium alginate dressing, apply once daily and as needed if saturated, soiled, or dislodged for 23 days; Leptospermum honey, apply once daily and as needed if saturated, soiled, or dislodged for 30 days; and gauze island with border, apply once daily and as needed if saturated, soiled, or dislodged for 23 days. Additionally, Resident #64 had diaper dermatitis (primarily results from prolonged moisture, urine, and feces). Zinc was ordered, apply twice daily. Review of the Wound Evaluation and Management Summary, dated 07/07/26 and authored by WD #300, revealed Resident #64's wound was unstable due to necrosis, full thickness, and measured 7.7 cm x 3.9 cm x 0.1cm. The wound was documented as improved as evidence by a decreased surface area of 30.03 cm. The wound had moderate serous exudate with 100% slough. A surgical excisional debridement procedure was completed, and 15.02 cm of devitalized tissue including slough, biofilm, and non-viable subcutaneous level tissues were removed at a depth of 0.1 cm and healthy bleeding tissue was observed. Previous treatment orders were continued.Further review of the care plan revealed no revisions related to Resident #64's pressure ulcer were made until 07/07/26 (15 days after the pressure ulcer was identified), when it was revised to include Resident #64 had a pressure ulcer to the coccyx. Interventions included assessing/recording/monitoring wound healing, report improvements and declines to the doctor, air mattress per order, and turn and reposition frequently as tolerated.Review of the Wound Evaluation and Management Summary, dated 07/14/26 and authored by WD #300, revealed Resident #64 had a stage IV pressure ulcer to the coccyx, full thickness, and measured 7.4 cm x 3.9 cm x 0.4 cm. and a surface area of 28.86 cm. The wound had moderate serous exudate and was documented to be improved as evidence by decreased necrotic tissue, and decreased surface area. WD #300 performed a surgical excisional debridement procedure and excised 14.43 cm of devitalized tissue, including slough, biofilm, and non-viable subcutaneous level tissues were removed at a depth of 0.5 cm and healthy bleeding tissue was observed. Treatment orders were continued and Resident #64 continued to be treated for diaper dermatitis.Review of a nursing progress note, dated 07/16/26 at 1:33 A.M. and authored by Registered Nurse (RN) #200, revealed a 16 French (FR) 30 cubic centimeters (cc) Foley (indwelling) catheter was inserted per physician orders (for wound healing). Resident #64 was subsequently transferred to the hospital for evaluation and treatment due to complications from the catheter placement. Review of a nursing progress note dated 07/16/26 revealed Resident #64 was admitted to the hospital intensive care unit (ICU) for wound debridement. The hospital was ruling out osteomyelitis (bone infection) and gangrene in the wound, and a septic work up was being done.Review of the Emergency Department (ED) history and physical, dated 07/16/26, revealed Resident #64 had a sacral decubitus ulcer with extensive surrounding erythema with slight warmth, fibrinous and necrotic tissue, extension into the muscle and fascia, with no obvious tunneling noted. Resident #64 was noted to have a number of problems, including sepsis, infected (pressure) ulcer, cellulitis, abscess, and osteomyelitis. The plan for treatment included a general surgery consultation for wound evaluation and management. The resident was started on IV Vancomycin (antibiotic) 1000 milligrams (mg) every eight hours for treatment of sepsis due to osteomyelitis of the coccyx.Review of the hospital wound care progress note dated 07/16/26 revealed Resident #64 was assessed for a pressure injury to the coccyx. Upon assessment, Resident #64 had a large, unstageable pressure injury encompassing the coccyx and right ischium (lower, back part of the hip). Resident #64 also had severe Moisture Associated Skin Damage (MASD) noted to the bilateral ischium. The wound measured 7.5 cm x 10 cm x 3.2 cm. The wound bed was 60% brown, moist slough tissue with the thickest layer of slough having noted bogginess at the coccyx region. The wound was 30% yellow fibrotic tissue that resembled burn from repeated exposure to urine and feces from Incontinence Associated Skin Damage (IASD), and 10% red moist tissue. A mild odor was noted, mostly located at the coccyx region. Resident #64 was painful with assessment. The wound edges were raised, ill-defined, irregular, attached and without epibole (where the edges of the wound curl inward). The peri wound was very denuded and eroded. Erythema was present without significant calor (heat) noted. Concerns for wound infection, need for debridement and most likely diverting ostomy for wound healing and fecal management. Review of the hospital surgical progress note dated 07/20/26 revealed Resident #64 was found to have a stage four sacral pressure wound with a plan for operative debridement and a diverting colostomy.Interview on 07/20/26 at 9:46 A.M. with the Director of Nursing (DON) confirmed Resident #64 admitted to the facility on [DATE] with no open skin areas on his buttocks. Additionally, the DON verified the resident's care plan was not updated with additional interventions until 07/07/26. Interview on 07/20/26 at 10:07 A.M. with Licensed Practical Nurse (LPN) #150 revealed she completed a skin assessment on Resident #64 upon admission, and the resident did not have any open skin areas. LPN #150 stated the resident was sent out to the hospital on [DATE], and when he returned on the same day, she completed a new skin assessment. LPN #150 stated Resident #64 did not have an abrasion to the inner buttocks as documented on the 06/19/26 Weekly Skin and Body Review, adding he had redness on his buttocks. LPN #150 confirmed she inaccurately documented an abrasion. LPN #150 also confirmed the resident had no skin issues upon admission to the facility, even though the wound care provider documented on 06/23/26 that the resident's pressure ulcer was present upon admission, as relayed by staff. LPN #150 verified Resident #64 had an order for Triad paste two times daily from 06/19/26 through 06/23/26, at which time nursing staff should have been assessing the resident's buttocks for further skin breakdown, and no pressure ulcers or open skin areas were documented until the resident was seen by the wound care provider on 06/23/26. LPN #150 stated on 07/15/26, she suggested placing a Foley catheter to promote wound healing, as Resident #64 was incontinent.Interview on 07/20/26 at 2:02 P.M. with Certified Nurse Practitioner (CNP) #301 revealed she was notified on 06/19/26 that Resident #64 had a cut on his buttocks. She ordered Triad paste to apply to the area and a wound care consultation. CNP #301 stated she never examined the area on Resident #64's buttocks. CNP #301 stated on 07/15/26, LPN #301 requested an order for a Foley catheter for Resident #64 because she said she did not believe staff were changing (incontinence care) and repositioning the resident frequently enough and the wound was getting worse.Interview on 07/21/26 at 9:15 A.M. with Wound Doctor (WD) #300 revealed he first evaluated Resident #64 on 06/23/26 and was told by the facility staff that the resident had an open area on the coccyx that was present upon admission. WD #300 stated, based on assessment, the wound appeared to have been on the resident's coccyx for at least seven days. WD #300 stated the following week, on 06/30/26, the wound had gotten worse and the skin turned necrotic. WD #300 stated that the condition of the wound could have deteriorated from not being changed and repositioned and the diaper dermatitis was most likely caused from urine.Interview on 07/22/26 at 7:52 A.M. with Certified Nursing Assistant (CNA) #160 revealed Resident #64 was frequently incontinent of bowel and bladder. CNA #160 stated the third shift CNAs did not properly check the back of Resident #64's incontinence brief, and he was frequently left wet with urine that was not noticeable by just looking at the front of the brief. CNA #160 also stated the nurses would not change the resident's wound dressing if it was saturated with urine, only if it had bowel movement on it. Interview on 07/22/26 at 12:16 P.M. with hospital Medical Doctor (MD) #303 revealed he reviewed Resident #64's medical records, including those from prior to the resident's admission to the facility, and the resident did not have any pressure ulcers. MD #303 stated Resident #64 acquired the pressure ulcer to his coccyx due to lack of incontinence care and repositioning. MD #303 stated the wound would have been avoidable with proper care. Review of the facility policy titled, Pressure Ulcer Policy, approved 04/29/16, revealed a resident without a pressure ulcer would not develop a pressure ulcer unless the individual's clinical condition demonstrated they were unavoidable and appropriate preventative interventions would be implemented. Further review revealed a pressure ulcer was any lesion caused by unrelieved pressure that resulted in damage to the underlying tissues.The deficiency was corrected on 07/19/26 when the facility implemented the following corrective actions:-On 07/16/26, Resident #64 discharged to the hospital for further evaluation and treatment.-By 07/18/26, the Director of Nursing (DON) educated all licensed nursing staff on the accuracy of skin assessments, wound documentation expectations, and completing wound/skin evaluations. -On 07/19/26, the DON or designee audited all residents for accurate skin and wound assessments, with no concerns identified.-By 07/19/26, the DON or designee audited all residents with skin issued identified between 06/13/26 and 07/16/26 to ensure accurate wound documentation. -On 07/17/26, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review facility policies and corrective action. In attendance were the Administrator, DON, Administrator in Training (AIT) #340, Assistant Director of Nursing (ADON) #330, Activities Director (AD) #335, LPN/CM #150, Resident Services Coordinator (RSC) #345, Human Resource Coordinator (HRC) #350, and Business Office Manager (BOM) #355. Also present via telephone were Physician #360 and CNP #301.-Beginning on 07/17/26, the DON or designee will audit all current and new skin issues for accurate documentation and assessment five times weekly for four weeks.-Verification was received that audits were completed on 07/17/26, 07/21/26, 07/22/26, 07/23/26, 07/24/26 and 07/27/26, with no concerns identified.-All findings from the audits will be reviewed by the QAPI committee for four weeks to ensure ongoing compliance.-Interviews on 07/29/26 from 1:01 P.M. through 1:10 P.M. with LPN #375, LPN/CM #150, and RN #320 verified education was received regarding accurate skin/wound assessments and documentation of skin issues. -Review of two (#7 and #33) additional open resident medical records, reviewed for urinary catheters, revealed no concerns.This deficiency represents non-compliance investigated under Master Complaint Number 3097696 and Complaint Number 3073936.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on closed medical record review, hospital record review, interviews, review of the Emergency Medical Services (EMS) run report and review of the facility's skills competency checklist, the facility failed to ensure an indwelling urinary catheter was medically necessary and further failed to ensure proper catheter insertion. This resulted in Actual Harm to Resident #64 when on 07/15/26 the facility obtained a physician order to place an indwelling urinary catheter to promote wound healing and Registered Nurse (RN) #200 incorrectly inserted the indwelling urinary catheter. Consequently, Resident #64 was admitted to the hospital on [DATE] with a urethral injury tear obstruction (damage to the urethra). This affected one (#64) of three residents reviewed for indwelling urinary catheters of a total of five identified by the facility. The facility census was 63.Findings include:Review of the closed medical record for Resident #64 revealed an admission date of 06/13/26. Diagnoses included central cord syndrome (spinal cord injury), neuromuscular dysfunction of the bladder (lack of normal bladder control due to a disruption in the nerve signals), quadriplegia, intellectual disability, and Fragile X chromosome (mutation which prevents the body from producing a protein critical for normal brain development). Resident #64 discharged to the hospital on [DATE].Review of the admission Minimum Data Set (MDS) assessment, dated 06/18/26, revealed Resident #64 was cognitively impaired. Resident #64 was dependent on staff for all activities of daily living (ADLs). Further review of the MDS revealed Resident #64 did not have a urinary catheter and was frequently incontinent of bowel and bladder.Review of the care plan dated 06/15/26 revealed Resident #64 had bladder incontinence related to neuromuscular dysfunction of the bladder. Interventions included checking and changing as required for incontinence. Further review revealed on 07/15/26, the care plan was updated to include Resident #64 had a catheter related to neurogenic bladder. Interventions included monitoring for signs and symptoms of discomfort on urination.Review of a physician order dated 07/15/26 revealed Resident #64 had an order for an indwelling catheter 16 French (FR) 30 cubic centimeters (cc), with no identified reason for the use of an indwelling catheter.Review of a nursing progress note, dated 07/15/26 at 4:22 P.M. and authored by Licensed Practical Nurse/Case Manager (LPN/CM) #150, revealed a new order was received to insert a 16 FR 30 cc Foley (indwelling) catheter. The resident's Power of Attorney (POA) was made aware.Review of the Medication Administration Record (MAR) revealed on 07/15/26 at 8:59 P.M., RN #200 signed that she inserted a 16 FR 30 cc Foley catheter.Review of the EMS run report dated 07/16/26 revealed EMS arrived at the facility at 1:10 A.M. (approximately four hours after the documented time of catheter insertion) due to a resident with penile bleeding. Resident #64 was found lying in bed with staff present. The nurse stated she was putting in a Foley catheter and did not get any flow after two hours. She then tried to flush it with no success. She attempted to remove the Foley, which caused him to begin bleeding out of his penis. No other symptoms were reported by the nurse, and the resident was unable to communicate any issues. The nurse was unable to estimate how much blood loss the resident had.Review of the Change in Condition nursing progress note, dated 07/16/26 at 1:33 A.M. and authored by RN #200, revealed a 16 FR 30 cc Foley catheter was inserted as per new orders. RN #200 checked for urine output every 30 minutes post Foley insertion. Two hours after the Foley was inserted, the resident had no urine output. The Foley was removed to insert a new Foley, with a goal of urine output. Immediately after the Foley exited the penis, blood began to steadily run out of the tip of the penis. RN #200 attempted to stop the blood flow. Blood continued to steadily run out of the resident's penis for six minutes, blood then slowed to a steady drip for another 15 minutes. The blood clotted shortly before the ambulance arrived. The Certified Nurse Practitioner (CNP) on call was notified of the resident's situation, current status and vital signs. The CNP ordered the resident to be sent to the hospital.Review of a nursing progress note, dated 07/16/26 at 4:31 A.M. and authored by RN #200, revealed Resident #64 was admitted to the hospital and had damage to his urethra from catheter placement.Review of the emergency department (ED) history and physical, dated 07/16/26, revealed Resident #64 was sent from the facility for evaluation following unsuccessful Foley insertion. The facility nurse experienced difficulty with the Foley catheter placement, having to attempt multiple times and one time expanded the balloon in the urethra, so retracted and there was spurting of blood. Resident #64 reported his stomach, penis, and butt were painful. Resident #64 had a small amount of blood at the urethral meatus (opening where urine exits the urethra through the penis) with no active bleeding or drainage noted. A bedside urethrogram (specialized X-ray used to examine the urethra) was completed to ensure no urethral injury secondary to being unable to void. Slight extravasation, if any, (leakage of urine from urethra into surrounding tissue) possible at the prostatic urethra (widest and longest segment of the male urethra). A Foley catheter was successfully placed. The resident was admitted with a plan to continue the indwelling urinary catheter and consult urology.Review of the urology consultation note, dated 07/17/26, revealed Resident #64 was under evaluation for traumatic catheter placement. The ED was able to place the catheter. There was probable extravasation in the prostatic urethra. Catheter to remain in place and follow-up with urology outpatient.Interview on 07/20/26 at 9:00 A.M. with Resident #64's POA revealed he was called by LPN/CM #150 on 07/15/26 and was told that she was going to place a Foley catheter in Resident #64 on 07/16/26 because the facility did not have the right size catheter to do it that day. The POA stated he was contacted by RN #200 the morning of 07/16/26 to let him know that during Foley catheter insertion, Resident #64 did not have any urine output, so she pulled out the catheter, the resident was bleeding, and he was sent to the hospital.Interview on 07/20/26 at 10:07 A.M. with LPN/CM #150 revealed Resident #64 drank a lot of fluids and was frequently incontinent. LPN/CM #150 stated she contacted CNP #301 to obtain an order for the Foley catheter to help with wound healing.Interview on 07/20/26 at 2:02 P.M. with CNP #301 revealed LPN/CM #150 asked for an order for a Foley catheter for Resident #64 due to staff not properly providing incontinence care and repositioning Resident #64. CNP #301 stated she knew Resident #64's wound was getting worse, but she had not evaluated it and did not know the exact extent. CNP #301 stated that when RN #200 did not get urine return during the Foley catheter insertion, the catheter balloon should not have been inflated, and the catheter should have been immediately removed and the on-call CNP should have been notified. CNP #301 stated that the balloon being inflated in the urethra caused the urethral injury Resident #64 sustained.Interview on 07/21/26 at 9:15 A.M. with Wound Doctor (WD) #300 revealed the facility would typically consult with him first regarding placement of a Foley catheter for wound healing, but they did not contact him regarding Foley catheter placement for Resident #64. WD #300 further stated he would not have ordered a catheter for Resident #64, adding he did not believe it would have helped him.Interview on 07/21/26 at 4:05 P.M. with RN #200 confirmed she was the nurse who inserted the Foley catheter for Resident #64 on 07/15/26. RN #200 stated when she inserted the catheter, she got a drop of urine. RN #200 verified she inflated the balloon without urine output (to ensure the catheter tip entered the bladder). RN #200 stated she checked on Resident #64 for two hours with no urine output noted. RN #200 stated she removed the catheter and the resident began bleeding from his penis. RN #200 notified the CNP on-call and Resident #64 was sent to the ED for further evaluation and treatment.Interview on 07/22/26 at 11:30 A.M. with Service and Support Administrator (SSA) #302, with the local county board of developmental disabilities, revealed she worked with Resident #64. SSA #302 stated on 07/16/26 at 2:45 A.M., the hospital contacted her with concerns related to Resident #64's care at the facility. SSA #302 stated the hospital verbalized concern about the facility inserting a Foley catheter incorrectly, including no return of urine before inflating the balloon. SSA #302 stated the hospital reported that after the catheter had been inserted for two hours with no urine output, the facility nurse attempted to flush the catheter and when there was still no urine return, she removed the catheter, causing bleeding.Review of the facility's Skills Competency Checklist-Catheterization, dated July 2009, revealed when inserting a Foley catheter, gently insert the catheter until urine flows, then gently insert one more inch. If no urine flows, assess. Do not inflate the balloon if no return urine is noted.The deficiency was corrected on 07/18/26 when the facility implemented the following corrective actions:-On 07/16/26, Resident #64 discharged to the hospital for further evaluation and treatment.-On 07/17/26, the Director of Nursing (DON) audited five (#7, #17, #33, #42 and #44) residents identified with indwelling urinary catheters, with no concerns identified.-On 07/17/26, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held to review facility policies and corrective action. In attendance were the Administrator, DON, Administrator in Training (AIT) #340, Assistant Director of Nursing (ADON) #330, Activities Director (AD) #335, LPN/CM #150, Resident Services Coordinator (RSC) #345, Human Resource Coordinator (HRC) #350, and Business Office Manager (BOM) #355. Also present via telephone were Physician #360 and CNP #301.-Beginning on 07/17/26, the DON or designee will audit all newly inserted indwelling urinary catheters for correct placement and urine output for four weeks.-By 07/18/26, the Director of Nursing (DON) or designee educated all licensed nursing staff on indwelling urinary catheter placement and removal. Verification was received of the education provided and the staff in attendance.-Verification was received that audits were completed on 07/17/26, 07/24/26 and 07/27/26, with no concerns identified.-All findings from the audits will be reviewed by the QAPI committee for four weeks to ensure ongoing compliance.-Interviews on 07/29/26 from 1:01 P.M. through 1:10 P.M. with LPN #375, LPN/CM #150, and RN #320 verified education was received regarding appropriate urinary catheter placement and removal.-Review of two (#7 and #33) additional open resident medical records, reviewed for urinary catheters, revealed no concerns.This deficiency represents non-compliance investigated under Master Complaint Number 3097696.

Based on observation, medical record review, interviews and review of the facility policy, the facility failed to ensure water was readily available to residents. This affected three (#51,#54, and #56) of four residents reviewed for hydration. The facility census was 63.Findings include: 1. Review of the medical record for Resident #56 revealed an admission date of 05/05/26. Diagnoses included restless leg syndrome, chronic myeloproliferative disease, and atherosclerotic heart disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition, evidenced by a Brief Interview for Mental Status (BIMS) score of eight. Resident #56 was assessed to require total assistance with Activities of Daily Living (ADLs). Review of the care plan dated 05/12/26 revealed Resident #56 had a potential for dehydration related to diuretic use. Interventions included monitoring vital signs as ordered per protocol and record. Observation on 07/20/26 at 3:05 P.M. revealed Resident #56's water pitcher was on the bedside table and was empty, and no other fluids were available in the room. Observation on 07/21/26 at 8:33 A.M. revealed Resident #56's water pitcher was on the bedside table and was empty, and no other fluids were available in the room. Observation on 07/21/26 at 11:15 A.M. revealed Resident #56's water pitcher was on the bedside table and remained empty, and no other beverages were available in the room. Interview on 07/20/26 at 3:12 P.M. with Resident #56's family revealed ice water was only given if requested. Resident #56's family further stated that when visiting the resident, his water pitcher was frequently empty. Interview on 07/21/26 at 8:17 A.M. with Certified Nurse Assistant (CNA) #165 revealed the CNAs tried to pass water to residents when they had the time to get to it. Interview on 07/21/26 at 11:30 A.M. with CNA #165 confirmed Resident #56 did not have fresh water passed to him during the shift, his water pitcher was empty, and no other beverages were available in the room. Interview on 07/22/26 at 7:52 A.M. with CNA #160 revealed ice water was passed upon request from the residents. 2. Review of the medical record for Resident #51 revealed an admission date of 07/02/18. Diagnoses included constipation, atrial fibrillation, and cardiomegaly. Review of the MDS assessment dated [DATE] revealed Resident #51 was cognitively impaired. Further review of the MDS revealed Resident #51 required set-up assistance with eating. Review of the care plan dated 05/15/18 revealed Resident #51 had the potential for dehydration related to having recent infection which affected fluid needs. Interventions included encouraging and assisting Resident #51 with fluid intake in order to meet daily requirements and ensuring that Resident #51 had access to cold water and favorite fluids whenever possible. Review of the nursing progress note dated 07/18/26 revealed staff were to increase oral fluids as tolerated. Observation on 07/21/26 at 8:37 A.M. revealed Resident #51 laying in bed. Resident #51 did not have a water pitcher or other beverages available in her room. Interview on 07/21/26 at 8:40 A.M. with Resident #51 revealed the facility had not given her a water pitcher. Resident #51 further stated she had not been served breakfast yet, so no fluids were available. Interview on 07/21/26 at 9:00 A.M. with CNA #170 confirmed Resident #51 did not have a water pitcher or other beverages available to her in her room. CNA #170 stated she was passing breakfast trays and would get to Resident #51 soon. 3. Review of the medical record for Resident #54 revealed an admission date of 06/04/26. Diagnoses include calculus of the kidney, obesity, and right knee effusion. Review of the MDS assessment dated [DATE] revealed Resident #54 was cognitively intact. Additional review of the MDS revealed Resident #15 required set up assistance with eating. Review of the care plan dated 06/05/26 revealed Resident #54 had potential for fluid deficit related to diuretic use. Interventions included ensuring Resident #54 had access to fluids of choice whenever possible. Further review of the care plan revealed Resident #54 had an increase in hydration needs related to right knee effusion, kidney stones, and edema. Interventions included monitoring for signs and symptoms of dehydration. Observation on 07/21/26 at 11:17 A.M. revealed Resident #54 was up in the wheelchair in her room. Resident #54 did not have a water pitcher in her room. Concurrent interview with Resident #54 revealed the facility never provided a water pitcher for her. Interview on 07/21/26 at 11:25 A.M. with CNA #165 confirmed Resident #54 did not have a water pitcher and further confirmed the CNAs did not pass fresh water to residents. Review of the facility policy titled, Hydration Policy, dated August 2025, revealed nutrition services offered fluids per preferences at mealtimes and bedtime. Water may be provided at bedside. This deficiency represents non-compliance investigated under Master Complaint Number 3097696 and Complaint Number 3073936.

Based on closed medical record review, hospital record review and interviews, the facility failed to ensure residents who required the use of a Continuous Positive Airway Pressure (CPAP) machine had physician orders for use and further failed to ensure the CPAP was used per physician orders once received. This affected one (#64) of one resident reviewed for respiratory care. The facility census was 63.Findings include:Review of the closed medical record for Resident #64 revealed an admission date of 06/13/26. Diagnoses included central cord syndrome, neuromuscular dysfunction of the bladder, and quadriplegia. Resident #64 discharged to the hospital on [DATE].Review of the admission Minimum Data Set (MDS) assessment, dated 06/18/26, revealed Resident #64 was cognitively impaired. Additional review of the MDS revealed Resident #64 was dependent on staff for all Activities of Daily Living (ADLs).Review of the care plan, initiated 06/15/26, revealed no interventions related to the use of a CPAP.Review of the physician orders revealed an order dated 06/19/26 for CPAP setting pressure of 9.0 to 11.0 Ramp Time- Auto, humidity level four, and full size mask every morning and at bedtime. Review of the Medication Administration Record (MAR) for June 2026 revealed on 06/19/26 at bedtime, the CPAP was marked as not applicable (NA). Further review revealed on 06/20/26, the CPAP was marked NA in the morning and at bedtime.Review of the Emergency Department (ED) physician note on 06/19/26 revealed Resident #64 had been taken to the ED from the facility for altered mental status. Resident #64's family revealed Resident #64 had not been acting himself and had not used his CPAP for six days. Further review of the ongoing medical history revealed Resident #64 had obstructive sleep apnea (OSA).Review of the nursing progress note dated 06/19/26 revealed Resident #64's Power of Attorney (POA) called the facility while the resident was at the ED. The POA mentioned a CPAP, and the writer stated there were no orders for one. The Certified Nurse Practitioner (CNP) was notified and an order was obtained to use the settings on the machine (located in the resident's room) until respiratory therapy (RT) evaluated. Interview on 07/20/26 at 10:07 A.M. with Licensed Practical Nurse (LPN) #150 revealed Resident #64's CPAP machine was brought to the facility upon admission and was in a bag on the bedside table. LPN #150 stated they did not know what it was and further confirmed the facility did not inquire about it. Further interview with LPN #150 verified that after the orders were obtained for the CPAP, it was documented as not used on 06/19/26 and 06/20/26.Interview on 07/20/26 at 10:50 A.M. with Resident #64's POA revealed the resident's CPAP machine was brought to the facility with the resident upon admission. The POA stated the CPAP machine remained in a box on the bedside table, even after he notified facility staff, including LPN #150, that Resident #64 required it.Interview on 07/20/26 at 2:02 P.M. with CNP #301 revealed she was contacted about Resident #64's CPAP machine on 06/19/26. CNP #301 stated she was not aware that he required one; however, she was told that the machine was at the facility. CNP #301stated it was possible Resident #64's mental status was affected by not using the CPAP. Interview on 07/22/26 at 7:52 A.M. with Certified Nursing Assistant (CNA) #160 revealed Resident #64's CPAP machine was in his room upon admission. CNA #160 stated she inquired with nursing about the CPAP machine multiple times; however, she never heard of any follow-up on it and the resident did not utilize if when first admitted .This deficiency represents non-compliance investigated under Complaint Number 3073936.

Based on observation, resident and staff interview, and policy review, the facility failed to ensure temperatures in the facility were maintained between 71 and 81 degrees Fahrenheit. This affected all 28 residents who resided on the C hall (#54, #43, #13, #48, #53, #69, #39, #44, #55, #37, #32, #51, #30, #8, #52, #6, #67, #64, #41, #63, #66, #3, #16, #15, #60, #50, #27 and #28) of 63 residents reviewed for temperature. Additionally, the facility failed to ensure a clean environment related to dust in resident rooms in the facility. This affected five residents (#36, #37, #52, #50, and #3). The facility census was 63.Findings include:1. Observation and concurrent interview with Resident #37 on 06/01/26 at 9:27 A.M. revealed Resident #37 had lots of dust on her personal items on her shelves. Resident #37 stated this bothered her as she likes to have a clean room. Resident #37 stated she could no longer clean her room herself and the housekeepers did not dust her room.Interview on 06/01/26 at 9:41 A.M. with Certified Nurse Aide (CNA) #325 verified the dust on Resident #37's shelves and personal items. CNA #325 reported the facility did not dust the resident rooms and she had reported this as a problem to administration before.Observation and concurrent interview with CNA #325 on 06/01/26 at 9:46 A.M. verified the dust on the shelves and personal items in Resident #50's room.Observation and concurrent interview with CNA #325 on 06/01/26 at 9:47 A.M. verified the dust on the shelves and personal items in Resident #52's room.Observation and concurrent interview with CNA #325 on 06/01/26 at 9:48 A.M. verified the dust on the shelves and personal items in Resident #3's room.Observation and concurrent interview with Activities Director (AD) #300 on 06/04/26 at 1:21 P.M. verified the dust on the shelves and personal items in Resident #36's room.2. Observation and concurrent interview with Maintenance Assistant (MA) #332 on 06/02/26 at 11:07 A.M. in the C hall sitting area near the entrance to the unit revealed the temperature to be 69.6 degrees Fahrenheit.Observation and concurrent interview with MA #332 on 06/02/26 at 11:08 A.M. in the C hall dining room revealed the temperature to be 66.6 degrees Fahrenheit.Observation and concurrent interview with MA #332 on 06/02/26 at 11:10 A.M. at the end of the C hall in the sitting area revealed the temperature to be 69.6 degrees Fahrenheit.Interview on 06/08/26 at 10:41 A.M. with MA #332 revealed the facility purchased a new thermometer. Review of the handwritten document provided by MA #332 revealed MA #332 took temperatures on the C hall with the new infrared thermometer the facility purchased and the temperatures were as follows: 64 degrees Fahrenheit in the C hall sitting area near the entrance to the unit, 66 degrees Fahrenheit near the C hall nurses station, and 62 degrees Fahrenheit at the end of the C hall in the sitting area.Review of the facility policy titled Environment Policy with a revision date of May 2005 revealed the manor will provide a safe, clean, comfortable, and homelike environment.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects. This affected five (#1, #23, #8, #52, and #6) of five residents reviewed for unnecessary medications. The facility identified 42 residents receiving psychotropic medications. The facility census was 63. Findings Include: 1. Review of Resident #1's medical record revealed an admission date of 03/07/26. Diagnoses included fracture of lower femur subsequent encounter, chronic kidney disease, depression, cellulitis, and pneumonia. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. Resident #1 was dependent on staff for toilet use, bathing, dressing and transfer. Resident #1 required moderate assistance with bed mobility. Resident #1 displayed no behaviors at the time of the review. Review of Resident #1's care plan revised 05/29/26 revealed supports and interventions for risk for pain, self-care deficit, risk for falls, depression, risk for bleeding and bruising, potential for constipation, increased nutritional and hydration risk, potential for psychosocial wellbeing problem, psychotropic medication use, and risk for adverse effects due to psychotropic medication use. Review of Resident #1's physician orders revealed an order dated 03/07/26 for trazodone HCl 100 milligrams (mg) at bedtime for antidepressant and Venlafaxine HCl 75 mg give two tablets twice a day for antidepressant. Review of Resident #1's medical record found no indication Resident #1 was being monitored for side effects for the psychotropic medication use of trazodone HCl 100 milligrams (mg) at night, and Venlafaxine HCl 75 mg two tablets twice a day. Interview on 06/04/26 at 2:33 P.M. with the Director of Nursing (DON) verified there was no daily monitoring for psychotropic medication use side effects. The DON reported the nursing staff would document if they saw anything out of the ordinary and there was monitoring for behaviors but not side effects. 2. Review of Resident #23's medical record revealed an admission date of 09/22/25. Diagnoses included aftercare following joint replacement surgery, dementia, major depressive disorder, muscle weakness, presence of right artificial hip joint, and presence of bilateral artificial knee joints. Review of Resident #23's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #23 was cognitively intact. Resident #23 was independent with toilet use, dressing, bed mobility and transfer. Resident #23 required supervision with bathing. Resident #23 displayed no behaviors during the review period. Review of Resident #23's care plan revised 04/20/26 revealed supports and interventions for risk for falls, risk for pain, risk for bruising and bleeding, behavioral symptoms of agitation and confusion, self-care deficit, at risk for constipation, dementia, depression and at risk for side effects due to psychotropic medication use. Review of Resident #23's physician order revealed an order dated 04/02/26 for Mirtazapine 15 milligrams (mg) once a day for major depressive disorder and Duloxetine HCl delayed release particles 30 mg once a day for depression. Review of Resident #23's medical record found no indication Resident #23 was being monitored for side effects for the psychotropic medication use of Mirtazapine 15 milligrams (mg) once a day for major depressive disorder and Duloxetine HCl delayed release particles 30 mg once a day for depression. Interview on 06/04/26 at 2:33 P.M. with the Director of Nursing (DON) verified there was no daily monitoring for psychotropic medication use side effects. The DON reported the nursing staff would document if they saw anything out of the ordinary and there was monitoring for behaviors but not side effects. 3. Review of Resident #6's medical record revealed an admission date of 04/26/25. Diagnoses included hypertensive heart and chronic kidney disease with heart failure, type two diabetes mellitus, major depressive disorder, anxiety, spinal stenosis, and acute cystitis without hematuria. Review of Resident #6's quarterly MDS assessment dated [DATE] revealed Resident #6 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13. Furthermore, Resident #6 required the use of antianxiety, antidepressant, and hypoglycemic medications. Review of Resident #6's care plan dated 06/04/26 revealed Resident #6 had diagnoses of depression and anxiety disorders and took anti-depressant and anti-anxiety medications with interventions that included to monitor/document/report to the nurse or Medical Director signs and symptoms of depression and to monitor/record/report to the Medical Director as needed for risk of harm to self. Review of Resident #6's physician order revealed an order for Venlafaxine HCL Extended Release 150 milligrams (mg) with instructions to give one tablet by mouth one time a day for depression. Review of Resident #6's Medication and Treatment Administration Record (MAR TAR) for the month of May 2026 revealed no monitoring was in place for psychotropic medication. 4. Review of Resident #8's medical record revealed an admission date of 09/27/16. Diagnoses included Parkinson's disorder, dementia, osteoarthritis, muscle weakness, major depressive disorder, and gastroesophageal reflux disease. Review of Resident #8's quarterly MDS assessment dated [DATE] revealed Resident #8 had moderately impaired cognition with a BIMS score of nine. Furthermore, Resident #8 required the use of antipsychotic, antianxiety, antidepressant, opioid, antiplatelet, and anticonvulsant medications. Review of Resident #8's care plan dated 03/23/26 revealed Resident #8 was prescribed antipsychotic medications related to psychotic disorder with delusions due to a known physiological disorder with interventions that included to monitor/record the occurrence of target behavioral symptoms per facility protocol and to monitor/record/report symptoms of psychotropic medications to the Medical Director. Review of Resident #8's physician orders revealed the following orders: Ativan 0.5mg with instructions to give three tablets at bedtime for anxiety/agitation, Ativan 0.5mg with instructions to give one tablet by mouth three times a day for tremors, Cymbalta capsule delayed release 30mg with instructions to give one capsule by mouth at bedtime for depression, Cymbalta capsule delayed release 60mg with instructions to give one capsule by mouth one time a day for major depressive disorder, Nuplazid 34mg with instructions to give one tablet by mouth one time a day for delusions, and Risperdal 0.5mg with instructions to give one tablet by mouth at bedtime related to psychotic disorder with delusions. Review of Resident #8's MAR and TAR for the month of May 2026 revealed no monitoring was in place for psychotropic medication. 5. Review of Resident #52's medical record revealed an admission date of 02/23/26. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure with hypoxia, chronic kidney disease, major depressive disorder, and anxiety disorder. Review of Resident #52's quarterly MDS assessment dated [DATE] revealed Resident #52 had intact cognition with a BIMS score of 15. Resident #52 required the use of antianxiety, antidepressant, diuretic, opioid, and anticonvulsant medications. Review of Resident #52's care plan dated 03/03/26 revealed Resident #52 utilized psychotropic medications with interventions that included to administer medications as ordered and to monitor and document side effects and effectiveness, and to consult with the pharmacy and Medical Doctor (MD) to consider dosage reduction when clinically appropriate. Review of Resident #52's physician orders revealed the following orders: Buspar 10mg with instructions to give one tablet by mouth three times daily for anxiety, Duloxetine HCL oral capsule delayed release 40mg with instructions to give one tablet by mouth one time a day for depression, and Paroxetine 20mg with instructions to give one tablet by mouth at bedtime for depression. Review of Resident #52's MAR and TAR for the month of May 2026 revealed no monitoring was in place for psychotropic medication. Review of the facility policy titled, Psychotropic Drugs, revised 05/09/17 revealed residents who used psychotropic medications would be monitored for adverse consequences or complications of drug therapy.

Based on observation, staff interview, review of a handwritten document, and policy review, the facility failed to ensure medications were properly stored. This had the potential to affect all residents. The facility census was 63. Findings include:Observation on 06/04/26 at 9:30 A.M. of C hall medication cart one revealed four whole pills and four pills that were in halves sitting in the bottom of the medication cart. Concurrent interview with Registered Nurse (RN) #319 verified the pills in the bottom of the medication cart.Interview on 06/04/26 at 9:34 A.M. with the Director of Nursing (DON) verified there were four whole pills and four half pills that were found at the bottom of the C hall medication cart number one and would attempt to identify the pills.Observation and concurrent interview on 06/04/26 at 9:37 A.M. with Licensed Practical Nurse (LPN) #392 verified there were 18 whole pills and one half of a pill in the bottom of A hall medication cart one.A follow-up interview on 06/04/26 at 9:45 A.M. with the DON verified there were 18 whole pills and one half of a pill in the bottom of A hall medication cart one and would attempt to identify the pills.Review of the handwritten document from the DON revealed the medications identified in the bottom of the C hall medication cart one to be midodrine, baclofen 10mg and 20mg, losartan, and Plavix with multiple half pills that were unidentifiable. Furthermore, the DON revealed the medications in the bottom of the A hall medication cart one to be folic acid, duloxetine, gabapentin, vitamin D, cinacalcet, trazadone, metoprolol, two famotidine pills, iron, hydroxyzine, promethazine, lamotrigine, Rexulti, tizanidine, galantamine, lisinopril, and the DON was unable to identify one and a half pills.Review of the facility policy titled Medication Storage in the Facility with a revision date of 02/11/21 revealed medications and biologicals are stored safely, securely, and properly following manufacturers recommendations or those of the supplier.

Based on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were provided a dignified dining experience. This affected three (Residents #50, #37 and #66) out of three residents reviewed for assistance with meals. The facility census was 63. Findings Included: 1. Review of Resident #50's medical record revealed an admission date of 04/22/21. Diagnoses included Alzheimer's disease, anxiety disorder, major depressive disorder, peripheral vascular disease, osteoarthritis and chronic pain. Review of Resident #50's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #50 was rarely or never understood. Resident #50 was dependent on staff for eating, toilet use, bathing, dressing, bed mobility and transfer. Resident #50 displayed no behaviors and was receiving hospice services at the time of the review. Resident #50 had no significant weight loss or gain during the review period. Resident #50 received a mechanically altered diet. Review of Resident #50's care plan revised 06/01/26 revealed supports and interventions for communication deficit, allergies, impaired cognitive function, self-care deficit with one assist for eating, and risk for impaired nutritional status. Observation on 06/01/26 at 11:48 A.M. of Resident #50 was seated in the dining area on the C unit with 15 other residents waiting for her meal. The Certified Nursing Assistant (CNA) #350 was seated next to Resident #50 waiting to assist when Resident #50's meal was delivered. Observation on 06/01/26 at 12:29 P.M. Resident #50 continued to be seated in the dining area waiting for her meal to be provided. The majority of the other residents had been provided their meals and were eating independently. Some residents had completed eating their meals and had left the dining area. Interview on 06/01/26 at 12:31 P.M., with CNA #350 verified Resident #50 was dependent on staff for eating and had been waiting close to an hour for her lunch while other residents who could feed themselves had already been served and were done with their meals. Observation on 06/01/26 at 12:39 P.M. Resident #50 continued to wait for her lunch to be provided. Five other residents were finishing their meals while one other was being assisted with eating. The other nine residents had finished their meals. Observation on 06/01/26 at 12:44 P.M. Resident #50 was provided her lunch meal of thickened tomato soup, blueberries, and a grilled cheese sandwich cut into quarters. 2. Review of Resident #37's medical record revealed an admission date of 05/01/23. Diagnosis included hemiplegia and hemiparesis following cerebral infarction, type two diabetes mellitus, anxiety, dysphagia, hyperlipidemia, and hypertension. Review of Resident #37's Medicare five-day MDS assessment dated [DATE] revealed Resident #37 had a memory problem. Furthermore, Resident #37 required set up or clean up assistance with eating and was dependent for toileting hygiene, showering and bathing. Resident #37 was dependent for chair to bed and bed to chair transfers. Review of Resident #37's care plan dated 05/07/26 revealed Resident #37 was at risk for decline or fluctuating Activities of Daily Living (ADL) self-care performance related to hemiplegia, weakness, and cerebral infarction with interventions that included a Physical and Occupational Therapy (PT, OT) evaluation and treatment as ordered by the physician and that Resident #37 required to be fed all meals. Review of Resident #37's physician orders revealed an order for a regular diet, regular texture with nectar thick/mildly thick consistency. May have pleasure food. Furthermore, Resident #37's physician orders specified to make sure staff assist resident with meals every shift. 3. Review of Resident #66's medical record revealed an admission date of 04/26/25. Diagnoses included hypertensive heart and chronic kidney disease with heart failure, type two diabetes mellitus, paraplegia, major depressive disorder, anxiety, cognitive communication deficit, and muscle weakness. Review of Resident #66's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 13. Furthermore, Resident #66 required setup or clean-up assistance with eating. Review of Resident #66's care plan dated 06/04/26 revealed Resident #66 was at risk for decline or fluctuating Activities of Daily Living (ADL) self-performance related to pain and paraplegia with interventions that included Resident #66 required one staff participation to eat for set up and one staff participation with personal hygiene and oral care. Review of Resident #66's physician orders revealed an order for a regular diet with regular texture and consistency. Observation on 06/01/26 at 9:38 A.M. of Resident #37 revealed oatmeal was spilled down the front of Resident #37's shirt in multiple areas. Interview on 06/01/26 at 9:39 A.M. with Resident #37 revealed it took a long time for staff to come and assist her so she would attempt to feed herself. Resident #37 stated she required assistance to eat but staff were not always there to help her with eating. Resident #37 stated it embarrassed her to have food on her clothing, but she was unable to clean the food from her shirt. Interview on 06/01/26 at 9:41 A.M. CNA #325 verified the oatmeal on Resident #37's shirt. CNA #325 stated Resident #37 would feed herself and go back to her room before the staff were able to clean off the food from her shirt. Observation on 06/02/26 at 12:14 P.M. of dining service in the C hall dining room revealed two residents (#37 and #66) who were sitting on opposite sides of the dining room and required assistance with eating. CNA #302 was assisting both residents with eating. Observation on 06/02/26 at 12:14 P.M. revealed CNA #302 gave Resident #37 a bite of her food while standing next to her. Observation on 06/02/26 at 12:15 P.M. revealed CNA #302 walked away from Resident #37 and walked to Resident #66. CNA #302 stood next to Resident #66 and gave her a few bites of food. Observation on 06/02/26 at 12:16 P.M. revealed CNA #302 walked away from Resident #66 and walked to Resident #37. CNA #302 stood next to Resident #37 and gave her a few bites of food. Observation on 06/02/26 at 12:18 P.M. revealed CNA #302 walked away from Resident #37 and walked to Resident #66. CNA #302 stood next to Resident #66 and gave her a bite of food. Interview on 06/02/26 at 12:23 P.M. with CNA #302 verified she usually bounced around the dining room to assist multiple residents who required eating assistance. CNA #302 verified she would stand next to a resident, give them a bite of food, watch them swallow the food safely, and walk to the next resident to do the same thing until all residents were fed. Review of the facility policy titled Resident Rights Policy with a revision date of November 2016 revealed the resident has a right to a dignified existence and the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each residents individuality.

Based on medical record review, review of the admission authorizations document, staff interview, and policy review, the facility failed to notify a resident's representative of a change in condition. This affected one (Resident #78) out of three residents reviewed for representative notification. The facility census was 63.Findings include:Review of Resident #78's medical record revealed an admission date of 10/06/25 and a discharge date of 02/11/26. Diagnoses included schizophrenia, neuromuscular dysfunction of the bladder, aneurysm of the ascending aorta, anxiety, hypertension, depression, and hypercalcemia. Review of Resident #78's modification of admission/Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of seven. Furthermore, Resident #78 was frequently incontinent of urine and bowel and was dependent for toileting hygiene. Review of Resident #78's care plan dated 10/06/25 revealed Resident #78 had an indwelling urinary catheter with interventions that included to monitor intake and output per the facility policy, monitor, record, and report to the Medical Director signs or symptoms of Urinary Tract Infections (UTI) such as pain, burning, blood tinged urine, cloudiness, and change in behavior, and to provide catheter care per the physician orders and as needed. Review of Resident #78's admission authorization document dated 10/07/25 revealed Resident #78 had a resident representative that signed the admission authorization alongside Resident #78.Review of the provider progress note for Resident #78 dated 12/02/25 revealed Resident #78 was experiencing severe penile pain and swelling with a pain rating of nine out of ten. The pain was described as excruciating and was localized to the glans penis, which appeared swollen. There was a significant amount of serosanguineous discharge around the urethral meatus, but no blood was noted in the indwelling catheter bag. Resident #78 had been given tramadol and other pain medications, but there had been no improvement in his pain. The plan was to refer Resident #78 to the hospital for urological evaluation due to significant pain and potential risk of urethral injury. Resident #78 consented to the hospital transfer for further assessment and management by a urologist.Interview on 06/03/26 at 3:13 P.M. with Certified Nurse Practitioner (CNP) #405 verified Resident #78 was supposed to have been sent to the hospital on [DATE] and was not sent. CNP #405 verified she did not have any triage note or any knowledge of him being sent to the hospital.Interview on 06/08/26 at 8:52 A.M. with the Director of Nursing (DON) verified Resident #78 was not sent to the hospital per the physician's order on 12/02/25 and was unable to state why he was not sent to the hospital. The DON called the hospital and there was no documentation that Resident #78 was sent to the hospital on [DATE]. Furthermore, the DON verified the resident's representative was not made aware of the change in condition or the order to send Resident #78 to the hospital.Review of the facility policy titled Notification of Changes Policy with a revision date of November 2016 revealed the manor would inform the resident, the attending physician, and the resident's representative or interested family member of changes which affect the resident.This deficiency represents non-compliance investigated under Complaint Numbers 3005035 and 2795186.

Based on record review, interview, and form instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10095, and Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review, the facility failed to ensure notices were given appropriately. This affected one (Resident #69) of three residents reviewed for NOMNCs and Advance Beneficiary Notice of Noncoverage (ABN). The facility census was 63.Findings include:Review of medical record for Resident #69 revealed an admission date of 01/20/26 with diagnoses including Parkinson's disease, type two diabetes, malignant neoplasm of the prostate, and rhabdomyolysis.Review of SNF Beneficiary Protection Notification Review for Resident #69 revealed Medicare Part A skilled services episode start date: 01/20/26. Last covered day of Part A Service: 02/16/26. There were no other check marks noted on the form as to how the service was terminated or why discharge occurred for Part A Services. The form is absent of whether the ABN or the NOMNC were issued to the resident.Interview on 06/04/26 at 8:46 A.M. with Clinical Educator (CE) #450 revealed the facility was unable to locate the therapy cut letter for Resident #69 or the ABN and NOMNC. CE #450 verified Resident #69 remained in the facility and should have been given a ABN and NOMNC for the end of skilled Part A stay.Review of form instruction for the NOMNC revealed a Medicare health provider must give an advance, completed copy of the NOMNC to enrollees receiving skilled nursing, home health, or comprehensive outpatient rehabilitation facility services, no later than two days before the termination of services.

Based on record review, discharge notice, interview, and policy review the facility failed to issue a 30-day discharge. This affected one (Resident #77) of three residents reviewed for discharge. The facility census was 63.Findings include:Review of medical record for Resident #77 revealed an admission date of 07/11/25 and discharge date of 02/27/26 with diagnoses including but not limited to dementia, blindness right eye category three, and other specified sepsis.Review of minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors during the look back period. Resident #77 was independent for bed mobility, transfers, and ambulation.Review of physician orders revealed 15-minute checks until further notice (02/21/26-02/27/26), check placement of secure care (wander guard) device every shift (07/30/26-08/06/26) and (01/03/26-02/27/26), and check function of secure care device daily (07/30/26-08/06/26) and (01/06/26-02/27/26).Review of care plan dated 07/11/25 revealed resident is an elopement risk/wanderer as evidenced by history of attempts to leave the facility unattended. The resident with multiple attempts to leave the facility and cutting off secure care device. Interventions included 15-minute checks, distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, remove all sharp objects from room and educate family not to provide scissors, and wander alert device.Review of alert note dated 02/21/26 at 11:37 A.M. revealed the nurse was alerted to the resident being down the road at the neighboring assisted living facility at approximately 8:45 A.M. Staff immediately went to pick the resident up from the assisted living facility. When the resident returned to the facility, they stated that they were going to the bank. Nurse asked the resident where his wander guard bracelet was. The resident stated he cut it off and it was in his chair. Nurse inspected the chair noting the wander guard bracelet in between the chair cushion and the arm of the chair and noted to be cut.Review of Mental Health Services note dated 02/23/26 at 1:31 P.M. revealed the writer met with the client per facility request due to recent elopement incident. During the session, client was alert and oriented, able to recall recent and remote events, denied auditory or visual hallucinations, denied suicidal or homicidal ideations. The client was able to process with the writer his elopement incident and stated, I just wanted to get out of the building and explained that he planned to leave the facility to see his grandchildren. Although future behavior cannot be predicted, the client appeared fully aware of his actions and their implications and expressed no remorse at the time of the assessment. Continued monitoring and reinforcement of safety planning are recommended.Review of alert note dated 02/25/26 at 6:54 A.M. revealed the resident was alert and oriented times three and well aware of what he is doing and expressed that he wanted to go to the bank when it was daytime. The nurse mentioned that he needed to have someone accompany him and approval from the office.Review of Case management note dated 02/25/26 at 4:55 P.M. revealed spoke with daughter about transferring the resident to a secure unit for the resident's safety. Daughter gave consent for transfer.Review of notification note dated 02/26/26 at 11:54 A.M. revealed daughter notified of transfer to secure unit will take place on 02/27/26. Daughter stated okay and if refrigerator cannot be kept in new room she will pick it up.Review of Discharge summary dated [DATE] at 11:22 A.M. revealed the resident discharged to sister facility. All medications and orders were sent with the resident. The resident does not need discharge appointments or pharmacy. Daughter notified of transfer and will pick up fridge. The resident took all other belongings with him.Review of Interdisciplinary Team Progress Note (IDT) dated 03/04/26 at 9:27 A.M. revealed IDT team met with the resident's family to discuss the resident's continued plans to elope and determined that this facility was no longer appropriate for the resident. Referral made to sister facility with secure memory care unit. The resident discharged to secure memory care unit on 02/27/26.Review of discharge notice dated 02/27/26 revealed the resident was discharged to sister facility on 02/27/26 which included that if less than a 30-day notice was being provided it was because: the welfare and needs of the resident cannot be met in the facility.Interview on 06/04/26 at 11:15 A.M. with Resident Services Coordinator (RSC) #369 revealed Resident #77 would go through cycles which seemed to happen at the first of the month when he wanted to go out and get his money. RSC #369 stated the resident would case the facility and find out the routines of the staff and had plans to cut off secure care bracelet and leave the facility. RSC #369 verified they did not issue a 30-day notice due to speaking with family and that they were agreeable to transferring the resident to sister facility with a secure unit. RSC #369 verified the referral was sent on 02/25/26 and the resident was transferred on 02/27/26.Review of policy titled Admission, Transfer, Discharge and Room Change Policy not dated revealed the facility will notify resident and/or responsible part in writing, by certified mail, return receipt requested, in advance of any proposed transfer or discharge from the manor. Written notification will also be provided to the resident (whether facility or resident initiated) which will include the following information: the reason for transfer or discharge, the effective date of transfer or discharge, the location to which the resident is transferred or discharge, a statement of the resident's appeal rights, including the name, address, and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request, and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman. The notice shall be provided at least thirty (30) days in advance of the proposed transfer or discharge, unless any of the following applies: an emergency arises in which the resident's urgent medical needs require a more immediate transfer or discharge. If the resident is discharged for any forgoing reasons, the facility will provide the resident/representative the notice as many days in advance of the proposed transfer or discharge is practicable. This deficiency represents noncompliance investigated under Complaint Number 2962360.

Based on record review and interview, the facility failed to ensure care conference notices were sent out timely and care conferences were attended by appropriate Interdisciplinary Team (IDT) members. This affected three (Resident #31, #47, and #77) of four residents reviewed for care conferences. The facility census was 63.Findings include:1. Review of the medical record for Resident #31 revealed an admission date of 02/20/25 and discharge date of 05/31/26 with diagnoses including Alzheimer's disease, epilepsy, depression, and cognitive communication deficit.Review of minimum data set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Resident #31 required setup or clean-up assistance for activities of daily living, transfers, and bed mobility. Resident #31 was independent with mobility in wheelchair.Review of nursing interdisciplinary meeting opened on 04/28/26 revealed the resident/responsible party were notified on 04/29/26. Care conference was held on 05/13/26 with the following in attendance: resident, nursing, and social services.Review of nursing interdisciplinary meeting opened on 05/12/26 revealed the resident was notified on 05/12/26 and the representative was notified on 04/28/26. Care conference held on 05/14/26 with the following in attendance: resident, family, and Resident Service Coordinator.2. Review of the medical record for Resident #47 revealed an admission date of 01/07/26 with diagnoses including dementia, anxiety, and senile degeneration of brain.Review of the MDS dated [DATE] revealed Resident #47 was rarely/never understood.Review of the nursing interdisciplinary meeting opened on 02/04/26 revealed the resident/representative was notified on 02/23/26. Care conference held on 02/23/26 with the following in attendance: family and the Assistant Director of Nursing.3. Review of medical record for Resident #77 revealed an admission date of 07/11/25 and discharge date of 02/27/26. Diagnoses included dementia, blindness right eye category three, and other specified sepsis.Review of minimum data set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors during the look back period. Review of the nursing interdisciplinary meeting opened 08/11/25 revealed the resident/responsible party notified on 09/06/25. Care conference was held on 09/06/25 with the following in attendance: resident, family, and social services.Review of nursing interdisciplinary meeting opened 11/06/25 revealed the resident/responsible party notified on 11/06/25. Care conference held on 11/28/25 with the following in attendance: resident, family, and social services.Review of nursing interdisciplinary meeting opened on 02/04/26 revealed the resident/responsible party notified on 02/24/26. Care conference held on 02/27/26 (day of discharge) with the following in attendance: resident, family, and nursing.Interview on 06/04/26 at 11:28 A.M. with Clinical Educator (CE) #450 verified the care conferences for the residents listed above were not attended by the IDT team. CE #450 verified timely notification was not given for the care conferences for Resident #77 and #47.This deficiency represents noncompliance investigated under Complaint Number 2962360.

Based on observation, medical record review, staff interview and review of the facility policy, the facility failed to provide repositioning for dependent residents. This affected one (Resident #50) of four dependent residents reviewed for activities of daily living. The facility census was 63. Findings Include: Review of Resident #50's medical record revealed an admission date of 04/22/21. Diagnoses included Alzheimer's disease, anxiety disorder, major depressive disorder, peripheral vascular disease, osteoarthritis and chronic pain. Review of Resident #50's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #50 was rarely or never understood. Resident #50 was dependent on staff for eating, toilet use, bathing, dressing, bed mobility and transfer. Resident #50 displayed no behavior at the time of the review and was receiving hospice services at the time of the review. Review of Resident #50's care plan revised 06/01/26 revealed supports and interventions for risk for falls, mood problem, risk for pain, communication deficit, impaired cognitive function, and self-care deficit. Resident #50 required assistance of one staff for repositioning. Observation on 06/01/26 at 11:10 A.M. Resident #50 was seated in a geriatric (geri) chair in the common area outside the nurses station positioned in front of the television. An interview was attempted and Resident #50 was unable to be interviewed. Interview on 06/02/26 at 10:43 A.M. with Certified Nursing Assistant (CNA) #335 revealed Resident #50 was dependent on staff for everything and was unable to make her needs known and needed to be checked on for care needs. Observation on 06/02/26 at 10:50 A.M. of Resident #50 was sitting in her geri chair in the common area outside of the nurses station in front of the television (TV). Resident #50 was leaning to the right side with her head over the edge of the chair and the back of her head on the metal bar of the back support of the geri chair. The position appeared uncomfortable for Resident #50. Observation on 06/02/26 at 10:53 A.M. a second resident was brought down to the common area by a CNA and positioned in front of the TV next to Resident #50. Resident #50 continued to have her head positioned over the right side of her chair with the back of her head on the metal bar. The CNA looked at Resident #50 but made no attempts to reposition her. Observation on 06/02/26 at 11:04 A.M. Registered Nurse (RN) #368 walked past Resident #50 who continued to have her head hanging over the right edge of her geri chair. RN #368 was observed looking at the two residents in front of TV. No assistance with repositioning was provided. Observation on 06/02/26 at 11:07 A.M. Therapy Assistant (TA) #401 assisted the other resident seated in front of the television with applying foot rests to her wheelchair and taking her down to get her weight. TA #401 was observed looking at Resident #50 while assisting the other resident with her wheelchair foot rests but made no attempts to reposition Resident #50. Resident #50's head continued to be hanging over the right side of her geri chair with her head on metal bar. Observation on 06/02/26 at 11:12 A.M. of Resident #50 the Housekeeper (HK) #313 working in the area of Resident #50. HK #313 was observed seeing Resident #50 positioned uncomfortably in her geri chair but made no attempts to get Resident #50 assistance with repositioning. Observation on 06/02/26 at 11:22 A.M. of Resident #50 continued to be positioned uncomfortably in her geri chair with her head hanging over the right side of wheelchair and her head on the metal bar of the back support outside of the chair back padding. Observation on 06/02/26 at 11:32 A.M. of Resident #50 continued to be seated in front of the TV in the common area with her head hanging over the side of the wheelchair. Various staff were observed assisting other residents past Resident #50 and down to the dining area for lunch. Resident #50's head continued to be over the edge of the wheelchair and on the metal bar. No staff assisted Resident #50 with repositioning. Observation on 06/02/26 at 11:40 A.M. Resident Services Coordinator (RSC) #369 assisting another resident with repositioning her wheelchair approximately 12 feet away from Resident #50. Resident #50 was not assisted. Observation on 6/02/26 at 11:44 A.M. CNA #308 walked past Resident #50, looked briefly at her and did not assist with repositioning. Resident #50's head continued to be hanging over the right side of her geri chair. Observation on 06/02/26 at 11:55 A.M. of Resident #50 continued to still be seated in the common area in front of the TV with her head leaning off the right side of the geri chair and the back of her head resting on the metal bar outside of the chair padding. Observation on 06/02/26 at 12:03 P.M. of Resident #50 attempting to move herself in the geri chair. The chair creaked but Resident #50 was unable to move herself. Interview on 06/02/26 at 12:09 P.M. with CNA #350 verified Resident #50's head was hanging over the right side of her geri chair and was on the back support bar of the chair. CNA #350 verified Resident #50 was unable to move herself at all and was totally dependent on staff for positioning. CNA #350 verified Resident #50 was not positioned the way she should have been and repositioned Resident #50 properly in the geri chair. Review of the facility policy titled, Quality of Care Policy Activities of Daily Living, revised 04/29/26 revealed a resident who was unable to carryout activities of daily living was to receive the necessary services to maintain the highest level of practicable physical, mental and psychosocial wellbeing in accordance with their comprehensive assessment and plan of care.

Based on medical record review, staff interview, and policy review, the facility failed to send a resident to the hospital as ordered for a change in condition. This affected one (Resident #78) of three residents reviewed for changes in condition. The facility census was 63.Findings include:Review of Resident #78's medical record revealed an admission date of 10/06/25 and a discharge date of 02/11/26. Diagnoses included schizophrenia, neuromuscular dysfunction of the bladder, aneurysm of the ascending aorta, anxiety, hypertension, depression, and hypercalcemia. Resident #78 had a urinary indwelling catheter.Review of Resident #78's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of seven. Furthermore, Resident #78 was frequently incontinent of urine and bowel and was dependent upon staff for toileting hygiene. Review of the provider progress note for Resident #78 dated 12/02/25 revealed Resident #78 was experiencing severe penile pain and swelling with a pain rating of nine out of 10. The pain was described as excruciating and was localized to the glans penis, which appeared swollen. There was a significant amount of serosanguineous discharge around the urethral meatus, but no blood was noted in the indwelling catheter bag. Resident #78 had been given tramadol and other pain medications, but there had been no improvement in his pain. The plan was to refer Resident #78 to the hospital for urological evaluation due to significant pain and potential risk of urethral injury. Resident #78 consented to the hospital transfer for further assessment and management by a urologist.Review of Resident #78's progress notes revealed no progress notes indicating Resident #78 was sent to the hospital as ordered.Interview on 06/03/26 at 3:13 P.M. with Certified Nurse Practitioner (CNP) #405 verified Resident #78 was supposed to have been sent to the hospital on [DATE] and was not sent. CNP #405 verified she did not have any triage note or any knowledge of him being sent to the hospital.Interview on 06/08/26 at 8:52 A.M. with the Director of Nursing (DON) verified Resident #78 was not sent to the hospital per the physician's order on 12/02/25 and was unable to state why he was not sent to the hospital. The DON called the hospital and there was no documentation that Resident #78 was sent to the hospital on [DATE].This deficiency represents non-compliance investigated under Complaint Number 2795186.

Based on record review, observations, interview, and policy review, the facility failed to ensure fall investigations included a root cause and intervention. This affected one (Resident #47) of four residents reviewed for falls. The facility census was 63.Findings include:Review of the medical record for Resident #47 revealed an admission date of 01/07/26 with diagnoses including dementia, anxiety, and senile degeneration of brain.Review of the minimum data set (MDS) dated [DATE] revealed Resident #47 was rarely/never understood.Review of the physician orders revealed change gripper socks every night shift, dycem to recliner and cushion, and floor mats.Review of care plan dated 05/01/26 revealed the resident is at risk for falls due to instability related to history of hip fracture, history of falls and weakness, tremors, and hospice services related to end of life care. Interventions included flat call light pad to be attached to recliner and one to the bed, anti-rollbacks on wheelchair, wheelchair to be locked at bedside at all times when in bed, nonskid footwear when transferring or mobilizing in wheelchair, gripper socks to be worn at all times, dycem to recliner chair and on top of cushion in recliner chair, dycem to wheelchair cushion, and fall mats to both sides of bed on the floor.Review of fall investigation dated 04/19/26 at 2:00 A.M. revealed the resident was observed on the floor sitting with two hands leaning on the fall matt on the left side of the bed facing the television area. No signs of injury noted. The resident denied pain or discomfort at that time. Intervention frequent checks and reminding the resident to use call light for assistance. Interdisciplinary note (IDT) dated 04/22/26 revealed the root cause and the resident was noncompliant with current interventions. Intervention changes: all interventions currently in place are to prevent injury. Review of fall investigation dated 04/19/26 at 6:05 P.M. revealed the resident was observed lying on the floor between the wheelchair and the bed lying on left side with head towards the foot of the bed and feet towards the head of the bed. The landing mat was between the body and the floor. No gripper socks or shoes were noted on the resident's feet. Immediate action was the resident assisted to bed. IDT note meeting dated 04/22/26 revealed the root cause as the resident was noncompliant with all interventions and the resident was found lying on the floor mats next to the bed. Observation on 06/01/26 at 9:52 A.M. revealed fall mats on bilateral sides of the bed with the bed in high position with the resident sitting on the side of the bed with legs dangling and head rested on the mattress with the head of the bed elevated.Interview on 06/08/2026 at 9:01 A.M. with the Director of Nursing (DON) verified the falls for the resident did not have root cause analysis and fall interventions were not in place for the fall on 04/19/26 at 6:05 P.M. The DON stated the root cause was that the resident was non-compliant, and they do not know what the root cause should be as the resident was just confused and she had her mind set that she could go wherever and do whatever. The DON verified the resident cannot be redirected or educated which was part of the immediate intervention for the fall on 04/19/26 at 2:00 A.M. The DON verified no immediate intervention was put into place for the fall on 04/19/26 at 6:05 P.M.Review of policy titled Fall Reduction Policy revised 04/2016 revealed if a resident experiences a fall, nurses will investigate and document the incident in the nurse's notes. Follow-up documentation will be done each shift for a minimum of three days or longer if needed. Follow-up investigations will be done to ascertain the cause of the incident to reduce the risk for further occurrences.This deficiency represents noncompliance investigated under Complaint Number 2977286.

Based on record review, interview, and policy review, the facility failed to ensure residents were seen by the physician timely. This affected one (#49) of three residents reviewed for physician visits. The facility census was 63.Findings include: Review of medical record for Resident #49 revealed an admission date of 01/18/20 with diagnoses including quadriplegia C5-C7 incomplete, anxiety, major depressive disorder, and noncompliance with other medical treatment and regimen for other reason.Review of encounter note dated 12/04/25 revealed the resident was seen by the physician for a regulatory visit.Review of encounter note dated 04/09/26 revealed the visit type as non-billable and no transition of care occurred. Note signed by the physician.Review of encounter note dated 05/14/26 revealed the resident was seen by the physician for an acute/follow-up visit.Interview on 06/04/26 at 2:07 P.M. with the Director of Nursing (DON) revealed Medical Records provided the list to the physician of residents he needed to see. The DON stated Resident #49 would refuse to see the physician sometimes. The DON stated the physician should document refusals as well as visits. The DON verified Resident #49 was seen in December 2025 and then non-billable in April 2026 and visited in May 2026 which was longer than the 60 days required by regulation.Review of policy titled Physician Services revised 11/2018 revealed the resident must be seen every 30 days for the first 90 days after admission, then every 60 days thereafter, unless the resident's condition requires more frequent visits. A physician visit is considered timely if it occurs no later than 10 days after the date the visit was required. At the option of the physician, after the initial visit, required visits may alternate between visits by the physician and visits by a physician assistant, nurse practitioner or advanced practice nurse in accordance with regulation and the Non-Physician Practitioners Policy.This deficiency represents noncompliance investigated under Complaint Number 2977286.

Based on observation, medical record review, and staff interview, the facility failed to ensure resident dietary orders were followed. This affected one Resident (#50) of three residents reviewed for provision of meals. The facility census was 64.Findings Include: Review of Resident #50's medical record revealed an admission date of 04/22/21. Diagnoses included Alzheimer's disease, anxiety disorder, major depressive disorder, peripheral vascular disease, osteoarthritis and chronic pain. Review of Resident #50's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #50 was rarely or never understood. Resident #50 was dependent on staff for eating, toilet use, bathing, dressing, bed mobility and transfer. Resident #50 displayed no behavior and was receiving hospice services at the time of the review. Resident #50 had no significant weight loss or gain during the review period. Resident #50 received a mechanically altered diet at the time of the review. Review of Resident #50's care plan revised 06/01/26 revealed supports and interventions for hospice services, self-care deficit, communication deficit, dietary risk and allergies. Resident #50's allergies included Aspirin, Codeine, Doxycycline, Erythromycin, Sulfa Antibiotics, Chocolate, Shellfish, mercury and dairy. Review of Resident #50's physician orders revealed an order dated 10/12/22 for a regular diet, mechanical soft texture, honey thick/moderately thick liquids consistency dairy free diet. Observation on 06/01/26 at 12:44 P.M. found Resident #50 was provided a lunch meal of thickened tomato soup, blueberries and a grilled cheese sandwich. Observation on 06/01/26 at 12:46 P.M. of Resident #50 found Certified Nursing Assistant (CNA) #350 fed her a grilled cheese sandwich that had been cut into quarters. Interview on 06/01/26 12:48 P.M. with CNA #350 verified Resident #50 was being fed and was eating a grilled cheese sandwich.

Based on medical record review, staff interview, review of a investigation, and review of the facility policy, the facility failed to ensure residents were not physically restrained in a wheelchair. This affected one (Resident #39) of three residents reviewed for restraints. The facility census was 72. Findings include: Review of the medical record for Resident #39 revealed an admission date of 07/11/22. Diagnoses included dementia with agitation, anxiety, and psychotic disorder with hallucination. Review of the Minimum Data Set (MDS) assessment 02/13/25 revealed Resident #39 had moderate impaired cognition, did not exhibit behaviors during the review period, dependent on staff for toileting, and required substantial to maximal assistance from staff for mobility. Resident #39 had a restraint and it was a wander or elopement alarm and it indicated used less than daily. Review of the plan of care dated 04/02/25 revealed Resident #39 was at risk for wandering or elopement with interventions including the resident will not leave facility unattended, the resident's safety will be maintained, engage the resident in purposeful activity, and identify if there is a certain time of day wandering or elopement attempts occur. Review of the investigation for Resident #49 revealed on 04/16/25, the situation was during shift report, night shift reported that Resident #49 was restless, hallucinating and combative. The resident was crawling out of bed and attempting to stand or walk. Night shift staff reported the resident was brought to the nursing station for increased monitoring. After the night shift change report, and first shift began working with residents, it was noted that the resident was in the wheelchair with a gait belt wrapped around the wheelchair arms to prevent the resident from falling or standing up again. A CNA immediately removed the gait belt. Unit Manager and or designee notified the resident's family and Medical Director. Medical Director gave orders for labs if no labs have been drawn in the past six weeks. Licensed Social Worker or designee assessed residents' psychosocial well-being with no concerns. Interview on 05/01/25 at 5:45 A.M. with Certified Nursing Assistant (CNA) #122 stated there was an incident involving Resident #39 which occurred one night (04/16/25) when Resident #49 almost fell out of the wheelchair. CNA #122 verified after Resident #49 stood up from the wheelchair, a gait belt was placed on the front arms of the wheelchair to keep Resident #49 safe from getting hurt when trying to stand up. CNA #122 verified at the time this occurring, it was not meant to be harmful but helpful and did not know it was wrong to do this. Interview with the Administrator on 05/01/25 at 4:15 P.M. verified there was an investigation completed when informed CNA #122 placed the gait belt on the wheelchair of Resident #49 to keep the resident safe from falling when getting up from the wheelchair. Resident #49 was not harmed, and CNA #122 was suspended until the investigation was concluded. Review of the employee file for CNA #122 revealed the date of hire of 08/23/24. There was a disciplinary action due to performance and or conduct. The discipline dated 04/16/25 was for carelessness in performance of job duties, observance to safety rules or disregard of common safety practices or failure to use Personal Protective Equipment. The employee was suspended pending investigation. Review of the facility's policy titled Restraint Policy dated 2016 revealed the resident has the right to be free from any physical or chemical restraint imposed for the purpose of discipline or convenience and not required to treat the resident's medical symptoms. Residents shall not be restrained unless restraints are authorized by a physician in writing, used in an emergency, or requested by an alert oriented resident or representative of the risks and benefits associated with restraint use so that the choice is an informed one. The definition of a restraint are physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached to the resident's body that the individual cannot move easily, which restricts freedom of movement or normal access to one's body. Physical restraints are not defined by the device used, but rather by the impact the device had on the resident's freedom of movement, functional status and quality of life. This deficiency represents non-compliance investigated under Complaint Number OH00165184.

Based on medical record review, review of the facilities Self-Reported Incidents (SRI), staff interview, and review of the facility policy, the facility failed to report an allegation of abuse when a resident was found to be physically restrained by a gait belt in her wheelchair to the State Survey Agency, the Ohio Department of Health. This affected one (Resident #39) of three residents reviewed for restraints. The facility census was 72. Findings include: Review of the medical record for Resident #39 revealed an admission date of 07/11/22. Diagnoses included dementia with agitation, anxiety, and psychotic disorder with hallucination. Review of the facilities investigation for Resident #49 revealed on 04/16/25, the situation was during shift report, night shift reported that Resident #49 was restless, hallucinating and combative. The resident was crawling out of bed and attempting to stand or walk. Night shift staff reported the resident was brought to the nursing station for increased monitoring. After the night shift change report, and first shift began working with residents, it was noted that the resident was in the wheelchair with a gait belt wrapped around the wheelchair arms to prevent the resident from falling or standing up again. A CNA immediately removed the gait belt. Unit Manager and or designee notified the resident's family and Medical Director. Medical Director gave orders for labs if no labs have been drawn in the past six weeks. Licensed Social Worker or designee assessed residents' psychosocial well-being with no concerns. Review of the SRIs revealed there was no allegation of abuse reported to the State Survey Agency involving Resident #39 being found physically restrained by a gait belt to her wheelchair. Interview on 05/01/25 at 5:45 A.M. with Certified Nursing Assistant (CNA) #122 stated there was an incident involving Resident #39 which occurred one night (04/16/25) when Resident #49 almost fell out of the wheelchair. CNA #122 verified after Resident #49 stood up from the wheelchair, a gait belt was placed on the front arms of the wheelchair to keep Resident #49 safe from getting hurt when trying to stand up. CNA #122 verified at the time this occurring, it was not meant to be harmful but helpful and did not know it was wrong to do this. Interview with the Administrator on 05/01/25 at 4:15 P.M. verified there was an investigation completed when they were informed that CNA #122 placed the gait belt on the wheelchair of Resident #49 to keep the resident safe from falling when getting up from the wheelchair. The Administrator verified this allegation of abuse was not reported to the Ohio Department of Health. The Administrator explained he did not feel this was done to be abusive. Resident #49 was not harmed, and the staff member was suspended until investigation was concluded. Review of the policy titled Abuse, Neglect, Injuries of Unknown Origin and or Misappropriation of Resident Property revealed the definition which included as the willful act of of unreasonable confinement resulting in mental anguish. The administrator or designee will notify Ohio Department of Health of all alleged violations as soon as possible, but in no event later then twenty-four hours from the time of incident was made known to the staff member. This deficiency represents non-compliance investigated under Complaint Number OH00165184.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure urinary catheter care was performed with proper infection control procedures. This affected one (Resident # 42) of three residents reviewed for catheter care. The facility census was 72. Findings include: Review of the medical record for Resident #42 revealed admission date of 11/05/24. Diagnoses included malignant neoplasm of bladder obstructive and reflux uropathy, urinary tract infection, infection and inflammatory reaction to catheter and methicillin resistant staphylococcus aureus. Review of the physician's orders dated 04/05/25 revealed an order for an indwelling catheter care every shift. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition, had impaired bilaterally lower extremities, dependent on staff for toileting, and had an indwelling catheter. Review of the plan of care dated 04/11/25 revealed the indwelling catheter was due to uropathy with interventions including provide catheter care per order and as needed. Observation of catheter care on 05/01/25 at 11:40 A.M. revealed Certified Nurse Assistant (CNA) #136 was providing catheter care to Resident #42. CNA #136 gathered a basin of warm water, three washcloths, one towel and liquid wash solution. CNA #136 placed the washcloths in the basin, took one washcloth out of the basin, and placed the liquid wash solution on the washcloth. CNA #136 cleaned the tube of the catheter which had a moderate amount of yellow film. CNA #136 then placed the used washcloth back into the basin and took out another washcloth from the now contaminated water basin and rinsed the soap off from the catheter. This second used washcloth also was placed back into the contaminated basin. CNA #136 took out the washcloth previously used to clean the tubing out of the contaminated water basin, placed liquid wash solution on it, and cleaned around the end of the penis. The used washcloth was placed back into the basin and the washcloth used to rinse the tubing was taken out of the contaminated water basin and used it to rinse around the penis. CNA #136 dried of the penis and tubing with the towel. Interview with CNA #136 on 05/01/25 at 11:58 A.M. verified they placed the washcloths back into the basin which contaminated the water, continued to use and reuse two of the washcloths from the contaminated basin, and only used two of three washcloths that were originally placed into the basin. Interview on 05/01/25 at 12:15 P.M. with the Regional Nurse #200 verified the facility had some issues with the CNAs using washcloths in the basin and placing them back into the basin which contaminated the water. The CNAs have been redirected several times to bring in a bag to place the dirty washcloth in and to not place it back into the basin. Review of the facility's policy titled Indwelling Catheter dated 11/13/17 revealed a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary. Residents who are incontinent of bowel or bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. This deficiency represents non-compliance investigated under Complaint Number OH00165263.

Based on medical record review, review of resident fluid intakes, review of physician orders, staff interview, review of physician communication sheets, review of a hospital history and physical, review of hospital consultation notes, and review of facility policy, the facility failed to ensure a resident's hydration status was maintained to decrease the risk of dehydration. This resulted in actual harm when Resident #58 had a decrease in oral fluid intake for three days and was subsequently hospitalized with acute kidney injury, severe dehydration, and severe sepsis. This affected one (#58) of three residents reviewed for hydration status. The facility census was 71. Findings include: Review of Resident #58's medical record revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, dysarthria, aphasia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), chronic kidney disease, heart disease, anxiety disorder, bipolar disorder, hypertension, and atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was severely cognitively impaired and required extensive assistance with activities of daily living, including eating. Review of a plan of care focus area initiated 09/11/23 and revised 10/12/23, revealed Resident #58 was at increased nutrition/hydration risk related to stroke, dysphagia with need for mechanically altered diet, and takes medication which can affect appetite or weight. Additionally, Resident #58 had decreased food and fluid intake, avoidable weight loss over past 30 days due to decline in condition, refusal of meals and poor oral intakes. Interventions included encourage honey thickened liquids between meals, monitor for signs and symptoms of dehydration/fluid volume deficit, monitor labs as available, monitor for decline in eating ability and assist as needed, monitor weight, and diet as ordered. Review of physician orders revealed Resident #58 was on a regular, pureed diet with honey thickened liquids and was ordered furomeside (diuretic - used to remove water and electrolytes from the body by increasing urination) oral tablet 10 milligrams (mg) two times daily. Review of the Medication Administration Record (MAR) from 09/15/23 through 09/22/23 revealed Resident #58 was administered furomeside 10 mg as ordered on each of the days reviewed. Review of a Nutritional assessment dated [DATE] revealed Resident #58 received honey thickened liquids, required limited assist/supervision with feeding, had inadequate fluid intake, and swallowing difficulty. Inadequate fluid intakes were related to resident doesn't know to drink fluids as will just hold cups. Additionally, fluid intakes do not meet 100% estimated fluid needs. Continue with regular pureed diet with honey thickened liquids. Will add magic cup three times daily and honey thickened facility nourishment three times daily. Goals are for no signs or symptoms of dehydration, no difficulty with chewing or swallowing, and no significant weight change. Review of a nursing alert progress note dated 09/18/23 revealed Resident #58 ate less than 50% over the last three shifts. Inadequate fluid intake, swallowing difficulty related to recent CVA (stroke) as evidenced by need for mechanically altered diet. Inadequate fluid intakes related to resident doesn't know to drink fluids and will just hold cups as evidenced by fluid intakes do not meet 100% estimated fluid needs. Continue with a regular pureed diet with honey thickened liquids. Review of e-mail correspondence dated 09/18/23 revealed Case Manager (CM) #250 communicated to Registered Dietitian (RD) #200 and therapy that Resident #58 had consumed less than 50% of her meals for several days. RD #200 responded Resident #58 was on multiple supplements and weight was stable since admission. Review of a physician communication form dated 09/19/23 revealed nursing notified Physician Assistant (PA) #300 Resident #58's oral intake was inadequate. Gags with pureed food but ok with magic cup and pudding. PA #300 responded on 09/20/23 and indicated resident was followed by speech therapy and have dietitian see for further recommendations. Review of State tested Nurse Aide (STNA) documentation revealed on 09/20/23 and 09/22/23, fluid intakes were documented as either resident refused or not applicable. There was no documentation Resident #58 received any fluids on those dates. Review of STNA documentation dated 09/21/23 revealed Resident #58 had consumed 480 ml (approximately 16 ounces) of fluids. Review indicates the resident did not have adequate fluid intake for three days. Review of a physician communication form dated 09/21/23 revealed RD #200 notified PA #300 Resident #58 disliked the facility nourishment and threw it at the nurse. The nurse tried Boost Breeze with the resident and the resident drank that. RD #200 recommended Boost Breeze, eight ounces two times daily. PA #300 responded on 09/22/23 and ordered Boost Breeze as recommended. Review of a nursing alert note dated 09/21/23 revealed Resident #58 ate less than 50% over the last three shifts. Speech therapist and dietitian are working with patient. Has appropriate supplementation ordered. No weight loss noted since admission. Further review of a nursing progress note dated 09/21/23 revealed Resident #58 was alert to self, post CVA. Right side has no movement. Medications crushed. Refusing meals, drinking some juice. Incontinent of bladder and bowel. Additional review of a nursing progress note dated 09/23/23 at 9:45 A.M. revealed Resident #58 had noted increased drowsiness and weakness, aggressive when writer tried to give her medicine. Vital signs taken and blood pressure (BP) was 90/30, temperature 97.8, Pulse 96, and oxygen saturation (SpO2) 95%. Resident does not answer appropriately due to previous CVA. Notified physician (MD) and order received to send to the hospital. Attempted to call daughter, number cannot be reached. Resident picked up at 9:40 A.M. Report given to emergency room (ER) nurse. Review of a hospital History and Physical, dated 09/23/23, revealed emergency medical services (EMS) reported the resident had altered mental status and failure to thrive at the facility. Resident was lethargic on arrival and hypotensive. EMS stated the resident had no food or water in a couple of days. Additionally, Resident #58 now had altered mentally so they decided to send her to the Emergency Department (ED). Resident #58 had acute encephalopathy (alteration of mental status), severe sepsis with hypotension (likely due to significant dehydration), severe dehydration due to no oral intake of food/water for the last three days (reported), significant hypernatremia (likely due to dehydration and leading to altered mental status), acute kidney injury on top of chronic kidney disease, mild acute respiratory failure with hypoxemia due to COPD exacerbation, and mild COPD exacerbation with unknown trigger at this time. Physical examination revealed the resident had a very dry tongue and oral mucosa (the mucus membrane or skin inside the mouth, including cheeks and lips). Resident #58 was admitted to the intensive care unit for closer monitoring of oxygen levels, regular diet started, daily weight and strict input and output, ED given boluses, continue Intravenous (IV) one-half normal saline (NS) at 75 milliliters/hour (ml/hr.), doing no antibiotics now as there is no evidence of infection. Lastly, furomeside (diuretic) was discontinued. Review of hospital consultation notes dated 09/23/23 revealed Resident #58 was admitted to the hospital due to acute kidney injury, hypernatremia (high concentration of sodium in the blood), acute encephalopathy (alteration of mental status), hypotension (low blood pressure), severe sepsis, hyperkalemia (high potassium), and dehydration. Additional review revealed resident admitted with report of more than two days of poor oral intake of food and water. Treatment included dextrose 5 percent in water IV solution 1,500 milliliters (ml) 150 milliliters/hour (ml/hr) and sodium chloride 10 ml IV push two times daily. Further review of the medical record revealed no evidence Resident #58 was assessed for dehydration signs and symptoms prior to hospitalization . Interview on 10/16/23 at 2:07 P.M. with PA #300 revealed she recalled a conversation with someone at the facility about supplements for Resident #58. She did not specifically recall a conversation about fluid intakes. PA #300 stated she knew the resident's intakes were poor, but she was unaware the resident had not consumed any fluids on 09/20/23 and 09/22/23 and had only had 420 ml (16 ounces) on 09/21/23. PA #300 stated she saw Resident #58 on 09/20/23, but the resident was on transmission-based precautions, so she only saw her from the door and did not physically examine her. PA #300 stated she did not recall any specific concerns related to Resident #58's fluid intakes, noting the facility wanted her to back them but she did not remember notification of fluid concerns. PA #300 stated she probably would have discontinued Resident #58's furomeside if she had known the resident's fluid intakes were that low. Interview on 10/16/23 at 2:24 P.M. with CM #250 revealed she had a conversation with PA #300 about a supplement for Resident #58 due to poor meal intakes. No changes were made because the dietitian stated the resident's weight was stable. CM #250 confirmed the communication with PA #300 was related to poor meal intakes and not inadequate fluid intakes. Interview on 10/17/23 9:41 A.M. with Corporate Nurse (CN) #275 revealed Resident #58's vital signs had been monitored two times daily and had been stable up to the day the resident was sent out to the hospital. CN #275 stated Resident #58 had stable pulses and BP and there were no outwardly signs of obvious dehydration. The facility had been trialing some different things to increase the resident's intakes. CN #275 stated Resident #58 refused meals, fluids, care, and would become aggressive toward staff. CN #275 stated based on Resident #58's presentation, the staff were doing whatever they could and did what they needed to do. Additionally, CN #275 stated Resident #58 was on a pureed diet, and while she could not measure the amount of fluid in pureed diets, Resident #58 was receiving fluids through meals. Interview on 10/17/23 at 10:19 A.M. of Registered Dietitian (RD) #200 revealed Resident #58 had been discussed at the facility's weekly nutrition at risk meetings. RD #200 stated Resident #58 refused meals and fluids and would hit staff. RD #200 stated all foods contain a certain percent of water, based on the food, and it was possible Resident #58 received enough fluids to sustain her through a pureed diet. RD #200 stated she would review the meals and Resident #58's intakes to calculate an estimate of fluids the resident would have received from eating a pureed diet. Follow up interview on 10/17/23 at 12:03 P.M. with PA #300 revealed she may have been remembering the wrong resident when she spoke with this surveyor on 10/16/23. PA #300 stated she was now retired, working off of memory, and could not recall all of the details. PA #300 stated she had the resident confused with another resident and she did actually evaluate Resident #58 on 09/20/23 and had no concerns related to dehydration. While PA #300 stated she was notified by the facility on 09/19/23, Resident #58 had poor oral intakes, she believed that to mean the resident was drinking low liquids, not no liquids, which was why she deferred to the dietitian. Additionally, on 09/21/23, PA #300 stated she ordered Boost Breeze, and that was a fluid. PA #300 confirmed she was unaware Resident #58 had only consumed one - eight ounce Boost Breeze on 09/21/23 and none on 09/22/23. While some fluids could be obtained through foods, she was uncertain if it would be a sufficient amount to prevent dehydration. PA #300 verified furomeside would increase the risk of dehydration, especially in someone who was not consuming sufficient fluids, and she did not know why that was not addressed for Resident #58. Follow-up interview on 10/17/23 at 2:45 P.M. with CN #275 confirmed while Resident #58's vital signs were stable in the days leading up to her hospitalization , there was no evidence of nursing assessment for other indicators of dehydration, including sunken eyes, skin turgor, or oral mucosa. Interview on 10/18/23 at 9:24 A.M. with RD #200 verified she was not in the kitchen when Resident #58's meals were prepared and was unable to verify if the proper amounts of fluid was added to the resident's pureed meals and/or served to the resident. Review of facility policy titled, Hydration Policy, approved 03/17/16, revealed the facility will provide each resident with sufficient fluid intake to maintain proper hydration status. Sufficient fluid means the amount of fluid needed to prevent dehydration and maintain health. The amount needed is specific for each resident, and fluctuates as the resident's condition fluctuates. This deficiency represents non-compliance investigated under Complaint Number OH00146850.

Based on medical record review, resident interview and staff interviews and review of the product recommendation, the facility failed to ensure a resident was free from accident hazards when one resident (#42) requested that State tested Nurse Aide (STNA) #220 heat a resident's personal gel pad for use. This resulted in Actual Harm when Resident #42 sustained a second degree burn after placing the heated gel pad onto the left shoulder. This affected one (#42) of three residents reviewed for skin conditions. The facility census was 73. Findings included: Review of Resident #42's medical record revealed an admitted [DATE]. Diagnoses included fusion of the cervical spine due to an unspecified injury, diabetes mellitus, [CONDITION(S)], and spinal stenosis. Review of Resident #42's quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a high cognitive function. The resident required extensive assistance for dressing and personal hygiene. Section M1040 other ulcers, wounds, and skin problems Letter F documented Resident #42 had a second-degree or third-degree burn. Review of Resident #42's most recent care plan revealed she had an actual impairment to the skin integrity related to a burn on the left shoulder. Review of Resident 42's physician's note dated 12/14/21 revealed to use a moist compress on the right side of the neck three times daily for 10-15 minutes for 10 days. Review of Resident #42's nurses note dated 12/18/21 revealed the resident had a change in condition. The resident requested the nurse the come to her room. Resident #42 informed the nurse she had a sore area on her shoulder. Upon examination, a large blister was noted. The physician was notified, and an order was received to keep an abdominal pad covering on the area and apply triple antibiotic ointment twice daily if the blister ruptured. The resident's responsible party was notified. Review of Resident #42's Skin Issue Report dated 12/18/21 revealed the unit manager was informed of an area on her shoulder. Upon investigation it was noted the resident purchased a gel hot pack herself. On 12/17/21 Resident #42 requested a staff member, STNA #220 to heat up the gel pack. The staff member, STNA #220 complied as requested and then wrapped it in a towel. Resident #42 placed the hot pack on her shoulder/neck area. On 12/18/21 she complained of pain to her left shoulder. The resident reported it slipped, and it was noted that she had a blister. She told the nurse she was not sure how it got there but thought it could have been from the hot pack because she had moved it, or it had slipped. The nurse #202 educated the resident about it not being a good idea for her to have a gel pack and the nurse would apply the ordered moist compress if she needed it. The resident threw away the gel pack she had purchased. The nurse educated the staff they were not to put a compress on residents, they should always ask the nurse. Review of Resident #42's physician note dated 12/20/21 revealed the patient was seen due to a clinical change. Resident #42 developed a burn on her left upper shoulder secondary to warm compresses. The resident stated that the heat source slipped and moved from her neck to the shoulder. She sustained a burn. There was a second-degree burn at the top of the left shoulder. The blister was fluid filled. It was about one and a half inches by one inch in diameter. Staff were to continue the current treatment plan and add [MEDICATION(S)] (a cream used to treat and prevent wound infections for second and third-degree [CONDITION(S)]) cream with a non-adherent dressing and monitor for infection. Interview with Resident #42 on 02/02/22 at 9:39 A.M. revealed she suffered a burn to the left shoulder after a State tested Nursing Aide (STNA) #220 heated a gel pack for the resident. The gel pack was wrapped in a towel but slid out of the towel and onto her left shoulder where the burn occurred Interview with Registered Nurse (RN) #207 on 02/02/22 at 9:54 A.M. revealed she was aware of Resident #42's burn which resulted from a hot pack. The nurse stated she did not work the day it occurred. RN #207 stated only nurses were allowed to apply any heated treatments to residents which included heating pads and heated gel packs. If the treatment was scheduled, the nurses would complete the treatment. Interviews with STNA's #200 and #208 on 02/02/22 between 10:10 A.M. and 10:58 A.M. revealed it was the facility policy that STNA's were not allowed to provide residents with heating pads or heated gel pads. The STNA's were to report the request from the resident to the nurse. Interview with the Director of Nursing (DON) on 02/02/22 at 10:39 A.M. revealed Resident #42 asked the staff to heat a gel pack that was not supplied by the facility. The resident applied the gel pack to her shirt. The resident then moved the gel pack and put it on her shoulder. The DON stated the resident was independent on that type of care. Interview with Unit Manager/RN #202 on 02/02/22 at 11:36 A.M. revealed Resident #42 had purchased a gel pack and asked an STNA #220 to heat it. The resident placed the heat pack on her neck, then unwrapped it and placed it on her left shoulder. Resident #42 did not notice the burn until the next day when it was painful. The nurse assessed the area and saw the blister. This was reported to the physician timely. Follow-up interview with the DON on 02/02/22 at 11:40 A.M. revealed the facility had no policy regarding this issue. Review of the product information revealed the heat times would vary depending on the wattage of the microwave. Once heated carefully check the for desired temperature. If gel pack is too hot allow to cool before applying. If gel pack in not hot enough, microwave for additional 10 second intervals, until a safe and desired temperature is reached. Knead gel pack to distribute heat evenly. Always wrap with a towel before applying. Hot or Cold therapy should not be used by individuals who are sensitive to temperature extremes, such as those with circulatory problems, diabetes, nerve damage, paralysis, or sensitive skin. Hot or Cold therapy should not be used by people with circulatory problems, except under the direct supervision of a Health Care Professional. Always use a sleeve or towel before applying. Excessive heating could cause skin [CONDITION(S)], gel pack deterioration, and possible leakage. To eliminate the possibility of skin [CONDITION(S)], always use a sleeve or towel when handling or applying the hot gel pack.

Based on medical record review, observation, review of the hospital emergency room notes, family interview, resident interview, staff interview, and review of the facility policy, the facility failed to ensure adequate supervision was provided during toileting. This resulted in actual harm when one resident (#361) was left unattended on the toilet, suffered a fall, and required transfer to the hospital with treatment of [REDACTED]. Four residents were reviewed for falls. In addition, the facility failed to ensure the toilet safety frames were in safe stable condition for five (#4, #15, #36, #64 and #93) out of 47 residents who utilized toilet safety frames within the facility, which did not rise to the level of harm. The facility census was 111. Findings Include: 1. Review of Resident #361's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of a fall risk assessment dated [DATE] revealed Resident #361 was identified as a high fall risk. Review of the physician orders dated 10/09/17 revealed occupational, physical and speech therapy consultations for [MEDICAL CONDITION] and [MEDICAL CONDITION] related to cerebral infarction and associated right extremity deficits. Review of the care plan initiated 10/31/17 revealed Resident #361 was at risk for falls. Interventions included anticipating and meeting the resident's needs. It further stipulated staff/family were to be with the resident while in the bathroom. Review of the 30 day Minimum Data Set 3.0 (MDS) assessment, dated 11/06/17, revealed Resident #361 had intact cognitive ability. Resident #361 was assessed as requiring extensive two person assistance with toileting. Review of the nursing progress notes dated 11/28/17 at 2:45 P.M. revealed Resident #361 was found on the bathroom floor by the husband and the staff was alerted. The nurse, State tested Nursing Assistant (STNA) and Certified Nurse Practitioner (CNP) responded and found Resident #361 laying on her right side with a laceration to the top of the right eye measuring two centimeters by two centimeters, which was open and bleeding. First aid care was provided and the ambulance was called. Resident #361 was transported to the local emergency room for further care. Review of the physician emergency room notes, dated 11/28/17, revealed Resident #361 was assessed for a closed head injury without loss of consciousness secondary to a fall. The physical exam documented a two centimeter laceration to the right eyebrow with the brow intact. The laceration was closed with five sutures. Review of the CNP progress note, dated 11/28/17, revealed follow up for Resident #361 who sustained a fall off of the toilet in the bathroom. The progress note further indicated Resident #361's spouse reported Resident #361 had been left alone in the bathroom. Resident #361 sustained a laceration to the right eyebrow. Observation of Resident #361 on 12/05/17 at 9:32 A.M. revealed a healing laceration above the right eyebrow. Resident #361 was also observed with bruising over the right cheek bone. Resident observed to be aphasic with right sided [MEDICAL CONDITION]. Interview on 12/05/17 at 9:32 A.M., Resident #361's daughter revealed the resident had a recent fall in the bathroom when the resident was left unattended. The daughter further reported the resident received stitches above her right eyebrow as a result of the fall. Interview on 12/06/17 at 9:51 A.M., Registered Nurse (RN) #206 stated the STNA left Resident #361 alone on the toilet on 11/28/17. RN #206 further revealed the STNA was immediately counseled by the Director of Nursing (DON) on the aspects surrounding the fall. RN #206 also indicated all of the staff on the hall were counseled regarding Resident #361's right sided weakness and the resident was not to be left unattended during toileting. Interview on 12/06/17 at 10:20 A.M. with STNA #300 revealed Resident #361 was a two person assist due to the right sided weakness. In addition, staff were to be with the resident at all times when toileting. Interview on 12/06/17 at 4:24 P.M., RN #200 confirmed Resident #361 had been left unattended on the toilet on 11/28/17 when the fall occurred. RN #200 further reported education was provided to all staff following the incident. Interview on 12/07/17 at 9:21 A.M., RN #207 revealed Resident #361 was in the bathroom on 11/28/17 when she fell forward resulting in an eyebrow laceration that required transport to the local emergency room for sutures. RN#207 confirmed Resident #361 had been left alone when the fall occurred and per the care plan was supposed to be attended to while in the bathroom Review of facility policy titled Accidents and Incidents, reviewed 04/2016, revealed the intent of the procedure was to ensure the resident's environment remains as free of accident hazards as possible. Each resident is to receive adequate supervision and assistive devices to reduce accidents. 2. Review of Resident #64's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Observation on 12/06/17 at 9:10 A.M. of Resident #64's bathroom revealed the toilet safety frame was loose and wobbly. Interview on 12/06/17 at 9:13 A.M., Resident #64 stated the hand rails on the over the toilet device are loose and he does not feels safe. Interview on 12/6/17 at 9:40 A.M., the DON verified Resident #64's toilet safety frame was loose and should be tighter. 3. Review of Resident #93's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 11/06/17, identified the resident to have intact cognition. The resident required limited one person assistance with transfers. Observation on 12/05/17 at 9:59 A.M. revealed the resident had a toilet safety frame over her toilet. The hand rail on the left side of the toilet safety frame was tight, however, the hand rail on the right side was loose and wobbly. Interview on 12/05/17 at 9:59 A.M., Resident #93 voiced the rail has been loose and she has to be careful using it. Interview on 12/06/17 at 9:40 A.M., the DON confirmed the hand rail on the left side of the toilet safety frame was tight and the rail on the right side was loose and wobbly. 4. Observations during the environmental tour with the DON on 12/06/17 at 10:01 A.M. revealed toilet safety frames were loose, wobbly, and unsecured in the bathrooms for Room A-3 (Resident #15), Room #A-12 (Resident #36), and Room #A-60 (Resident #4). Interview on 12/06/17 at 10:01 A.M. the DON confirmed the observations of the loose, wobbly, and unsecured toilet safety frames. Interview on 12/06/17 at 10:55 A.M. the Assistant Administrator admitted some of the toilet safety frames were very wobbly and unsafe.